HospitalInspections.org

Based on observation, interview, and record review the hospital staff failed to implement the Emergency Medical Treatment and Labor Act (EMTALA) and related policies and procedures when it failed to:

1. Document the ongoing evaluation of vital signs for Patient 6 and Patient 8 while in the emergency department (ED).

2. Obtain a physician order to transfer Patient 2, Patient 3, and Patient 6 from the ED to another facility.

3. Check crash carts (portable cart that carries emergency medical equipment and medications to treat patients experiencing medical emergencies) every shift in the ED.

These facility failures had the potential to result in negative patient outcomes, jeopardizing the quality and safety of patient care.

Findings:

1. During a concurrent interview and record review on 9/24/24 at 3:14 pm with the EDD. EDD confirmed that Pt 6 and Pt 8 did not have their vital signs monitored every 2 hours per facility policy. Review of Pt 6's medical record indicated, Pt 6 was given an acuity level (measurement of the severity of a patient's illness or medical condition) of 2 in the ED. Pt 6's first set of vital signs were documented at 7:02 p.m. on 7/6/24, the next set of vital signs was documented at 2:30 a.m. on 7/7/24. Review of Pt 8's medical record indicated, Pt 8 was given an acuity level of 3 in the ED. Pt 8's first set of vital signs were documented at 7:35 p.m. on 7/25/24, thee next set of vital signs was documented at 10:19 p.m. on 7/25/24.

During a review of the facility's policy and procedure (P&P) titled, "Assessment/ Reassessment of Patients," dated 5/2021, the P&P indicated, "Reassessment is performed by the RN's and physicians based on the assessed acuity level...Level 2 Emergent VS every 30-60 mins until stable, then per admit level of care or every 2 hours as appropriate...Level 3 Urgent VS every 2 hours if stable, then per admit level of care or every 2 hours until discharge."

2. During a concurrent interview and record review on 9/20/24 at 2:50 p.m., with the Quality Director (QD) and the Regulatory Compliance Director (RCD), QD and RCD confirmed that a physician's order is required to transfer a patient per facility policy and procedure. Pt 2, Pt 3, and Pt 6 were transferred from the ED to another facility without a physician's order.

During a review of the facility's policy and procedure (P&P) titled, "EMTALA - Transfer Policy," dated 2/2016, the P&P indicated, "Any transfer of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual's behalf or by a physician order with the appropriate physician certification as required under EMTALA."

3. During a concurrent observation, interview, and record review on 9/20/24 from 10:43 a.m. until 10:49 a.m. with the EDD, EDD confirmed that review of facility form titled, "Crash Cart Control Sheet," dated September 2024 indicated, crash carts #8, #1, #39, and #30 were not checked every shift.

During a review of the facility's policy and procedure (P&P) titled, "Cardiopulmonary Emergency Protocol," dated 2/2024, the P&P indicated, "An external defibrillator is located on every crash cart...Every defibrillator is evaluated for operational readiness on a routine basis...For departments open 24/7, units will be checked once each shift...Both the External Paddle cable and the Defibrillator Pad/Test Load cables will be checked...Crash carts will be checked by the designated unit personnel at least once a shift...This check includes: lock integrity...The suction unit will be tested to ensure minimum vacuum of 40 mmHg...The oxygen tank will be checked to ensure a minimum volume of 1000 PSI..."



35399

Based on interview and record review, the recipient/receiving hospital [Hospital B] failed to report to the State agency or Center for Medicare/Medicaid services (CMS) that the hospital had received the transfer of Patient 19 (mother) and Patient 20 (newborn) into their labor and delivery (L&D) unit, via emergency medical service (EMS) ambulance from the sending hospital [Hospital A] emergency department (ED), without patients being provided with a medical screening examination (MSE), determine if patients had an emergency medical condition (EMC), and stabilized the patients before the patients were inappropriately transferred to Hospital B's L&D unit.

