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Based on review of medical records, on-call OB (Obstetrician) schedule, Baptist Health Call Center documentation, Hospital Transfers and Direct Admit Tracking log, Baptist Medical Center South (BMC-S) Labor and Delivery (L&D) census, facility EMTALA (Emergency Medical Treatment and Labor Act) policy, and interviews, it was determined the facility failed to ensure the on-call OB accepted the transfer of Patient Identifier (PI) # 1 from Hospital # 1, that BMC-S had the capacity and capability to treat.

PI # 1 was transferred from Hospital # 1's ED (Emergency Department) on 7/10/19 at 1:42 AM to Hospital # 2, and delivered in route to Hospital # 2. This affected one (1) of 6 emergency requests reviewed for transfer appropriateness and had the potential to affect all patients who require emergency transfers to BMC-S.

Findings include:

Refer to A2411 - Recipient Hospital Responsibilities for findings.

Based on review of medical records, on-call OB (Obstetrician) schedule, Baptist Health Call Center documentation, Hospital Transfers and Direct Admit Tracking log, Baptist Medical Center South (BMC-S) Labor and Delivery (L&D) census, facility EMTALA (Emergency Medical Treatment and Labor Act) policy, and interviews, it was determined the facility failed to ensure the on-call OB accepted the transfer of Patient Identifier (PI) # 1 from Hospital # 1, that BMC-S had the capacity and capability to treat.

PI # 1 was transferred from Hospital # 1's ED (Emergency Department) on 7/10/19 at 1:42 AM to Hospital # 2, and delivered in route to Hospital # 2. This affected one (1) of 6 emergency requests reviewed for transfer appropriateness and had the potential to affect all patients who require emergency transfers to BMC-S.

Findings include:

Baptist Health Patient Care Policy and Procedure
Emergency Department
Title: Patient Management Screening, Stabilization Transfer, Consultation and Referral
Review Dates: 12/17

Policy
To ensure that all patients are evaluated, and/or stabilized for transfer to another facility or discharged to home, in a safe, efficient manner consistent with EMTALA guidelines. This policy is adapted from EMTALA and applies to Health Care Providers, nursing staff, and hospital.

Screening Stabilization and Transfer...

Emergency Medical Condition:
An individual has an emergency medical condition is his/her medical condition is marked by acute symptoms or sufficient severity, including severe pain, or the absence of immediate medical attention could reasonable (reasonably) be expected to result in:
Placing the person's health in serious jeopardy,
Serious impairment of body function; or
Serious dysfunction of any body organ or part.

SPECIAL NOTE REGARDING PREGNANT WOMEN:
Women in active pre-term labor or other conditions that pose a threat to the health or safety to the mother and fetus will be presumed to have an emergency medical condition. ALL EMTALA guidelines apply to labor and delivery.

In a phone interview on 10/7/19 at 10:37 AM, PI # 1 reported she was taken by ambulance from her work to Hospital # 1 after going into labor. The ED doctor, EI (Employee Identifier) # 1, (Hospital # 1) "checked me, said I was in labor, recommended I go to (location of Hospital # 2) or Montgomery, said there was no OB services at Hospital # 1". PI # 1 reported I didn't have a preference, "wanted to go wherever they would take me". PI # 1 reported she "was taken to Hospital # 2 because they (Hospital # 2) would accept me". PI # 1 reported she delivered her baby in the ambulance before arriving at Hospital # 2.

1. Review of PI # 1's medical records from Hospital # 1 (the transferring hospital) revealed:

PI # 1 presented to Hospital # 1's emergency department via ambulance on 7/10/19 at 12:34 AM with chief complaint, labor pains. EI # 1, ED physician, evaluated the patient at 12:37 AM and documented the following:

