HospitalInspections.org

Based on facility policy review, hospital document review, medical record review, and interview, the hospital failed to ensure the hospital's emergency department was integrated with other departments in order to provide to the fullest extent possible all resources necessary to provide emergency medical care to all patients with emergency medical conditions. The hospital failed to ensure its ED Physicians performed a medical screening on all patients who required emergency medical services (EMS) transfer to the hospital's ED for a second ED visit in order to determine if an emergency medical condition existed and provide stabilization and treatment.

The failure of the hospital to ensure its ED services were integrated and organized resulted in a SERIOUS AND IMMEDIATE THREAT to Patient #19 who was diverted from the hospital's ED and partially delivered a baby breech during the EMS transport to another hospital, resulting in the baby being brain dead and subsequently expired on 9/1/2020. The hospital's failure places all patients seeking a medical screening examination for a potential emergency medical condition at risk for SERIOUS AND IMMEDIATE THREAT of injury and or death..

The findings included:

1. The facility failed to have a system in place to ensure all departments of the hospital were integrated and organized with the hospital's ED services in order to ensure all patients seeking a medical screening examination received the examination within the hospital's capability in order to determine if an emergency medical condition existed.

Refer to 1103.

.

Based on review of the hospital's medical Staff By-laws, policy review, medical record review, document review, and interview, the hospital failed to ensure it provided the necessary emergency care and services within the hospital's capabilities and ensure all patients seeking a medical screening examination (MSE) received the examination in order to determine if an emergency medical condition existed which could adversely affect the health and safety of patients who required emergency care for 1 of 1 (Patient #19) Obstetrical (OB) patients who emergency medical services (EMS) was seeking emergency medical care for a premature breech birth.

The findings included:

Review of the Medical Staff Rules and Regulations which were Board approved on January 23, 2018 revealed, in part, "...On-Call Coverage Definition, Emergency Condition 1. An emergency condition is a medical condition manifesting acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the patient in serious jeopardy, or to result in impairment of body functions. An emergency condition shall include a pregnant woman who is having contractions when there is inadequate time to affect a safe transfer before delivery or when a transfer may pose a threat to the health or safety of the woman or unborn child..."

Review of the "Utilization of Labor and Delivery Services for ED Patient" policy revealed, "... patients with a life threatening condition or who are medically unstable (in association with or independent of their pregnancy) will remain in the Emergency Department (ED) to receive a Medical Screening Exam (MSE) by the ED Physician or Licensed Independent Practitioner (LIP) and the Labor and Delivery department will be notified for patients 20 weeks gestation or greater, the perinatal Registered Nurse (RN) will come to the ED, the perinatal RN will place the patient on a fetal monitor, and perform a vaginal examination as needed, the perinatal RN will remain with the patient until the OB (Obstetric) condition is stabilized The ED MD will consult the OB MD on call for a consult..."

Medical record review for Patient #19 revealed an admission date of 8/23/2020 at 1:51 AM to Hospital #1's [Baptist Tipton] ED. The patient's chief complaint was abdominal pain and vaginal bleeding at 32 weeks gestation (pregnancy). This was the patient's third pregnancy, with no complications from the first two.

Nurse #2 initiated triage at 1:58 AM and documented Patient #18 had a prenatal checkup on Friday 8/21/2020 and was told she was 2 centimeters dilated and not progressing. The Nurse documented the patient's last ultrasound showed the baby was in a breech position (breech position is when a baby is bottom first in instead of head first - head first is the normal position).

At 2:04 AM, Labor and Delivery (L&D) Registered Nurse (RN) #4 performed a MSE, and placed a fetal monitor on Patient #19. The fetal monitor showed the baby's heart rate at 140 beats per minute throughout monitoring (normal fetal heart rate at 32 weeks is 120 - 160 beats per minute).

A vaginal exam was performed on Patient #19 by L&D Nurse #4. The nurse documented there was a small smear of pink blood, dilation of two, effacement 50 (effacement means the women's body is getting ready for delivery of the baby - measured on a scale of 0 - 100 with 100 meaning the women is fully ready). The nurse documented no contractions were noted.