Hospital B's failure resulted in hospital violating the emergency medical treatment and labor act EMTALA requirements.

Findings:

A review of the document titled "Ventura County, American Medical Response (AMR) Electronic Patient Care Report", dated 6/1/24 at 8:04 and 36 seconds, indicated "E46 arrived at a single-family residence to find one female patient (Patient 19) in a hands and knees position with crowning present. Patient stated she was having contractions and started to bear down. Baby (Patient 20) was delivered with no complications. Both were transported with AMR initially to Hospital A, then diverted to Hospital B."

During an interview with Patient 19 on 9/25/24 at 4:45 p.m., patient reported that on 6/1/24 morning at around 8:11 am, she delivered her baby at home. Patient stated "I literally pushed when the paramedics were walking thru the door into my house, and they caught the baby. They were going back and forth whether they were going to take me to Hospital A or Hospital B. My first stop was at Hospital A. When we arrived at Hospital A, there were two nurses standing at the sidewalk and they were telling the paramedics that Hospital A does not have an L&D department. The paramedics said "Well, when I called you, you told me to bring her here." I heard them arguing back and forth between the nurses and the paramedics. The paramedics were pushing for me to be treated at Hospital A to deliver the placenta, stitch me up because I had a laceration and transfer me to Hospital B for further care. But the two nurses were telling the paramedics "No, you cannot bring her here, we do not have L&D, she cannot stay here." The paramedics finally decided to take me to Hospital B. Patient was asked if any Hospital A doctor came out to see her in the ambulance. Patient stated "No, there were only two nurses, no doctor standing at the sidewalk, where the ambulance parked." Patient was asked if she requested to come to Hospital B when she was at Hospital A's ED. Patient stated "No". Patient was asked if staff at Hospital B, L&D department asked her if she had been at Hospital A, first, before coming to Hospital B. Patient stated "No, no one asked but I would assume the paramedics told them. I think, I heard the paramedics telling them..."

Review of Hospital A's document titled "Emergency Department Reports, dated 6/8/24 at 12:15 p.m., indicated chief complaint: LATE ENTRY: brought in by BIB AMR s/p delivery approximately x 15 minutes...holding baby in arms...per paramedics' placenta not delivered, cord clamp not cut...

History (History of Present illness) we were contacted by paramedics regarding a live birth. Apparently, the patient is full term and had given birth at home. During a phone conversation with the paramedics, it was our recommendation that the patient be brought to this facility for evaluation, stabilization, and eventual transfer.

The paramedics had arrived shortly thereafter. In the ambulance she stated to the emergency medical technicians (EMT's) that she would prefer to be transferred to [Hospital B's name] with her child. I therefore had no direct contact with this patient at any time. I never spoke to her directly. She always remained in the ambulance...under the circumstances the paramedics were told to take the patient and child to Hospital B.

Hospital A's transfer document indicated, Transfer Disposition: Yes. Registered Nurse (RN) receiving report: LD Charge. Transported to: Hospital B's name LD. Date/Time of Transport: 6/1/24 at 08:36 PDT. Estimated time of arrival: 6/1/24 at 08:56 PDT. Reason for transfer: Higher level of care.

Hospital A's document titled "Working View Sections", in the Textual Results part of the document indicated "6/1/24 08:34 PDT (Clinical Note ED) LATE ENTRY: spoke to LD RN @ Hospital B's name and made aware of patient coming with ETA 20 minutes. 6/1/24 08:34 PDT (Clinical Note ED) LATE ENTRY: notified Hospital B's name ER charge regarding incoming LD patient."

Hospital A base station to Hospital B base call transcript: "8:39 a.m., nine seconds. June 1, 2024. Robles 239. Hi Robles, this is Simi base. Alright. We have 433 is coming to you with about a 15-minute ETA. They have mom who was 40 weeks pregnant. Who delivered in the field. Baby and Mom are both stable and doing well. They delivered approximately 15 minutes ago. I don't have any vital signs. I know mom has access. Think that's it. OK, OK. Bye. Bye."

