HospitalInspections.org

Based on policy review, medical staff bylaws rules and regulations, medical record review, review of the Patient Placement Center (PPC) recordings, Emergency Medical Services (EMS) patient care report and interview, the hospital failed to ensure a patient who was experiencing signs of pre-term labor was transferred to a hospital who had agreed to accept the transfer and who had the appropriate higher level of care such as a Neonatal Intensive Care Unit (NICU), and qualified NICU personnel for 1 of 8 (Patient #1) sampled patients who required transfer to a higher level of care.

The findings included:

Refer to A2409.


30996

Based on policy review, medical staff bylaws rules and regulations, medical record review, review of the Patient Placement Center (PPC) recordings, Emergency Medical Services (EMS) patient care report and interview, the hospital failed to ensure a patient who was experiencing signs of pre-term labor was transferred to a hospital who had agreed to accept the transfer and who had the appropriate higher level of care such as a Neonatal Intensive Care Unit (NICU), and qualified NICU personnel for 1 of 8 (Patient #1) sampled patients who required transfer to a higher level of care.

The findings included:

1. Review of the facility's Evaluation and Transfer of Patients with Emergency Medical Conditions, Including Pregnancy with Contractions policy revealed, "...Emergency Medical Condition...Medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in...Placing health of individual (or with respect to pregnant woman, health of woman or unborn child) in serious jeopardy...Scope of Responsibility...The patient is provided, within capabilities of the staff and facilities available at hospital, further medical examination and treatment as required to stabilize the medical condition or transfer the patient...Transfers...If the physician, or other qualified medical personnel...determines, based on the information available at the time of transfer, that reasonably expected medical benefits of the transfer outweigh and increased risks from transfer to the patient, and, in case of a woman in labor, to the patient or unborn child and the following criteria are met...The transferring hospital provides medical treatment within its capacity, which minimizes the risks to individual health and, in the case of a woman in labor the health of the unborn child...The receiving facility: a. Has available space and qualified personnel for the treatment of the individual, and b. Has agreed to accept transfer of the individual and to provide appropriate medical treatment..."

2. Review of the Medical Staff Bylaws Rules and Regulations revealed, "... Transfer To Another Facility...General Requirements... A patient shall be transferred to another medical care facility only upon the order of the attending practitioner...only after arrangements have been made for admission with the other facility, including its consent to receiving the patient...The medical doctor from the transferring facility will be responsible for notifying a medical doctor at the receiving institution an [and] documenting his name in the patient's medical record..."

3. Medical record review for Patient #1 revealed the patient arrived at Hospital #1 on 11/30/2020 at 4:40 PM with the chief complaint of Abdominal Pain and was taken to the Labor and Delivery (L&D) unit. Patient #1 was pregnant with twins with a gestational age of 31 weeks and 3 days (The gestational age is the common term used during pregnancy to describe how far along the pregnancy is. A normal pregnancy can range from 38 - 42 weeks. Infants born before 37 weeks are considered premature).

On 11/30/2020 at 5:00 PM, L&D Registered Nurse (RN) #2 initiated the medical screening exam (MSE) for Patient #1.

An Ultrasound was ordered at 5:53 PM and completed at 6:00 PM. The Obstetrical Ultrasound revealed, "...There is mild funneling of the os [OS is the lower part of the cervix] the cervical length is 2.0 cm [centimeters]..." (Funneling is cervical incompetence; the cervix is too weak or damaged to stay closed during pregnancy therefore resulting in premature birth or possible loss of the baby).

An external tocotransducer (detects how often contractions occur and the duration of the contractions) was placed on Patient #1 at 5:54 PM and an external fetal heart monitor (assesses the heart rate and rhythm of the fetus) was placed at 6:20 PM.

Review of Patient #1's external tocotransducer flowsheet revealed on 11/30/2020 at 6:20 PM, Patient #1 had three (3) mild contractions in a ten (10) minute period lasting 30-45 seconds.

At 6:21 PM there were two (2) mild contractions in a ten (10) minute period lasting 45-60 seconds.

