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Based on policy and procedure review, medical record review, Ambulance Report, bed census reports, CMS (Centers for Medicare and Medicaid Services) form Hospital /CAH (Critical Access Hospital) database worksheet-Version 2, and staff interviews, the facility failed to hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. Based on observations, medical record reviews, Policy and Procedure reviews, Ambulance Report review, video surveillance footage review, Labor and Delivery EMTALA Log review, and staff interviews, the facility failed to ensure if an individual comes to the Emergency Department, the individual must be provided an appropriate medical screening examination within the capability of the hospital's Emergency Department to determine whether or not an emergency medical condition exists for an obstetrical patient 1 (#13) of 27 sampled patients ED medical records reviewed.

~ cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

2. Based on observations, review of medical records, policy and procedure review, bed census reports, and CMS form Hospital /CAH database worksheet-Version 2, and staff interviews it was determined the facility failed to provide medical treatment within its capacity that minimizes the risk of the individuals health for 1 (#19) of 27 Emergency Department medical records reviewed. As this resulted in an inappropriate transfer of the Patient #19 who was involuntary committed for inpatient hospitalization for an emergency psychiatric condition. As the hospital had beds in their Behavioral Health Unit from 8/22/22 through 8/26/22, before transferring the patient to Hospital B for Electroconvulsive Therapy.

~cross refer to 489.24 (e)(1)-(2) Appropriate Transfer - Tag A2409

Based on observations, medical record reviews, Policy and Procedure reviews, Ambulance Report review, video surveillance footage review, Labor and Delivery EMTALA Log review, and staff interviews, the facility failed to ensure if an individual comes to the Emergency Department, the individual must be provided an appropriate medical screening examination within the capability of the hospital's Emergency Department to determine whether or not an emergency medical condition exists for an obstetrical patient 1 (#13) of 27 sampled patients ED medical records reviewed.

The findings include:

The facility's Policy and Procedure titled, "Emergency Medical Treatment and Labor Act (EMTALA),13.0, Origination 7/2001, Effective 4/2020, Last revised 04/2020 was reviewed. The facility's Policy revealed in part, "Guidelines: Medical Screening Examination, " All individuals who seek medical treatment according to this policy will receive a Medical Screening Examination to determine if an Emergency Medical condition exists. . .Obstetrical Patients; Obstetrical patients presenting to the Emergency Department < (less than) 20 weeks gestation, will receive a Medical Screening Examination in the Emergency Department. Obstetrical patients presenting to the Emergency Department > (greater than) 20 weeks gestation with a pregnancy related complaint will receive a Medical Screening Examination in Labor & Delivery. If the patient has additional medical complaints, she will be examined in the Emergency Department once labor is ruled out."

The facility's Police and Procedure titled, "Triage & Classification System", Origination 11/1992, Effective 12/2021, and last revised 01/2019, was reviewed. The policy revealed in part, "Procedures and Responsibilities: Policy: A. All patients, at will, presenting to the Emergency Department (ED) for care will receive a Rapid Initial Screening. . . B. Triage acuity levels will be based on the Emergency Severity Index (ESI) categories 1-5, with 1 being the sickest patient. . .C. An ED registered Nurse is responsible for assigning an acuity level to each patient based on history, physical assessment, and sound clinical decision-making skills . . .E. All patients, at will, will be triaged and provided with an emergency medical screening examination according to established policy and procedure. . .DEFINITIONS: A. Vital Signs the measurement of heart rate, respiratory rate, blood pressure, and oxygen saturation (SpO2%) . . .1. Vital Signs will be done during the initial triage evaluation at the ED Registered Nurse discretion."

A review of the facility's Algorithm "OBSTETRICAL TRIAGE PREGNANT" Revealed in part, WITH LIFE THREATENING MEDICAL CONDITIONS . . . (WITHOUT SIGNS AND SYMPTOMS OF LABOR) WITH POSSIBLE OB COMPLICATIONS...Greater than or equal to 20 weeks...evaluation in the ED. Notify L&D of Patient arrival. L&D will notify OB."