ED Physician #1 performed a partial MSE on Patient #19 on 8/23/2020 at 2:37 AM. The ED Physician did not assess the patient's OB needs, perform a vaginal examination or asses the baby.

Review of Patient #19's discharge summary dated 8/23/2020 revealed Patient #19 was discharged home by ED Physician #1 at 3:50 AM. ED Physician #1 documented Patient #19 was ambulatory and stable at the time of discharge.

Review of the EMS 'Patient Care Report' dated 8/23/2020 for Pt #19 revealed on 8/23/2020 at 4:58 AM (1 hour and 8 minutes after being discharged from the Hospital), EMS was dispatched to the residence of Patient #19 with a 911 [emergency] call for a 32 week gestation (pregnant) female with active contractions and the umbilical cord [connects the fetus to the mother and carries nourishment to the fetus] protruding out.
EMS was enroute at 4:59 AM. The ambulance arrived on the scene at 5:07 AM and was at the patient's bedside at 5:08 AM.

Emergency Medical Technician/Paramedic (EMT/Paramedic) #1 documented, "...upon arrival patient supine [lying on the back with face upward] in bed inside residence alert and oriented. patient states she was seen at [Hospital #1] Labor and delivery department and was discharged with a diagnosis of Braxton Hicks contractions [Braxton Hicks are sporadic uterine contractions also called false labor] ...patient is in active labor with contractions about 2 minutes apart and patient has umbilical cord presentation..."

The EMT/Paramedic documented at 5:11 AM he contacted Hospital #1 via his cell phone due to it being the closest hospital and informed Hospital #1 of EMS' intent to transport Patient #19 to them due to the baby's umbilical cord presentation.

The EMT/Paramedic documented, "...The ED physician [ED Physician #1 at Hospital #1] stated, "do not bring that patient here we do not have OB tonight and bringing her here could cause her and or the baby more harm"..." The EMT/Paramedic diverted to Hospital #2 per ED Physician #1's orders (per Google map, the distance from Patient
#19's home to Hospital #1 is 5.5 miles and from Patient #19's home to Hospital #2 it is 35 miles).

At 5:32 AM the ambulance was enroute to hospital #2. The EMT/Paramedic documented, "...there is presently approximately 4 inches of umbilical cord present and is pulsating...the umbilical cord continued to pulsate until 5:40 AM, when there was a presentation of baby's foot, at which point patient was actively encouraged to push the baby out, this continued until EMS arrived at Hospital #2. Patient was only able to deliver the lower half of the baby, legs pelvis and partial torso presented. At 5:50 AM umbilical cord stopped pulsating and there was no capillary refill noted to baby's torso. Attempts were made to reposition baby to encourage delivery and reestablish cord circulation with no success during remaining transport..."

At 5:56 AM the ambulance arrived at Hospital #2; 45 minutes after notifying Hospital #1 of the need for emergent transport to them.

Review of Hospital #2's OB delivery procedure for Patient #19 revealed the date and time of birth of Patient #19's baby was 8/23/2020 at 5:57 AM, "with breech presentation and pre term delivery...infant in breech presentation... The infant was supported around the hips... delivered gently until the arms were in view. The right forearm was swept across the chest and delivered infant was rotated and left forearm was swept across the chest and delivered. Neck appeared at the introitus [vaginal opening] and head was flexed by placing two fingers over the maxima. The head was then delivered. Cord clamp and cut an infant immediately handed off the waiting NICU [Neonatal Intensive Care] team".