"...29-year- old...G2 P1001 (gravida/pregnancies 2, para/2 deliveries) presents with the onset of labor about 9:30 PM...she has not broken her water. She has been followed by EI # 2, OB, Primary Care Provider, at Hospital # 2 (the receiving hospital). Initial pelvic exam did not show any blood or fluid. The baby's head could be felt at the pelvic inlet. It was not visible at the introitus. I was not certain how far dilated she was. She was scheduled for elective C-section (cesarean section) 07/23/19 making her about 37 weeks. She had a low transverse C-section in the past in Montana according to EI # 2. We both felt it might be more expedient (to) send her to Montgomery given the frequency of the contractions. I spoke with Dr. (doctor) (name of EI # 3, BMC-S (Hospital # 3), on call OB, and to Dr. (name of EI # 4, on call OB, Hospital # 4) and both... advise me that since she had an obstetrician which was negibility for further away that I should send the patient to (location of Hospital # 2). EI # 2 agreed to accept the patient if they (BMC-S and Hospital # 4) would not. Prior to transfer...[EI # 1] did a 2nd (second) annual [manual] examination. The membranes felt intact and bulging. I could palpate the baby's head about 5 cm (centimeter) up from introitus. She had no bleeding or gush of fluid but had passed probably a mucus plug by her history. Fetal heart tones 140.

...Review of Systems...Pertinent Positives: G2 P1001, approximately 37 weeks gestation, C-section planned 07/23/2019. Blood type B-positive pre contractions about every "through" 4 minutes apart. Mucus plug passed.
Pertinent Negatives: Does not appear she has ruptured membranes, no bleeding, fetal heart tone 140.

...Physical Exam
Constitutional; Alert 29-year-old-...moderate distress with frequent Labor pain about every 4 minutes..."

Review of Hospital # 1 record revealed a Patient Transfer Form and Physician Certification dated 7/10/19 for ambulance transport, condition, active labor, a hospital to hospital transfer. The certification had this question marked yes, will this be the closest facility to treat patient's condition? Yes was marked, despite a 60 mile distance to Hospital # 2 (the receiving hospital) and a 45.3 mile distance to BMC-S (Hospital # 3).

Review of the Hospital # 1 ED Nursing documentation dated 7/10/19 at 1:51 AM revealed pt (patient) in labor, pelvic exam x (times) 2...last being just before departure, see MD (medical doctor) note, IV (intravenous) intact. OB kit with transporter. Belongings with transporter. Vital stable. pt agreeable and desires transfer where Epidural and or c-section can be provided. Paperwork given to EMS (emergency medical service) transport. Water has not broken although pt has stated that she lost some mucus, occasional sensation of having BM (bowel movement)/void per pt..but has not voided or had BM thus far. Report called. MD and transporter aware of all these findings."

Review of the ED Provider Note dated 7/10/19 at 1:54 AM by EI # 1, ED physician, Hospital # 1 revealed the following plan:

Additional Treatments: Normal Saline (NS)
Disposition: Transferred
Reason for Transfer: Services not available
Receiving Facility: Name (Hospital # 2)
Receiving Physician: EI # 5, On-call OB, Hospital # 2
Mode of Transportation ALS (advanced life support)
Evaluation Notes
Patient was in active labor and contractions were every 3-4 minutes. She had not ruptured her membranes not bleeding. Fetal heart tones 140. Attempts to get her accepted at Hospital # 4 and...BMC-S were not successful. She was transferred by EMS to Dr...EI # 5, On-Call OB for Primary OB Provider at Hospital # 2.

Review of the transferring facility, Hospital # 1's ED Discharge Instructions completed by EI # 1 on 7/10/19 at 2:31 AM, revealed the following:
...Diagnosis: Emergency medical treatment and active labor act medical screening examination...Disposition: Transferred, Receiving Facility: (Hospital # 2), Receiving Physician: Hospital # 2, EI # 2, OB, Primary Care Provider. Mode of Transportation: ALS.

Review of EMS transport documentation dated 7/12/19 at 6:33 AM, revealed an inter-facility transport, call date/time, 07/10/19 at 1:38 AM, (EMS) unit left scene on 07/10/19 1:42 AM with PI # 1. At 2:18 AM, the procedure documented was "childbirth".

