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Based on record review and interview the facility failed to follow policy and EMTALA regulations by transferring a pregnant patient without notification to the recipient hospital, without contact and agreement with an accepting physician, and without signed transfer forms explaining risks and benefits of transfer in 2 of 20 medical records reviewed (Pt. #1 and Pt. #20) and failed to maintain a complete log of Emergency Department patients including discharge disposition in 1 of 1 ED logs reviewed.


Facility staff failed to maintain a complete Emergency Department log See Tag 2405

Facility staff failed to provide appropriate transfer See Tag 2409

Based on record review and interview the facility failed to maintain an accurate Emergency Department (ED) log that includes discharge disposition in 59 out of 1,804 log entries.

Findings:
Record review of the ED electronic log from December 1, 2020 to present with ED Manager A, revealed 59 patients with no entry under the column "discharge disposition."

On 5/24/2021 at 3:30 PM during an interview with ED Manager A, Manager A stated that the provider or the nurse is supposed to enter that information in the log at discharge. "That was obviously not done on these."

Based on record review and interview the facility failed to provide an appropriate transfer by failing to call the receiving hospital, not obtaining an accepting health care provider, and not completing and sending transfer paperwork for 2 of 20 patients (Pt. #2 and Pt. #20) in a sample of 20 medical records reviewed.

Findings include:
Record review of the facility's policy titled, "Emergency/Non-Emergency Transfer/Inter Facility Transfer" #ED1003 dated 8/4/20 under Policy Statement revealed, in part, "Nursing and Medical Staff will conform to this policy and procedure regarding all inter facility transfers." The policy revealed under 5. "Appropriate Transfer will constitute that: ...if discharge would result in the reasonable medical probably of material deterioration of the patient, the emergency medical condition should not be considered to have been 'stabilized.' b. The receiving facility has available space and qualified personnel for the treatment of the patient and agrees to accept the individual..." 8. The INTER-FACILITY TRANSFER/PATIENT'S REQUEST/REFUSAL/CONSENT TO TRANSFER letter will be accessed within the patients EMR (electronic medical record) and completed in its entirety. This will include the patient's signature of understanding and acknowledgement for the transfer, including the risks/benefits of transfer. Form must be completed including physician signature and accepting physician name, nurse, patient..."

Review of Pt. #1's medical record revealed she presented to the Birthing Center on Saturday, 4/10/2021 at 2:30 PM and was assessed by RN H for complaints of "increased back pain radiating from uterine cramping that initially started Thursday and has increased in intensity today. Also reports increase in vaginal discharge earlier today, possibly fluid. UA (urinalysis) obtained upon admission then (Dr. E) performed a sterile vaginal exam with collection of an Amnisure (a test used to assess if fluid is amniotic indicating ruptured membranes), NAAT (Covid test), GBS (Group B strep), and FFN (used to assess the risk of preterm delivery.) Patient throughout the assessment was rating her back pain and cramping 6/10. After results of exam, it was advised to the patient based on her cervix at 2 cm (dilated - cervix starting to open) and 70% (effaced- cervix thinning) along with positive ROM (rupture of membrane) that she go to United in anticipation of a preterm delivery. Patient agreeable with advisement and chose to go to United by private car out of financial concern of ambulance cost." Record revealed this note was filed on 4/10/2021 at 7:23 PM.

Review of Pt. #1's medical record revealed a "Progress Note: Provider" filed at 4:38 PM that revealed, in part, "ASSESSMENT 1. 30 y/o (year old) gravida 1 (first pregnancy) at 33w0d (33 weeks, zero days) with preterm labor 2. SROM (spontaneous rupture of membranes) clear PLAN: 1. Preterm labor diagnosis explained to patient, along with plan of management. Risks/benefits/alternatives to tocolysis (the use of medications with the purpose of delaying the delivery of a fetus in women presenting preterm contractions) with calcium channel blocker, as well as risks and benefits of antenatal steroid treatment (administered to accelerate the maturation of the fetus' lungs) were discussed, and all patient questions answered...2. GBS specimen obtained 3. She was advised to immediately take their personal vehicle to United Hospital in St. Paul for appropriate level of neonatal care, should preterm labor progress."

On 5/25/2021 at 8:50 AM during an interview with RN H, RN H confirmed that she was the primary nurse taking care of Pt. #1 on April 10, 2021. RN H stated that she has never personally transferred a mom from the Birthing Center. RN H stated, "We always call the House Supervisor to come and do all of the transfer paperwork." RN H confirmed that she did not send any transfer paperwork or call report to United Hospital.

On 5/25/2021 at 11:00 AM during an interview with Dr. E when asked about transferring patients Dr. E stated, "I misunderstood EMTALA, I thought because I discharged her (Pt. #1) she could just present to United (hospital) for admission." Dr. E stated "United Hospital has the same EMR as us so I figured that they would just look at my records from here." When asked about calling for an accepting physician at United, Dr. E stated that the nurses usually take care of all of that. "I didn't think of this as a transfer so I didn't call anyone. It's my understanding that if someone comes to your ED you have to see them. I thought that I was providing appropriate follow up because we are not equipped to keep a baby born at 33 weeks."

Further review of Pt. #20's medical record, in a note filed on 12/9/2020 at 10:28 AM, revealed that she presented to the Birthing Center on Wednesday 12/9/2020 at 9:31 AM and was assessed in the Birthing Center after describing "a large rush of clear fluid at 8:51 AM at home." Pt. was 34 weeks 6 days gestation. "RN Comments" revealed, "Visibly leaking on pad in triage room, ROM+ obtained and positive. Contractions on monitor 5-7 minutes. Pt. unaware of contractions unless asked, then describes as pressure on sides of belly and back. Dr. E at bedside to discuss options with patient."

Review of Pt. #20's medical record revealed a note from Dr. E, acknowledged by Dr. E on 12/10/2020 at 3:00 PM, noting, "Extensively discussed risks/benefits of options for augmentation (process of inducing labor), delivery, and postpartum care, especially of preterm neonate, including possibility of infant needing transfer to higher level of care...She decides to drive to United Hospital for labor and birth." Record revealed that the patient discharged on 12/9/2020 at 11:00 AM.

Further review of Pt. #20's medical record revealed a "Progress Note: Nursing" filed on 12/9/2020 at 11:04 AM that revealed, "Patient and significant other (name) decided to go to United after discussion with (Dr. E) Due to baby's gestational age they would like to deliver where baby has access to higher level of care if needed...Patient plans to head to United now and denies any questions."

There are no transfer forms in Pt. #20's medical record, no documentation of contact with United Hospital or with an accepting physician. These findings were confirmed in interview on 5/25/2021 at 1:15 PM with Birthing Center Manager B.