HospitalInspections.org

Based on document review and staff interview, the Acute Care Hospital administrative staff failed to enforce the hospital's EMTALA policy to ensure the ED staff provided an appropriate medical screening examination for 1 of 30 sampled patients who presented to the hospital for emergency care from April 2016 through October 2016. The hospital administrative staff identified 626 patients per month who presented to the hospital seeking emergency medical care.

The failure to ensure the ED staff provided an appropriate medical screening examination within its capabilities and capacity resulted in Patient #8 potentially delivering twin babies in the back of an ambulance, which lacked the necessary supplies and personnel to safely deliver twin babies.

Findings included:

1. Review of the document titled "EMTALA: Medical Screening and Stabilizing Treatment," last revised 06/2016, revealed the following in part, "Any person who comes to the Hospital's dedicated emergency department ... or who a prudent layperson would believe, on the basis of the individual's appearance or behavior, requires examination or treatment for a medical condition, will be provided an appropriate medical screening examination within the capabilities of the dedicated emergency department..."

2. During an interview on 10/19/16 at 2:15 PM, Registered Nurse (RN) A stated that Patient #8 called into the ED, told RN A that she was in the hospital's parking lot, and in active labor.

3. During an interview on 10/19/16 at 1:30 PM, House Supervisor B, stated that she was the most senior administrative person on duty when Patient #8 presented to the hospital. House Supervisor B acknowledged that normally if a pregnant patient arrived at the hospital, the staff would take the patient inside to the ED and have the ED physician examine the patient prior to transferring a pregnant patient to another hospital. House Supervisor B acknowledged the hospital staff only asked Patient #8 questions about her pregnancy. The hospital ED staff did not provide Patient # 8 with an examination to determine whether transfer to another hospital placed her health and safety and that of her unborn child in jeopardy, or determine whether there would be adequate time to safely transport patient # 8 before delivering her babies at another hospital located 15 miles away with roads possibly flooded.

Please refer to A-2406 for additional information concerning the hospital's failure to provide patient # 8 with a medical screening examination.

Based on document review and staff interviews, the Acute Care Hospital staff failed to ensure Patient #8 received a medical screening examination. The investigation involved review of Emergency Department (ED) medical records for 30 sampled patients who presented to the ED seeking care from April 2016 through October 2016. The hospital's administrative staff identified an average of 626 patients each month who presented to the ED requesting emergency medical care and the hospital staff transferred an average of 21 patients per month to another facility.

Failure to provide Patient #8 with a medical screening examination and determine whether there would be adequate time to safely transport to another hospital posed a significant risk to the patient's health and safety and that of her unborn babies (patient # 8 did not know she was pregnant with twins). This failure potentially could result in Patient #8 delivering her babies in an ambulance, which lacked the equipment and personnel to handle twin births or complications during the birthing process.

Findings included:

1. Review of the document titled "EMTALA: Medical Screening and Stabilizing Treatment," last revised 06/2016, revealed the following in part, "Any person who comes to the Hospital's dedicated emergency department ... or who a prudent layperson would believe, on the basis of the individual's appearance or behavior, requires examination or treatment for a medical condition, will be provided an appropriate medical screening examination within the capabilities of the dedicated emergency department..."

2. During an interview on 10/19/16 at 2:15 PM, Registered Nurse (RN) A stated that Patient #8 called into the ED, told RN A that she was in the hospital's parking lot, and in active labor. RN A stated she ran to the parking lot and found Patient #8 sitting in her car. Patient #8 told RN A that she was in labor, she had three prior pregnancies, her water had not broken, and her contractions were 2 to 3 minutes apart.

RN A said that Patient #8 stated she was trying to go to Hospital A (15 miles away) but did not know if the roads had closed due to flooding. RN A said she asked Patient #8 if she wanted to receive an evaluation in the ED. RN A stated that Patient #8 declined and then she offered Patient #8 an ambulance to transport her to Hospital A. Patient #8 accepted the offer of an ambulance and RN A arranged for an ambulance to transfer Patient #8 to Hospital A. RN A stated she did not push Patient #8 to receive a medical screening examination or document that she had offered an examination but that patient # 8 refused.

3. During an interview on 10/19/16 at 1:30 PM, House Supervisor B, stated that she was the most senior administrative person on duty when Patient #8 presented to the hospital. House Supervisor B received notification by phone that Patient #8 was in the parking lot. When House Supervisor B arrived in the parking lot, RN A stated that Patient #8 did not want to receive care at Sartori. House Supervisor B acknowledged that normally if a pregnant patient arrived at the hospital, the staff would take the patient inside to the ED and have the ED physician examine the patient prior to transferring a pregnant patient to another hospital. House Supervisor B acknowledged the hospital staff did not provide Patient #8 with a medical screening examination to determine if Patient #8 could safely transfer to a hospital 15 miles away with roads possibly flooded.

4. During an interview on 10/19/16 at 12:10 PM, ED Physician C stated that s/he worked the day Patient #8 presented to Sartori. ED Physician C stated s/he had delivered 10 babies during residency and assisted with at least 30 more deliveries. ED Physician C stated s/he was comfortable examining Patient #8 and delivering her baby if needed. ED Physician C stated s/he did not go to the parking lot to examine Patient #8 or examine Patient #8 in the ambulance prior to the ambulance leaving the hospital's property. ED Physician C acknowledged s/he did not know if Patient #8 could safely make the 15 mile trip to Hospital A without delivering her baby in the ambulance. ED physician C stated that the ambulance staff would convince patient # 8 to come in and be seen if she needed to be seen.

5. During an interview on 10/19/16 at 4:20 PM, Health Unit Coordinator (HUC) D stated the ED had the supplies to handle delivering babies. HUC D stated s/he started getting an ED room ready for Patient #8 and gathering the supplies needed to deliver babies. HUC D stopped gathering the supplies when s/he was told that Patient #8 was going to transfer to Hospital A.

6. Review of Patient #8's emergency medical services (EMS) medical record revealed the patient was on her way to Hospital A and "when the pain began to get too severe, she pulled into the Sartori parking lot" and called the ED. Further documentation showed the patient rated her pain a 10 out of 10 (most severe pain) and that the ambulance left Sartori Medical Center at 10:04 PM on 9/23/16 and arrived at Hospital A at 10:21 PM on 9/23/16.

7. During an interview on 10/19/16 at 4:50 PM, Paramedic F stated the ambulance only had one set of the supplies needed to deliver a baby. The ambulance lacked sufficient supplies to deliver more than one baby. Additionally, Paramedic F stated they lacked the capabilities in the ambulance to handle complications with a delivery. Paramedic F stated that Patient # 8 was driving to Hospital A but decided to pull into the parking lot at Sartori because of a very painful contraction. "She was having a contraction every two to three minutes." "This was her fourth pregnancy." Paramedic F stated that "After the fact, I discovered [name of patient # 8] had twins and she did not get any prenatal care."

8. Review of Patient #8's medical record from Hospital A revealed Patient #8 did not know she was pregnant with twins and that she delivered her first baby 30 minutes after arriving at Hospital A and her second baby 5 minutes after the first.

9. During an interview on 10/20/16 at 2:10 PM, RN E stated s/he worked at Hospital A. When the EMS crew gave report on Patient #8, the EMS staff told RN E the EMS staff felt they could safely travel to Hospital A, but did not know if they could return to Cedar Falls (the city where Sartori Memorial Hospital was located) in the case of an emergency during the transfer.