Further review of the EMS report narrative (patient care report narrative) documentation revealed Hospital # 1 requested EMS for an immediate transport to Hospital # 2. Patient diagnosed with "O80-Normal delivery childbirth". Patient being transferred to specialized OB services, N/A (not available) at Hospital # 1. Patient transport refused by closer facilities due to patient's primary OB physician at transport location (Hospital # 2). Upon arrival EMS found...29 years...female...lying in bed. Patient is 33 weeks pregnant, para 1, gravida 2, contraction 2-3 minutes apart. Patient has a IV NS (Normal Saline)...patient alert...past medical history: NONE. Allergies...No known drug allergy...Pulse of 99...respirations of 24... blood pressure of 129/78. Patient starts active labor during transport...amniotic bag ruptures and contractions continue. Patient has normal delivery during transport. Cord is clamped and cut. Patient has minimal bleeding post deliver following fundus massage. Post deliver vitals were pulse 109, BP 149/73, O2 (oxygen saturation) 99. Patient's treatment included: Assessment...of patient at 07/10/19 at 01:38 AM (1:38 AM)...OB-Childbirth-EMS Personnel at 07/10/2019 02:18:08...Patient was physically moved and secured with 3 straps to stretcher and secured for transport by EMS. Patient left in care of Hospital # 2 staff. Patient was transported without incident.

Review of PI # 1's medical record at the receiving facility, Hospital # 2 revealed EI # 5, On-call OB, documented PI # 1 presented in transfer from Hospital # 1 ED having delivered en route. ER (emergency room) physician, EI # 1, (Hospital # 1) at the transferring hospital, deemed she was in labor, called our (Hospital # 2) L& D, spoke with PI # 1's Primary OB Provider, EI # 2, who recommended PI # 1 be transported to the nearest hospital with OB services. Dr...(physician name of EI # 4, on call OB at Hospital # 4), refused transfer. I was called at that point and echoed the recommendations of EI # 2, but did agree that if there was no accepting hospital in Montgomery that we would care for her here. ER physician (EI # 1, Hospital # 1) was unable to provide a description of cervical exam but stated that "head was high." She (PI # 1) delivered about 15 min (minute) prior to arrival at Hospital # 2. Per EMS, she had SROM (spontaneous rupture of membranes) in route. Fluid was bloody. Delivery soon thereafter without dystocia (difficult labor) or cord. Baby (PI # 2) had good color, cry, and heart rate.

PE (Physical Exam)...Gravid abdomen, non-tender...SVE (sterile vaginal exam):cord cut, placenta undelivered...Admit see delivery note for placenta and repair...Check UDS (urine drug screen). Routine care otherwise...signed...EI # 5, 07/10/19 at 03:23:08 (3:32 AM).

Review of Hospital # 2's Initial Newborn Profile for PI # 2 on 7/10/19 at 2:39 AM revealed weight 6 lb (pound) 11 oz (ounce), length 20.5 inches, temp 96.6, pulse 160, respiration 45.

Review of Hospital # 2 Delivery Note dated 07/10/19 at 5:09 AM revealed EI # 5 documented "G 3 now P2"...VBAC (vaginal birth after cesarean)...vigorous...infant...delivered in route from Hospital # 1 ER about 15 minutes prior to arrival at Hospital # 2. At time of arrival, cord had been clamped and cut and baby was in mother's arms. Intact placenta delivered with cord traction and fundal massage. Uterus firm with IV Pitocin and fundal massage. Second degree perineal laceration repaired in usual fashion. Mom and baby doing well.

Review of Progress Note documentation dated on 7/10/19 at 9:14 AM revealed EI # 2, OB, Primary Care Provider, Hospital # 2 documented PI # 1 was working in (city location of Hospital # 1) and presented for abdominal pain and contractions. Care of EI # 1, ED physician, Hospital # 1 and efforts to transfer were noted. I spoke with him (EI # 1) at 0100 (1:00 AM) and suggested her transfer to the nearest facility but that we would accept her if Montgomery would not. They did not. She delivered enroute.

Review of Hospital # 2 PPD (post parteum day) # 1, day of delivery documentation by EI # 2, Hospital # 2, OB, Primary Care Provider, on 7/11/19 at 8:44 AM revealed VBAC in ambulance in route to Hospital # 2.

In interviews on 10/8/19 at 9:35 AM during the ED tour, EI # 7, Director of Emergency Services and EI # 8, Interim Director of Women and Children Services reported BMC-S had not been on diversion for ED services and/or OB services in recent past (over the summer months).

In an interview on 10/8/19 at 9:50 AM with EI # 9, ED Manager, revealed the procedure for OB patient who present to the ED greater than 20 weeks pregnant get a quick assessment to determine safe transfer to the L&D unit then are sent directly to L&D. Patients less than 16 weeks are evaluated by the ED physician, and if needed, the on call OB is consulted.

