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Based on record review and interview, the hospital failed to ensure an appropriate screening medical examination was provided within the capacity of the emergency department. The deficient practice is evidenced by failure to provide continued monitoring according to the individual's needs in 1(#20) of 1 reviewed record of a woman with a term pregnancy presenting with complaints of labor.

Findings:

Review of the hospital policy "Treatment and Transfer of Individuals Requesting/ In Need of Emergency Medical Services," reviewed July 26, 2023, revealed in part, "For pregnant women, the MSE (medical screening examination) should include an ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal station and position, cervical dilatation and status of the membranes (i.e., intact, ruptured, leaking)."

Review of the medical record for Patient #20 revealed she was a Gravida 3 Para 2 with a term pregnancy who presented to the emergency department at Our Lady Of The Lake Regional Medical Center (OLOLRMC) on 10/09/2023 at 2:13 a.m. with complaints of contractions that began approximately 20 minutes prior to presentation. The patient experienced spontaneous rupture of membranes upon arrival to the hospital. In the attending note by S4MD documented on 10/09/2023 at 2:44 a.m., Patient #20 was noted to be contracting every two to three minutes, the baby was noted to be vertex presentation via ultrasound, and fetal heart tones were noted to be in the 120 - 130 beats per minute. S4MD documented the patient's cervical dilatation changed from 0 to 5 centimeters in approximately 30 minutes. Fetal heat tones were documented at 128 beats per minute at 2:50 a.m., "present" fetal heart tones at 3:02 a.m., 125 beats per minute at 3:26 a.m.

Hospital "B" was contacted and accepted the transfer of the patient for obstetrical care which was not a provided service at Our Lady of the Lake Regional Medical Center (OLOLRMC). The transfer time was documented as 10/09/2023 at 3:36 a.m.

Review of the medical records from Hospital "B" revealed Patient #20 delivered a female infant weighing 2899 grams on 10/09/2023 at 3:38 a.m. (2 minutes after being transferred from Hospital "A") in the ambulance prior to arrival. Patient #20 arrived at Hospital "B" at 3:45 a.m. where the cord was clamped and cut and the placenta delivered at 3:50 a.m.

In interview on 10/17/2023 at 10:50 a.m., S4MD stated she did two vaginal examinations on Patient #20. S4MD stated she examined the patient for cervical dilatation shortly after her membranes ruptured in triage and the cervix was noted to be closed. S4MD verified she checked for cervical dilatation again approximately 30 minutes later and the cervix was 5 centimeters dilated. S4MD verified she did not repeat the cervical examination for dilatation prior to transfer 50 minutes later.

Based on record review and interview, the hospital failed to ensure a patient with an emergency medical condition was stable prior to transport as required by the Emergency Medical Treatment and Labor Act (EMTALA). The deficient practice is evidenced by 1 (#20) of 1 pregnant patient in labor delivering the baby during the transport.

Findings:

Review of the policy "Treatment and Transfer of Individuals Requesting/ In Need of Emergency Services," last reviewed July 6, 2023, revealed in part, " Patient condition will be stabilized to the point that within reasonable medical probability, no material deterioration will occur during or as the result of transfer. In the case of a woman in labor, this standard applies to the unborn child, and it will be determined whether, within reasonable medical probability, there is adequate time to affect a transfer before delivery."

Review of the medical record for Patient #20 revealed she was a Gravida 3 Para 2 with a term pregnancy who presented to the emergency department at Our Lady Of The Lake Regional Medical Center (OLOLRMC) on 10/09/2023 at 2:13 a.m. with complaints of contractions that began approximately 20 minutes prior to presentation. The patient experienced spontaneous rupture of membranes upon arrival to the hospital. Patient #20 was noted to be contracting every two to three minutes and the baby was noted to be vertex presentation via ultrasound. An examination for cervical dilitation was performed at 2:44 a.m. and the cervix was documented as 5 centimeters dilated. Hospital "B" was contacted and accepted the transfer of the patient for obstetrical care which was not a provided service at Our Lady Of The Lake Regional Medical Center (OLOLRMC). The transfer time was documented as 10/09/2023 at 3:36 a.m.

In interview on 10/17/2023 at 10:50 a.m., S4MD stated she did two vaginal examinations on Patient #20 and thought Patient #20 would not deliver in route. S4MD stated she examined the patient for cervical dilatation shortly after her membranes ruptured in triage and the cervix was noted to be closed. S4MD verified she checked for cervical dilatation again approximately 30 minutes later and the cervix was 5 centimeters dilated. She then began calling Hospital "B" for possible transfer. S4MD verified she did not repeat the cervical examination for dilatation prior to transfer 50 minutes later.

Review of the medical records from Hospital "B" revealed Patient #20 delivered a female infant weighing 2899 grams on 10/09/2023 at 3:38 a.m. (2 minutes after being transferred from Hospital "A") in the ambulance prior to arrival. Patient #20 arrived at Hospital "B" at 3:45 a.m. where the cord was clamped and cut and the placenta delivered at 3:50 a.m.

In the self-report of the incident to Louisiana Department of Health, OLOLRMC determined the transfer was inappropriate.

Review of the document "Regulatory Management ECU EMTALA Update October 2023," presented as the education provided to the emergency department nursing staff, revealed information defining the scope of EMTALA, the definition of a medical screening exam, the definition of an emergency medical condition, sections titled "Stabilizing Treatment" and "Appropriate Transfer," and 12 scenarios based on EMTALA violations. Further review of the sections titled "Stabilizing Treatment" and "Appropriate Transfer" revealed no information related to patients who present in labor and how it relates to EMTALA. Review of the provided scenarios revealed only one scenario related to a patient in labor who left the emergency department by private vehicle because she was told by the nurse "that the hospital did not have and obstetrician on-site, and that the patient could either start treatment in the ED and be transferred later, or that her make companion could drive her immediately to another hospital, where her obstetrician practiced." The document did not have any information to educate the nursing staff about the specific EMTALA violation that occurred at their facility.

In interview on 10/17/2023 at 12:50 p.m., S2RM verified the transfer was inappropriate. S2RM verified the document "Regulatory Management ECU EMTALA Update October 2023," was the only education provided to nursing staff since the incident and the education had been sent to emergency department nursing staff the week the violation occurred. S2RM verified the planned education for the emergency department providers was not complete, but would be completed by November 22, 2023. S2RM verified the emergency department medical director had spoken with S4MD about the incident.