Review of the progress notes dated 8/23/2020 at 7:13 AM from Hospital #2 revealed the Neonatal Nurse Practitioner [NNP] documented, "...peds [pediatric] call to evaluation [eval] for 32 week delivery. Per L&D report mother brought in by ambulance with reported entrapment for unknown duration. Infant was delivered breech upon arrival to ED...Per L&D [baby's] Heart Rate [HR] was less than 60 and PPV [positive pressure ventilation] and CC [chest compressions] were initiated [Positive Pressure Ventilations (PPV) means giving the baby full breaths assisting with respirations. Chest compressions (CC) means maintaining blood flow to the baby's vital organs and to restore normal heart function after cardiac arrest]...
Peds arrived at approximately 2 minutes of life. No heart rate detected, infant was limp with no spontaneous movement or respiratory effort, infant was intubated by approximately 4 minutes of life, no color change detected initially, BBS [bilateral breath sounds] equal.
After one to two minutes color change detected. PPV and chest compressions were continued. 0.5 cc Epi [Epinephrine given to start the heart beating] given via ETT [endotracheal tube is a tube that was inserted into the baby's respiratory system for the primary purpose of establishing and maintaining the baby's airway and to ensure the adequate exchange of oxygen and used to administer,life-saving medications]
At 6 minutes of life, no response. Repeat dose given via ETT at 8 minutes of life, no response. Chest compressions and PPV via ETT continued ...UVC [Umbilical Venous Catheter] was placed [in the baby] for emergent access [of medications] at approximately 9 minutes of life.
At 10 minutes [of life] 10 cc [cubic centimeters] Normal Saline bolus given via UVC. HR remained undetectable.
A 0.3 cc Epi dose given UVC at 11 minutes.
At 13 minutes of life a HR [heart rate] of 45 was detected.
At 14 minutes a repeat dose 10 cc NS bolus was given via UVC. Heart rate remained approximately 60 beats per minute. Chest compressions were continued. Another 0.3 cc dose of EPI given UVC.
At 16 minutes, HR 80. Chest compressions discontinued.
At 17 minutes HR greater than 100. Infant remained limp, non- responsive with no spontaneous effort. No detectable sats [oxygen saturation - measures the amount of oxygen in the blood] during resuscitation. Infant was placed in transporter, continued PPV via bag. Unable to update mother at this time".

Review of hospital #2's history and physical and progress report dated 8/23/2020 at 3:55 PM revealed the physician documented,"... pre term [normal term is 40 weeks] 32 week HEA [measurement of fetus] by early US [ultrasound], with prolapse cord at home 1.5 hour prior delivery, partially breech delivery in ambulance on the way to the hospital and needed aggressive rescue with PPV/ intubation/CC/Epi/ Saline bolus. Seizures and 1st hour of life indicating possible severe HIE [Hypoxic Ischemic Encephalopathy - means brain dysfunction that occurs when the brain doesn't get enough oxygen for a period of time]...condition critical, prognosis guarded...on seizure meds, SIMV [ventilation to supply oxygen to the baby who wasn't breathing on her own], abx,[antibiotics] IVF [intravenous fluids], neurology consulted...Infant required intubation shortly after delivery d/t [due to] respiratory depression...Neurological: Extensive resuscitation required after delivery: Intubation, chest compressions...",

The baby's Apgar scores were documented as follows (an Apgar Score is given to newborns and stands for Appearance (skin color), Pulse (heart rate), Grimace (Reflexes), Activity (muscle tone) and Respiration (breathing rate and effort). The higher the score on a scale of 1-10 the better the baby is doing at birth. A score of 7, 8, and 9 are normal and a sign the baby is in good health):

At 1 minute (min) = 1,

At 5 min = 0,

At 10 min = 0,

At 15 min = 3

At 20 min =4.

Review of the Magnetic Resonance Imaging (MRI) of the brain for Patient #19's newborn baby dated 8/28/2020 revealed extensive changes in intracranial hemorrhage Stage 3 [bleeding in the brain - Stage 3 and 4 are most severe] with extension into the lateral ventricles associated with periventricular leukomalacia (PVL) [PVL - parts of the brain are dead - brain injury to the white matter in the brain resulting in seizures and cerebral palsy]. .