In an interview on 10/8/19 at 10:00 AM, EI # 10, Director of Community Care, reported after hour calls (after 9:00 PM/weekends) into the hospital are taken by the operator, then sent to the Transfer Center, (referred to as the HUB). EI # 9 reported the Transfer Center function is ER/in house bed control, and incoming transfers assistance. EI # 10 reported when an outside facility calls the Transfer Center, the facility (representative) requesting a transfer asks if beds are available for a specified care area? If beds are available, the caller is transferred/connected to the appropriate on call/speciality physician. EI # 9 stated OB calls are different, calls are transferred to the OB department.

In an interview on 10/8/19 at 10:35 AM during tour of the L&D unit, EI # 8, Interim Director of Women and Children Services, reported the L&D unit had 12 L&D beds and 4 triage beds. EI # 8 reported 2 OB's were on call for BMC-S OB services, a primary on call OB manages the ED and unattached patients and the secondary on call OB helps with back up (overflow) and assists with C-sections. EI # 8 reported there are 4 (four) OB's who managed on call responsibilities. EI # 8 reported the on call OB's usually do not remain in-house after hours, but L&D staff notify the on call OB by phone with patient needs. EI # 8 reported if L&D staff receives a call from the ED or bed control, this would be documented on the L&D log.

Review of the July 2019 L& D on call OB physician calendar (schedule) revealed the names of 2 physician documented each day, July 1, 2019 through July 31, 2019. On 7/9/19 from 7:00 AM through 7/10/19 at 7:00 AM, EI # 3, OB physician, was the primary on call OB at BMC-S. There was an additional physician name, a secondary on call OB documented on the 7/9/19-7/10/19 OB on call physician calendar.

Review of the BMC-S L&D census documentation dated 7/9/19 at 7:00 PM to 7/10/19 at 7:00 AM, revealed the total OB census was 10. Two (2) of the 10 OB patients were discharged home. The L&D unit was not at capacity on 7/10/19.

Review of the Diversion Hours (hrs) documentation provided to the surveyor on 10/9/19 at 9:50 AM revealed there were no facility diversion hrs in July 2019.

In an interview on 10/9/19 at 9:55 AM, EI # 6 Vice President of Quality reported because the ED is level II trauma and BMS-C has a high risk neonatal intensive care nursery, diversion would be a very rare occurrence for these units. No documentation of ED and OB diversion hrs were provided to the surveyor as of 10/10/19.

Review of the Call Center (Transfer Center) Documentation Form revealed a total of 14 calls were documented on 7/10/19 that included a 1:19 AM call from EI # 1, ED physician, Hospital # 1 (transferring hospital), to the BMC-S Call Center. The Call Center "operator" documented requested contact with Dr...(name of EI # 3, BMC-S, on-call OB). The operator documented the call was transferred at 1:20 AM, physician/physician contact made at 1:20 AM on 7/10/19. The operator initials were documented. There was no documentation regarding the purpose of the call, the patient name and no result/action of the 7/10/19 1:20 AM call was documented. The surveyor requested to interview the Transfer Center operator, but according to EI # 6, Vice President of Quality, the person was no longer employed at BMC-S.

Review of the facility document titled, Hospital Transfers & Direct Admit Tracking LOG, completed by Transfer Center staff on 7/10/19 revealed 7 patient names, the accepting physician, the assigned room and initials of the person who completed the log documentation. PI # 1's name was not documented on the BMC-S Hospital Transfers & Direct Admit Tracking LOG.

In a phone interview on 10/9/19 at 11:21 AM, EI # 1, ED physician, Hospital # 1 (transferring hospital) reported he recalled the events of 7/10/19 concerning the care/transfer of the OB patient, PI # 1. EI # 1 stated he completed a medical screening exam and pelvic exam, the babies head was not visible or was (PI #1) dilated. The patient wanted to go to Hospital # 2. PI # 1 was scheduled for a follow up C-section with Dr (EI # 2, OB, Primary Care, Hospital # 2), I wasn't sure she'd be able to safely deliver after the C section. I felt Montgomery was 15 minutes closer.

