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Based on record review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the reporting obligation. See A2401.

Based on a focused record review and interview, it was determined that the facility failed to report the receipt of an unstable patient experiencing an emergency medical condition. The findings include:

A 16 year old patient in her 8th month of pregnancy presented to the ED of a hospital approximately 40 miles from this facility on January 7, 2008 with shortness of breath and chest pains. The patient had previously been identified as being a "high risk pregnancy" due to a history of hypertension. The diagnosis of pneumonia in a high risk pregnancy patient prompted the determination to transfer the patient to this facility. The transferring hospital failed to test the patient for pre-eclampsia so the patient was transferred with an incomplete diagnosis. Transfer arrangements were finalized and the patient was transferred via ambulance.

Upon arrival at this facility, the patient was noted to be in severe distress and was taken to surgery for emergency C-Section. The patient expired during the procedure.

On July 14, 2010 review of the patient's medical record revealed that there was no evidence that this incident had been reported to either the State Agency or CMS. On July 14, 2010 at approximately 1720, the Vice President of Quality confirmed that neither the State Agency or CMS had been notified of this transfer and outcome.