Review of Hospital B's medical records for Patient 19 and Patient 20 was conducted on 9/19/24, 9/20/24 and 9/24/24.

During an interview with Hospital B's emergency department director (EDD) on 9/19/24 at 12:05 p.m., the EDD reported that when the EMS base station staff contacts Hospital B's base station, they speak to the MICN nurse to provide the age of the patient, the location where the patient was picked up, the gender, a brief situation of the patient's condition and will provide the ETA to hospital. Mobile Intensive Care Nurse (MICN): RN authorized by the Medical Director of the local Emergency Medical Services (EMS) agency to provide prehospital advanced life support (ALS) or issue instructions to prehospital emergency personnel within an EMS system according to standardized procedures developed. The MICN nurse documents this information on the template sheet which is scan or uploaded into the patient's medical record. If the patient coming to us is a woman in labor some MICN nurses will call the L&D to notify them the patient is coming and report the information provided by the EMS base station staff. Other MICN nurses will report the information to the ED charge nurse, for the charge nurse to call L&D to notify them patient is coming to them.

During a review of the American Medical Response (AMR) Ventura County Electronic Patient Care Report (run sheet), incident number 24-0044789, dated 6/1/24 at 08:04 am and 36 seconds with the EDD on 9/19/24 at 3:55p.m., the EDD reviewed the report thoroughly and stated "It looks like this patient (Patient 19) delivered the baby at home, was initially transported to Hospital A, then, someone directed EMS to bring patient to us. Patient was diverted to Hospital B. If patient would have requested to be transfer to Hospital B, this would have been documented on this run sheet. And this would have occurred through a physician-to-physician transfer. The physician at Hospital A would have contacted the physician at Hospital B and the patient would have been accepted. But then, there would have been some transfer paperwork. This is weird, the patient was taken to Hospital A, first then, diverted to Hospital B, here it doesn't say the reason why patient was rerouted to Hospital B ...this is weird, there was something wrong with this patient transportation ..."

During an interview with Hospital B's MICNRN on 9/20/24 9:45 a.m., MICNRN stated "I took the call on that date 6/1/24. I recall, the call came from Hospital A. Report from Hospital A, RN indicated, there was a pregnant woman who had delivered the baby in the field. Patient was stable and she was coming to our hospital. I wrote the information on the sheet (template sheet). I notify one of the ED doctors, I don't remember which doctor, and the charge RN, of the patient coming in to us from Hospital A ... No, I did not call the labor and deliver department to notify them the patient was coming and was on her way to the L & D."

During a concurrent review of Patient 19's medical record and interview with L&D RN (RN1) on 9/20/24 at 2:00 p.m., RN 1 reported Patient 19 was brought in by EMS ambulance on 6/1/24. RN 1 conducted an MSE at 9:42 a.m. RN 1 was asked what the report was the EMS staff provided to her. RN 1 reviewed the entire record and was not able to find the information reported to her from EMS staff. RN 1 stated "I don't remember what EMS staff said to me regarding the patient. Or if I was the one who took the report from EMS. There were several nurses when the patient first arrived. I just happened to document the MSE. This was not my patient. I think [RN 2's name] was the primary nurse for this patient according to the record." RN 1 was asked to show in the record where it indicated the patient's placenta had been delivered or the status of the placenta, at the time of patients arrival to the L&D. RN 1 navigated the patient's medical record for a while, however, RN 1 was not able to locate anywhere in the record the status of the placenta, at the time of the patient's arrival to the L&D unit. Then, RN 1 reviewed the EMS run-sheet and stated "It looks like this patient was taken to Hospital A first and then the patient was brought here to Hospital B. If the patient was taken to Hospital A, then patient would have been a transfer to us (Hospital B). In this case, the Hospital A doctor would have contacted one of our doctors for one of our doctors to accept the patient and then transfer the patient here." RN 1 was asked if on 6/1/24, RN was aware Patient 19 was coming to the unit or was notified by the ED staff that this patient was coming to their unit via EMS. RN 1 stated "No, I was not aware."