At 6:26 PM L&D RN #3 documented, "... Certified Nurse Midwife [CNM] called for an update on pt [Patient #1]. Informed still having occasional contractions and that unofficial US [Ultrasound] report stated that cervical length seems about 2 cm with funneling..." There was no documentation what time the CNM arrived to assess Patient #1.

Review of the medication administration list revealed Patient #1 received the following medications on 11/30/2020 at Hospital #1's L&D:
(a). Terbutaline (Brethine) 0.25 mg subcutaneous (SQ) at 5:44 PM and a repeat dose of Terbutaline 0.25 mg at 7:10 PM. (Terbutaline is an anti-contraction medication to delay pre-term labor for up to 48 hours).
(b). Stadol 2 milligrams (mg) IV at 9:10 PM. Stadol is an opioid analgesic used for mild to moderate management of pain.

Review of the Patient Placement Center (PPC) recordings transcribed by Hospital #1 revealed a telephone call was placed by L&D RN #1 to the PPC #1 on 11/20/2020 at 7:20 PM. L&D RN #1 stated, " ... the patient [Patient #1] has [Named Insurance] so she needs to go to [Hospital #2]...needs to go to [Hospital #2] if they have a NICU ...".

At 8:06 PM L&D RN #1 documented the CNM was on the telephone speaking with Physician #2 at Hospital #2. (In an interview on 12/14/2020 with Physician #2, Physician #2 stated he was not on a call with the CNM).

At 8:22 PM L&D RN #1 documented, "...CNM speaking with MD [medical doctor] at [Hospital #2]..." There was no documentation of who the MD was the CNM was talking to during this call.

There was no recordings of communications between the CNM and the Physicians provided to the surveyors.

At 8:40 PM the CNM documented, "...patient [Patient #1] presented with complaints of contractions that began at 1600 [4:00 PM] today. Patient was released from L&D [Hospital #4] in [City #3] on 11/28 status post Magnesium IV [Intravenous] for pre-term labor...Patient is resting well with mild irregular UCs [Uterine Contractions] status post 2 [two] doses of subcutaneous terbutaline. Plan of care discussed with [Physician #1]. Report given to [Physician #3] at [Hospital #2] with transfer accepted by him. [Physician #3] does not want Magnesium IV drip started prior to transport. Plan of care discussed with patient and her mother ...Plan to transfer to [Hospital #2] for higher level of care...". There was no documentation Physician #3 was affiliated with or practiced at Hospital #2. There was no documentation Hospital #2 had a higher level of care.

At 8:51 PM L&D RN #1 documented, "...Report called to [Girl's name #1], charge nurse [at Hospital #2]..." There was no documentation of an employee named Girl's name #1 at Hospital #2.

At 9:35 PM L&D RN #1 documented, "...Patient discharged in stable condition via ambulance to [Hospital #2]..."

Review of the Patient Condition and Certification for Transfer form dated 11/30/2020 revealed Patient #1 was pregnant with contractions. The form revealed the "Reason for Transfer" was a "NICU" to provide care for the babies upon birth. The form revealed the benefits of transfer were "higher level of care...specialized services/specialist...NICU..." The Destination Hospital was Hospital #2. There was no documentation Hospital #2 had a NICU or capabilities to provide care for babies born prematurely.

Review of the Emergency Medical Services (EMS) "Patient Care Report" for Patient #1 dated 11/30/2020 revealed the ambulance left Hospital #1 at 9:42 PM with Patient #1 and arrived at Hospital #2 at 10:32 PM. The medical Necessity for transport was listed as NICU for Pre-term Labor.