EI # 1 was asked by the surveyor, did he request a transfer from EI # 3, the on call OB at BMC-S on 7/10/19 around 1:00 AM? EI # 1 stated during the phone call, EI # 3 said "She needs to go to her doctor." Again, EI # 1 was asked did EI # 3 refuse the transfer to BMC-S, if not why, was the patient not transferred to BMC-S? EI # 1 reported EI # 3 said, "She has an obstetrician, she needs to go there, Well, if you send her up here, I'm not refusing. I think you should send her to...Hospital # 2. EI # 1 reported after I got off the call with BMC-S (EI # 3), Hospital # 2 was calling back. The patient was demanding to go down to her doctor at Hospital # 2.

In an interview on 10/8/19 at 2:40 PM, EI # 3, on call OB, BMC-S on 7/10/19, reported after routine office hours, BMC-S staff page the primary on call OB with a phone message sent by the staff through "PerfectService" to his/her phone. L&D staff call directly the home phone number or his/her phone cell. EI # 3 reported he has a notebook that handwritten notes were placed in to remind him of the need to notify other BMC-S OB if calls come in. EI # 3 reported ED consults are sent by PerfectService to his phone.

The surveyor asked EI # 3 when a call from a outside facility requesting a transfer is received, what information do you require to determine if the transfer is accepted? EI # 3 responded basic information, age, gravida, the EMC (emergency medical condition), patient status, if pre term labor, how dilated, if membranes are ruptured. EI # 3 stated BMC-S accepts patients who are high risk. EI # 3 stated the patient is accepted, I tell the referring facility to call back to the control desk (Transfer Center), to tell them (bed control) I accepted the patient and to do the transfer.

The surveyor asked EI # 3 when a transfer request is denied, was documentation completed for the transfer request and the reason(s) transfer was denied? EI # 3 reported he did not document a denied transfer. EI # 3 reported "...about 3 months ago I got a call about 1:00 AM, a call from a ED physician at Hospital # 1 who reported a young lady about...36 weeks, had a repeat C section scheduled, had mild contractions, (was) not dilated, and (had) no ruptured membranes (described PI # 1's condition)....EI # 1 had called the hospital (Hospital # 2) she was supposed to deliver at, where her primary OB was, and they accepted her. I told him to send her to her OB". EI # 3 confirmed the distance from Hospital # 1 (transferring facility) to BMC-S was 15 minutes closer than the distance from Hospital # 1 (transferring hospital) to Hospital # 2 (location of PI # 1's primary OB practice/the receiving hospital). EI # 3 confirmed facility distance was discussed with EI # 1 during the call. EI # 3 stated BMC-S was the closer facility. We had a conversation Montgomery was alittle closer, EI # 1 said the hospital (Hospital # 2) was in the area. EI # 3 reported "hospital (Hospital # 2) was not 2 hours away, and she was not imminent (to deliver)".

The surveyor asked EI # 3 if he/she had refused the request to transfer? EI # 3 responded I told him/her, she had a doctor, had a hospital that had already accepted the patient, I left it at that. EI # 3 reported the call from the Transfer Center was sent via phone message but the call had been erased. There was no documentation of Hospital # 1's request to transfer PI # 1 on 7/10/19 and no reason the transfer request was denied.

During a phone interview on 10/9/19 at 1:21 PM, EI # 12, EMT (Emergency Medical Technician), reported recall of PI # 1, having assisted with the transport to Hospital # 2. EI # 12 stated ER staff (Hospital # 1) said they might have an OB going out, so we waited. PI # 1's contractions were 5-10 minutes apart, the doctor (EI# 1) talked with PI # 1 about where the OB was. PI # 1 stated the name of the city (Hospital # 2 location). They called Hospital # 2. I understood Hospital # 2 felt Montgomery was closer due to rural road travel. EI # 1 called Montgomery, Hospital # 4 first, then BMC-S (Hospital # 3). They didn't want the patient, so the doctor called Hospital # 2 again. EI # 11 stated it would have been the same amount of time for any of these facilities. EI # 12 reported travel to BMC-S usually is around 45 minutes.

EI # 12 reported EI # 1 was basically begging one (provider) to take the patient, not sure which one. EI # 12 stated I don't know what they said, but PI # 1 wasn't accepted.