During a concurrent review of Patient 19's medical record and interview with L&D RN (RN2) on 9/20/24 at 2:35 p.m., RN 2 confirmed being present when Patient 19 arrived at the L&D unit on 6/1/24. RN 2 was asked to show in the record where it indicated the patient's placenta had been delivered or the status of the placenta, at the time of patients arrival to the L&D. RN 2 navigated the medical record for a while, however, RN 2 was not able to locate anywhere in the record the status of the placenta, at the time of the patient's arrival to the L&D unit. RN 2 was asked if on 6/1/24, RN was aware Patient 19 was coming to the unit or was notified by the ED staff that this patient was coming to their unit via EMS. RN 2 stated "No, I was not aware."

During an interview with Hospital B's L&D charge nurse (CN) on 9/20/24 at 3:36 p.m., CN was asked if on 6/1/24 CN receive a call from the ED staff to notify CN that a patient who had delivered her baby at home was coming to the L&D department via EMS ambulance. CN stated "No I don't recall getting a call from the ED to notify us that a patient who had delivered a baby out on the field was coming to our department. But they don't always notify us." CN further reported that approximately 75 to 80% of the time they don't get a call from the ED to notify them patients are coming to their unit."

During an interview with Hospital B's obstetrics physician (OBP) on 9/24/24 at 10:14 a.m., the OBP stated "I remember the patient coming to the L&D on a stretcher by EMS. Patient had delivered baby at home. I remember repairing a perineal laceration. Patient have been brought here for further care." OBP was asked if OBP deliver the patient's placenta. OBP stated, "No, the placenta had not been delivered. I deliver the placenta after patient arrived at the unit." The OBP was asked if the patient's labor and delivery process had been completed when patient arrived at the L&D unit. OBP stated "No, there are three stages of labor. The first one is the contractions. The second is the delivery of the baby. The third is the delivery of the placenta. Once the placenta has been delivered, at that point, you can consider or say that the labor and delivery process is complete." The OBP was asked if Patient 19's labor and delivery process had been completed prior to arrival. OBP stated "No."

During an interview with the L&D director (LDD) on 9/24/24 at 10:58 a.m., the LDD indicated the expectation was that the RN receiving the report from the EMS staff would document the report content in the record. Communicated to the LDD that if the EMS report content would have been documented in Patient 19's medical record then staff would have known that this patient had been transported to Hospital A, first, before being diverted here to Hospital B.

The LDD was asked again, if it was normal for an EMS ambulance to arrive to their L&D unit with a patient who had delivered at home, without the L&D unit being notified of the patient's arrival. LDD stated "No, it's not normal." LDD was then asked, if this is not normal, then the L&D nurse would have questioned the EMS staff, the reason for them showing up to L&D unit without anyone calling to the unit to notify them of their arrival. This event or incident would have triggered for an L &D management member to investigate this incident. If a management member would have investigated this event/incident, that member would have found out, by reviewing the run sheet (EMS report) that this patient was taken to Hospital A first and then patient was re-routed or diverted to Hospital B. As per EMTALA regulations, if EMS transported Patient 19 and 20 to Hospital A's ED, the patients should have been provided with a medical screening examination MSE, determine if an emergency medical conditions EMC exists, stabilize the patients with the ED capabilities and then transfer the patients to Hospital B that has L&D services which the patients required, and Hospital A does not have. This incident should have been reported to the State agency or CMS by Hospital B. The receiving hospital has a responsibility to report suspected incidences of individuals with a possible EMC being transferred to another hospital without the appropriate transfer method, paperwork etcetera. Hospital B was aware Patients 19 and 20 were transported first to Hospital A's ED where no care was provided, instead patients were rerouted to Hospital B. Hospital B administration failed to do their due diligence in investigating this incident and reporting it as a possible EMTALA violation.