EMS Paramedic #1 documented, "...patient [Patient #1] is 31 weeks gestation with twins...Patient accepted by [Physician #3] at [Hospital #2] labor and delivery department. Patient needing facility with NICU, which is not available at sending facility...Assessment during transport, patient became anxious and feeling like she needed to push during transport. EMS upgraded to lights and sirens at approximately 10:21 PM. Patient complaining of back hurting, anxious, needing to push. Very restless. Stated she feels like she is having contractions. On arrival [Hospital #2] was directed to L&D [labor and delivery] floor by ER staff. Directed to room by LD staff. Patient moved to hospital bed on her own. Report given to staff. EMS left patient in bed with staff at bedside. While obtaining signatures it was discovered by [Hospital #2] staff that this patient was to have been transported to [Hospital #3], that they don't have NICU or accepting doctor at their facility. EMS advised staff all paperwork had [Hospital #2] as receiving facility. EMS had conversation with nursing supervisor in parking lot after patient had been delivered to L&D and signed for. Was explained to her that EMS can't just load her [Patient #1] back up and take her to [Hospital #3] due to being in [State #2] we are licensed for [State #1]...". EMS stated they can transfer across the State line, however they can not transfer from hospital to hospital in a State they are not licensed in.

At 10:45 PM a L&D RN at Hospital #2 documented, "Moaning heard in the back hallway of labor and delivery. RN to hallway to find patient [Patient #1] on stretcher with 2 EMS [Emergency Medical Services] workers...escorted pt. [Patient #1] and EMS personnel to room...patient was moaning, stating 'I need to push.' RN asked EMS where they were from because no one from here was aware that we were receiving a transport... EMS states [Hospital #1]. RN asked how far along the patient was and he [EMS] replied '31 weeks pregnant, with twins.' RN states at this time 'are you sure she [Patient #1] is supposed to come here because we don't have a NICU [Neonatal Intensive Care Unit]?'... He [EMS] states 'we don't either and that's why they transported her here'. Pt [Patient #1] states at this time 'y'all don't have a NICU either? I need a NICU.' EMS states 'the patient was fine until the last 20 minutes or so' as he and RN assisted pt to bed. RN states that this patient was probably supposed to go to [Hospital #3] and EMS worker states 'the paperwork I have says [Hospital #2].' RN looked at paperwork and sees [Physician #3's] name as the accepting physician and informs them that he [Physician #3] does not practice here [at Hospital #2] ..."

At 10:50 PM the L&D RN at Hospital #2 documented, "...Pt [Patient #1] states that she is having contractions approximately every 2 minutes and has been having them all day...Pt states that she lost her mucous plug today. Pt states that this is a twin gestation at around 31 weeks and states that the fetuses were in breech position [bottom or feet first position] with last ultrasound. Pt states she is having constant lower back pain...RN called [Physician #2] to notify him of situation and that patient [Patient #1] is present in our OB [Obstetrics] dept. [department] [Physician #2] states that the patient was supposed to be sent to [Hospital #3], not [Hospital #2]... RN informs him [EMS] that the patient wasn't supposed to be transferred here, that [Hospital #3] is expecting her. He says that report was called to [Girl's name #1] RN, informed him that we don't have a [Girl's name #1] that works here...he brought them off at the wrong hospital ..."

At 11:10 PM an L&D RN at Hospital #2 documented, "... Physician states to admit pt, monitor for contractions and twins. He is on his way to evaluate the patient and arrange for transfer to [Hospital #3] ..."

Review of the Physician assessment of Patient #1 revealed the Chief Complaint to be Pre-term Labor and, "24-year-old at 31 weeks gestation, reportedly to be twins". The Physician documented the patient was initially seen at Hospital #1 and had been accepted at Hospital #3 by Physician #3. The Physician documented the patient was being monitored and the fetal heart tones had some variability and Patient #1 was experiencing a, "...short cervix with funneling; Reported pre-term contractions..."

The Physician explained to Patient #1 that Hospital #2 was not equipped to care for pre-term twin babies. The Physician explained the plan to transfer Patient #1 to Hospital #3 as was originally intended. The Physician documented the patient was stable for transport to Hospital #3 and to the care of Physician #3.

Review of Hospital #2's "Acute Care Transfer Form" revealed Patient #1 was transferred to Hospital #3 and into the care of Physician #3 with the "Principle Potential Benefits of transfer" to be "NICU " and the "Principle Potential Risks of Transfer" to be "Death/prematurity."

Review of Hospital #3's medical record for Patient #1 revealed the patient arrived at Hospital #3 via ambulance on 12/1/2020 at 12:46 AM.