Review of the EMS Transport record documentation dated 7/10/19 revealed PI # 1 had a vaginal delivery 40 minutes in route to an infant. PI # 1 and the newborn were taken to the nearest hospital at that time, which was Hospital # 2.

In an interview on 10/10/19 at 9:05 AM, EI # 11, Chairman of the OB department, BMC-S, OB, reported 4 (four) BMC-S OB physicians rotate call for OB services. EI # 11 stated calls within the Baptist system (internal communication) was sent by PerfectService phone contact. EI # 11 stated "after office hours, the operator contacts the on call OB about calls from outside facilities. Transfers go to the designated area, L&D usually, the L&D nurses assess the patient, notifies the on call OB to discuss the findings. I then call bed control to reserve the bed." The surveyor asked is there any reason(s) you might not accept an OB transfer? EI # 11 stated if the referring physician feels the transfer is needed and OB services are not available at the transferring facility, then I would accept the transfer.

EI # 11 reported he/she asks the referring physician if the patient's physician has been contacted, its a professional courtesy. The surveyor asked EI # 11 if the primary OB provider was not the closest facility, the primary OB had recommended the transfer and the transferring facility physician called to request a transfer, would this be a transfer you would accept? EI # 11 stated yes, I wouldn't question that.

On 10/10/19 at 1:40 PM, a phone interview was conducted with EI # 5, on call OB, Hospital # 2 (receiving hospital). EI # 5 recalled PI # 1 and the events of 7/10/19. EI # 5 stated "I was on call that night, I do remember the case, the patient delivered in route from Hospital # 1 to Hospital # 2." EI # 5 reported EMS personnel delivered an infant, a vaginal delivery about 20 minutes prior to arrival.

The surveyor asked EI # 5 what he recalled about the conversation with EI # 1, ED physician at the transferring hospital (Hospital # 1)? EI # 5 stated "...the patient was not accepted at another facility, EI # 1 had earlier called EI # 2, OB, Primary Care Provider at Hospital # 2, who recommended transfer to the nearest facility in Montgomery. She was in labor, it was closer by 15 minutes, she had a vaginal delivery in route, I met her at the hospital, she had her baby in her arms..."

The surveyor asked why PI # 1 was not transferred to the nearest facility with OB services as recommended? EI # 5 stated she "wasn't accepted there because she had another OB provider." The surveyor asked what the facility name was that did not accept PI # 1's transfer? EI # 5 stated Dr. name (EI # 4, on call OB, Hospital # 4). The surveyor asked if another Montgomery OB had refused transfer? EI # 5 stated,"I think there may be two, but I'm not sure of that".

A phone interview was conducted on 10/10/19 at 2:30 PM with EI # 2, OB, Primary Care Provider for PI # 1 at Hospital # 2 (receiving hospital).

EI # 2 reported recall the events of 7/10/19 surrounding PI # 1's care. EI # 2 stated he/she was not on call that evening, however the L& D staff at Hospital # 2 forwarded a call from EI # 1, ED physician at Hospital # 1 (transferring hospital). EI # 1 reported PI # 1 was transferred to the ED from work, may be in early labor, was in pain, not bleeding. EI # 2 stated he/she recommended transfer to the nearest facility with OB capabilities which was BMC-S. EI # 2 stated he/she called the L& D unit at Hospital # 2 and instructed them to fax PI # 1's prenatal records to Hospital # 1's ED to be sent to Montgomery.

The surveyor asked if there were additional conversations during the early morning hours on 7/10/19 with EI # 1? EI # 2 stated no, the next call from EI # 1 went to EI # 5, the actual on call OB at Hospital # 2 on 7/10/19.

The surveyor asked EI # 2 when you were notified your recommendation to transfer PI # 1 to the nearest OB facility did not happen? EI # 2 stated the next day she saw the baby's name on the nursery census, EI # 2 stated, I thought it was a done deal, I talked to EI # 5 the next day asked what happened? EI # 5 said PI # 2 delivered in route, V back (vaginal birth after c section) in the ambulance. EI # 1 called EI # 5, reported he/she couldn't send PI # 1 to Montgomery, so EI # 5 accepted the transfer to Hospital # 2. EI # 2 then stated, she couldn't stay in city (Hospital # 1), they couldn't monitor the baby.