Review of the progress notes dated 8/28/2020 at 2:58 PM revealed Physician #2 at Hospital #2 documented the MRI findings were discussed the newborn baby's family. The Physician documented, " ...Clinical status of the child included fixed dilated pupils, no spontaneous respiratory effort..." The Physician advised the poor quality of life for the newborn baby and asked the family to decide if they wanted to proceed with life supporting efforts for the newborn baby. The newborn baby's family asked for time with the newborn before making a decision.

Review of Hospital #2' progress notes dated 9/1/2020 for Patient #19 and her newborn baby revealed the physician documented , " ...Parents opted to proceed with withdrawal of care around approximately 1800 [6:00 PM]. At 1825...UAC was pulled [discontinued], PIV pulled around this time as well ETT pulled and mechanical ventilation discontinued approximately 1910. Parents held infant in their arms throughout the process. Shortly after extubation [discontinuance], I [Physician #2] auscultated but slow HR still present. At approximately 1948, I [Physician #2] presented to bedside again, auscultated for 1 minute with no heart rate. Infant time of death called at approximately 1950 [7:50 PM]. Autopsy declined..."

In an interview on 8/26/2020 at 9:34 AM, Hospital #1's ED/Intensive Care Unit (ICU) manager stated if the hospital does not have an OB on-call service available the ED physician will advise the ambulance to take the patient somewhere that provides those services. If the patient is over 20 weeks gestation and OB is on-call the patient would go upstairs to OB. If no OB on- call then they (patient) go to the ED to be treated by the ED physician who can treat OB patients. When asked if it was documented when patients are turned away or an ambulance is re- routed to another facility the ED/ICU manager stated it is not documented.

In a telephone interview on 8/26/2020 at 3:10 PM, Hospital #1's Nurse #1 stated they were working in the Emergency Department (ED) on 8/23/2020 when the call came in related to Patient #19. Nurse #1 stated, "... we have a radio where we hear traffic from 911 EMS and Fire for [county name] County. We heard the 911 dispatch call for a 32 week gestation female with protruding umbilical cord. [Named Ambulance] wanted to transfer patient here... The charge nurse looked at the schedule and saw that we didn't have OB/GYN [gynecology] coverage, which we don't always have. At that time, she called [name of the county] County 911 and told them to advise ambulance there was no OB/GYN coverage. We heard named [name of county] 911 dispatch tell the ambulance unit and they did acknowledge, however when the first responders got to the scene it was obvious more emergent, when the ambulance got there..."

Nurse #1 stated "...Our physician [ED Physician #1] was sitting right next to us in the ED and he said to us, "they do not bring the patient here" He [ED Physician #1] got upset. [EMT/Paramedic #1] called the ER [ED] via cell phone, not on MedCom so we didn't have a recording. He [EMT/Paramedic #1] attempted to give verbal report on the patient [Patient #19]. One of the nurses said they [the EMS with Patient #19] are coming here. [ED Physician #1] took the phone [from the ED nurse who was receiving report from the EMS] and told the paramedic, "there is no OB coverage here, do not bring the patient here, baby could die, it will be on you" . The doctor got off the phone and then we heard the medic on the radio call for a second ambulance and other paramedics to intercept them enroute for assistance. [Name of county] 911 #2 dispatched an ambulance but could not find them [the EMS who was transporting the Patient #19]. I guess they were enroute [to Hospital #2]. I believe [name] EMS #2 met them...I'm not sure of the outcome..."
When asked if ED Physician #1 was aware the EMT/Paramedic was talking about Patient #19 who had been in Hospital #1's ED a few hours earlier with bleeding and pain then discharged home, and Nurse #1 stated, "...Yes he was aware..."

Nurse #1 stated the patient lived in this city and this would have been the closest hospital.

Nurse #1 verified there was no recording of the conversation. Nurse #1 stated that more often than not, EMTs use their cell phones instead of MedCom to call report to the hospital, so there was not a recording.