The LDD stated "Yes, ok. I understand" acknowledging that herself or someone in the management team should have investigated the incident. Then, they would have found out the patients were denied care at Hospital A's ED, this is the reason patients were re-routed to Hospital B. As a result of that finding Hospital B was mandated to report the incident as a possible EMTALA violation and they did not report this.

During an interview with the regulatory compliance director (RCD) on 9/24/24 at 11:30 a.m., the RCD was asked if this incident was reported to the State agency or CMS. RCD stated, "No I did not report it to California Department of Public Health CDPH because I was not aware."

Based on interview and record review the facility failed to maintain the accuracy and completeness of the Emergency Department (ED) Emergency Medical Treatment and Active Labor Act (EMTALA) Central Logs when:

1. No disposition, chief complaint, or gender of the patient was documented.

2. Patient 4's (Pt 4) disposition on log was inaccurate.

These failures resulted in the ED EMTALA Central Logs to be inaccurate, incomplete, and out of compliance per regulation.

Findings:

During a concurrent interview and record review on 9/24/24 at 3:25 p.m. with the emergency department director (EDD), EDD confirmed that the ED EMTALA central logs reviewed for July 2024 and August 2024 were missing disposition, chief complaint, and gender of the patient for multiple patients.

During a concurrent interview and record review on 9/24/24 at 3:30 pm with the EDD. EDD confirmed that Pt 4 was discharged home, the disposition on the ED EMTALA Central Log for Pt 4 indicated, "Was Stabilized & Transf'd". Additionally, EDD confirmed the information on the ED EMTALA Central Log in the disposition column should have the correct information.

During a review of the facility's policy and procedure (P&P) titled, "EMTALA - Central Log Policy," dated 10/2022, the P&P indicated, "All hospitals must maintain the Central Log in an electronic format...The Central Log...must contain at a minimum, the name of the individual, the date, time and means of the individual's arrival, the individual's sex, the individual's record number, the nature of the individual's complaint, the individual's disposition, the individual's time of departure..."

Based on interview and record review, the hospital failed to ensure a labor and delivery (L&D) registered nurse (RN) performed a medical screening examination (MSE - process required to reach, with reasonable clinical. confidence, the point at which it can be determined whether the individual has an emergency medical condition EMC or not) to Patient 21 when patient presented to the L&D unit seeking medical attention for fetal concerns prior to patient being admitted to the unit.

The hospital's failure had the risk of patient's delay in treatment and potential for negative outcome.

Finding:

A review of the P & P titled "EMTALA- Medical Screening Examination and Stabilization Policy", dated 9/2022, indicated "An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and the individual or a representative acting on the individual's behalf request an examination or treatment for a medical condition... such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition (EMC)...then an appropriate MSE, within the capabilities of the hospital...shall we performed."

During a concurrent review of Patient 21's medical record and interview with the labor and delivery director (LDD) on 9/24/24 at 3:37 p.m., the record indicated patient was a 32-year-old female with intrauterine pregnancy at 38.5 weeks. Patient have had two prior visits to L&D unit within 24 hours. Patient returned to the L&D unit on 5/5/24 at 6:37 a.m., with complaints of fetal concerns. LDD reported during this patient's visit there was no triage or no MSE conducted by the night RN. It was at change of shift. The nurse communicated to the doctor the patient's condition at 7:12 a.m. The oncoming nurse did the first assessment at 7:30 a.m., after the patient was admitted to the L&D unit. The LLD reviewed the patient's 3rd visit records in efforts to locate the MSE that was conducted. However, LDD was not able to locate the MSE documentation for this visit. Therefore, LDD reconfirmed that there was no MSE conducted for the patient's third visit prior to patient's admission and delivering her baby. LDD stated "No, there's no MSE for this visit or patient's encounter by [L&D night RN's name]".