The Physician's H&P dated 12/1/2020 revealed, " ...Patient #1 is a 24-year-old with a reported gestational age of 31 weeks-4 weeks gestation...[Patient #1] was accepted several hours ago, however, due to unknown reasons, she was initially taken to [Hospital #2] across town. After being assessed for stability there, arrangement was then made for her to be transported here. Allegedly, records arrived with her at the initial hospital [Hospital #2], but they were not sent to this hospital ...Currently presenting with irregular contractions. She reports these to be severe in nature ...Prenatal care has been with a doctor in [another city]. It has been complicated by Twin gestation ..."

On 12/2/2020 at 9:42 PM the Physician documented, ''Patient noted to be 4 to 5 cm and in labor. Decision made to proceed with Cesarean section. Patient #1 delivered twins via Cesarean section on 12/2/2020 at 10:05 PM.
Baby A and Baby B were sent to NICU upon delivery and placed on Continuous Positive Airway Pressure (CPAP). (A CPAP is a breathing machine that forces oxygen into the lungs).

As of 12/15/2020 both Baby A and Baby B remains in the NICU at Hospital #3.

Patient #1 was discharged home on 12/5/2020.

4. In an interview on 12/8/2020 at 3:00 PM, the CNM stated she had assessed Patient #1 in the Labor and Delivery Unit at Hospital #1. The CNM stated, "...after assessing the patient and discussing the case with [Physician #1] it was decided she [Patient #1] would be transferred because of cervical shortening..."
The CNM stated, "...the first person I talked to was [Physician #2] at [Hospital #2]. We were connected with the call center. The transfer call center stated they were Baptist. Now I don't know which center I was speaking to...When I talked to [Physician #2] on the phone, I thought they [call center] said from [Hospital #2]. He [Physician #2] accepted the patient..."
The CNM stated after she had left Hospital #1 she had received a telephone call from the L&D RN #1 nurse at Hospital #1 to call Physician #3.
The CNM stated, "...when I returned the call to [Physician #3] he was very upset and stated the patient had been sent to the incorrect facility. He mentioned EMTALA and patient dumping law. I didn't know there were two hospitals in [there]..."
The CNM stated Patient #1 was stable at the time of transfer and was transferred so there would be a NICU available if needed at delivery.
The CNM verified she had not reported the need for a NICU on the telephone call with [Physician #2]. She stated, "...I wouldn't have because she [Patient #1] was still pregnant. I think I said higher level of care. I don't remember mentioning a NICU... "

In a telephone interview on 12/9/2020 at 11:25 AM, Physician #1 stated the only thing he remembered about the Patient #1 was that the CNM called and said the patient was having contractions and asked if it was okay to transfer. Physician #1 stated he agreed to the transfer. He stated Patient #1 needed to be sent to a hospital with a NICU. Physician #1 verified he had not seen the patient in the hospital but felt like she was stable, and treatment had been done based on assessment by the CNM.

In an interview on 12/9/2020 at 1:10 PM, the Risk Manager at Hospital #1 verified the Patient Condition and Certification for Transfer dated 11/30/2020 for Patient #1 was incorrect. The Risk Manager stated the destination hospital and accepting physician was incorrect.

In a telephone interview on 12/14/2020 at 11:10 AM Physician #2 stated, "... the patient [Patient #1] was supposed to be transferred to [Hospital #3]. Physician #2 stated the placement patient center at [Hospital # 3] arranged for transport..."
Physician #2 stated, "... I told the nurse midwife at [Hospital #1] that I was not on call and that [Hospital #3] will call you, they called her and arranged everything. [Physician #3] who worked for [Hospital #3] accepted the patient. [Hospital #3] not [Hospital #2]..."
Physician #2 stated he had not accepted Patient #1 to Hospital #2. He stated, "...It's illogical what they did...we told the ambulance sent to wrong hospital. They refused to take her to [Hospital #3]..."
Physician #2 verified an MSE was completed at Hospital #2 upon arrival. He stated the patient was transferred in stable condition to Hospital #3 that night. He stated the patient delivered the next day.

An attempt was made twice to contact Physician #3 via telephone. The physician has not returned the telephone call as of this writing.