In a telephone interview on 8/27/2020 at 11:55 AM, ED Physician #1 stated he recalled the patient [named Patient
#19] came in with abdominal cramping and bleeding. ED Physician #1 stated the patient was put on a Toco (tocodynamometer, a devise that is used to measure the duration, frequency and relative strength of uterine contractions in pregnant women) monitor, and there were no contractions, no active bleeding and the patient was not in labor. ED Physician #1 stated Patient #19 was seen by the L&D nurse and was discharged home in stable condition.

When asked about the 911 call from EMT/Paramedic #1 stating Patient #19 was in active labor with cord presentation, ED Physician #1 stated he didn't know EMT/Paramedic #1 was talking about Patient #19.
ED Physician #1 stated the call from EMS reported patient had presenting parts active labor. (Although according to Nurse #1, ED Physician #1 was listening to EMT/Paramedic #1's report being called in to the hospital's ED)

ED Physician #1 stated he told EMT/Paramedic the hospital did not have OB coverage and stated he "suggested" to the EMT/Paramedic that they take the patient to the nearest facility with OB coverage.

ED Physician #1 stated if Patient #19 had presented to the ED in active labor, the patient would have been stabilized. Physician #1 continued and stated, "this was an EMS call and not on the property 200 yards in".

ED Physician #1 verified Patient #19, "was active labor and presenting parts making her significantly at risk".

In a telephone interview on 8/28/2020 at 10:20 AM, EMT/Paramedic #1 stated the dispatch information he had received was Patient #19 was pre-term labor. EMT/Paramedic #1 stated, "...When we got there [Patient #19's home] the patient was in labor with cord presentation. She [Patient #19] told me she had been to [named Hospital
#1] earlier that morning. They [Hospital #1] told her she was having Braxton Hicks contractions and had discharged her. The cord presentation was a true emergency I told her. The first responders, was there and I had them go get the stretcher while I called the ER [ED]at [Hospital #1]. I told one of the nurses [ED nurses] the patient was in labor and with cord presentation. I was on my personal cell phone. The doctor got on the phone, [ED physician #1], said to me, 'do not bring her here no OB coverage, could be worse for mother, baby'. Not sure if that was the exact words but close. I pretty much hung up on him at that time. I mean it's hard to believe pre-term labor cord out is better driving down the road 30 miles away regardless whether they have OB there or not. During transport I was trying to get her not to push. The cord was still pulsating at this point and had good perfusion. The patient's blood pressure was high but not bad. I started a couple of IVs [intravenous]. At about 1/3 of the way, say 10 to 11 minutes into transport I got foot presentation. I told my partner to call for another ambulance for assist. I needed another set of hands in the back [in the back of the ambulance]. I did not hear his conversation because at this point the patient is pushing and at some point the cord stopped pulsating. The driver stated we would have to be stationary for another ambulance to intervene with us. I told him just to keep going. I tried to reposition the patient and cord but I never could feel cord pulsating after that. At this point both feet hips and part of the torso were out, everything else inside. I had MedCom on my speaker phone next to me. I heard Hospital #2 confirm breech presentation. When we got to Hospital #2, they took over. I told them I tried to take the patient to [name of Hospital #1] but the MD there had refused..."

In an interview on 9/1/2020 at 10:25 AM, Hospital #1's Chief Executive Officer (CEO) and Director of Quality and Risk Management stated there is one (1) OB provider that is employed by Hospital #1's group and is on active staff at Hospital #1. The CEO stated the OB practitioner is on-call 10 days a month taken in a ten (10) day consecutive block. The CEO stated when the OB provider was not on-call then the hospital has a contract with an OB Hospital Group for 15 days per month. The CEO stated in addition the hospital had partnered with OB Group
#2 to attempt to pick up unassigned shifts.

The CEO was asked how the hospital managed an OB emergency if there was no OB on-call, and the CEO stated if no one was on-call the emergency department physician would facilitate care for the OB patient, and the clinical nursing team from OB would come down from the OB Department to the ED and operate under the physician per hospital policy.