The ambulance report for Patient #13 dated July 22, 2022 was reviewed. The report revealed in the section titled Transport mode stated "Emergent (Immediate Response)" and the receiving hospital was Wilson Medical Center. The section of the report titled "History of Present illness" revealed in part, "A 39 y/o (year old) female-chief complaint -hemorrhage/possible miscarriage. Upon arrival, ems (emergency medical services) was frantically waved down by multiple family members screaming at front door ...ems was directed back to Pt. (patient). Pt. was found lying supine in doorway of bedroom and bathroom door, responsive to verbal stimuli, but very lethargic. Pt's bathroom walls/door were covered in copious amounts of blood, with bloody water spilling out of the toilet and multiple towels and rugs saturated with blood approximately 1.5 liters. Pt. stated that she had severe abdominal pain and was possibly pregnant but unable to equate how far along she was her pregnancy. The patient also stated that she had not received any prenatal care. Pt. #13 stated her last period was in November and this was her 7th pregnancy. Pt. was drug via upper extremities to middle of bedroom floor in order to have a better access. Pt's radial pulses were absent and pt. was clammy and cold to touch. Vitals assessed as noted in activity log. Vascular access established and LR (Lactated Ringers Intravenous Solution) bolus initiated ...During movement vascular access was lost. Once in unit, same was relocated for safety of crew. IO (intraosseous- emergency vascular access) access established and additional LR bolus initiated. Pt. was no longer responsive at this time. Bilateral IO access established with LR bolus going into both. Transport initiated. Medic alert sent to ED via radio report. Push dose of epi (epinephrine-medication used to improve breathing, stimulate the heart and to raise blood pressure) administered. Pt was continuously monitored enroute to ED with no further status changes noted. While enroute, Pt. became more alert, but was still extremely lethargic. Upon arrival to ED, pt. was take (taken) inside via stretcher, with all cardiac monitoring still intact. Once inside ED/ RN #5 stated that pt. #13 needed to be taken up to L&D (Labor and delivery) due to her "Obviously looking pregnant." Patient's acuity continuously reiterated to same, but still told to take patient up to L&D. Once pt. was in L&D, pt. was moved over to ED bed via draw sheet. Pt. care was transferred to RN in L&D triage. Crew was requested by RN to stay until MD arrived due to pt. (patient) acuity." Further review of the ambulance report revealed in part, under "Initial Physical Findings ... Assessment ...Generalize AB (abdomen): Pain, Pregnant-Palpable Uterus. Pelvis/Genitourinary: Bleeding Uncontrolled, Bleeding-Vaginal. ...Impression/Diagnosis. System: OB/GYN. Symptoms: Bleeding, Mental Status Changes, Weakness, Change in Responsiveness. Impression: Vaginal hemorrhage, Altered level of consciousness. Initial Patient Acuity: Critical (red). Patient #13's Vital Signs in the ambulance (Activity Log) were listed as:

3:45 P.M. Heart Rate: 132; (abnormal) BP Blood Pressure): No BP recorded; Resp. (Respiratory): 20- normal; Patient was on Cardiac monitor. Pt. was responding to voice. Patient #13 GCS (Glasgow Coma Scale-used to describe the extent of impaired consciousness in all types medical and trauma- GCS scores-3-eye opening to sound; 5-verbal response was oriented and 6 motor response-obeys commands. The normal GCS is 15). At this time the patients GCS was 3/5/6. = 14
3:59 P.M. Heart rare 111; Blood Pressure 33/17; O2 Saturation 98 %; Resp. 18 (normal). Patient #13's GCS at this time-was 1-1-1 (no spontaneous eye movement, Verbal response none, and no motor response) Severe 3-8;
3:57 P.M. the patient was placed on oxygen at 4 liters/minute via nasal prongs;
4:02 P.M. Heart rate 108; BP: 36/26; Pt. Unresponsive; Respiratory Rate: 28 (Tachypnea-abnormally rapidly breathing); GCS was 3. Epinephrine 10 MCG via IO concentration: 1:100,00 was given by EMT;
4:08 Heart Rate-99; BP 103/71; Pt. responds to voice; Oxygen saturation 99% on 4 liters of Nasal Cannula Respirations 33 still tachypneic; GCS -improved to 14; and
4:18 P.M. and 4:23 P.M. the patient remained Tachypneic, and on continuous cardiac monitoring. The patient's GCS remained at 14.

On 8/24/2022 at 1250 P.M., and 8/25/2022 at 3:54 P.M., the video surveillance footage dated 7/22/22 4:11:09 for Patient #13 was reviewed with the CMS surveyor and the Chief Medical Officer. The video surveillance review revealed the ambulance pulled up in the hospital's ED bay area. Three EMT's were observed hurriedly trying to get the patient into the ED. During the review of the video we were only able to see the back of the EMS ambulance gurney raised in semi-fowlers position.

Further review revealed no documentation in the medical record that the ED emergency room staff ED/RN Charge Nurse #5 triaged the patient, did not obtain vital signs; nor documentation of a clinical assessment of Patient #13's presenting signs and symptoms upon arrival to the ED. There was also no documentation in the medical record for Patient #13 that a brief history and medical screening examination was provided by ED Physician #1 on 7/22/2022.

Review of the Labor and Delivery EMTALA Log dated 7/22/2022. The Log revealed that the patient arrived to the L&D unit at 4:26 P.M. The reason for the visit was listed as "EMS Field abruption" (Placental Abruption- a serious condition where the placenta separates from the wall of the uterus before birth. If this happens the baby may not get enough oxygen and patient may have pain and bleeding; and requires prompt medical treatment)


The LD (Labor Delivery) Flow sheet for Patient #13 dated 7/22/22, revealed the following:

4:14 PM- L & D Charge RN #7 documented - ED registration to call patient up, as the patient was brought to the hospital via EMS, L and D staff informed ED registration that patient #13 needed to be triaged and evaluated by the ED physician for an EDC (expected date of confinement (expected date of delivery). The Registrar will register patient to the ED.

4:15 P.M.- ED RN Charge Nurse#5 called back and stated that she looked pregnant and the patient was not actively bleeding at present. The L&D RN Charge Nurse#7 discussed the obstetrical Triage Algorithm with the ED Charge Nurse #5 and stated ED needs to confirm pregnancy/EDC. ED Charge Nurse #5 stated the ED Doctor #1 was in with the patient now. L & D RN Nurse#7 informed ED Charge Nurse #5 that pregnancy needs to be confirmed may get "Fundal Height."

4:20 P.M.- ED Charge Nurse#5 called back and stated "Fundal Height was 37", and the EMS staff was bringing her up to L & D, and the patient was slightly responsive to stimuli and patient has 2 (two) IO's (Intraosseous lines) per EMS. There was no documentation in the medical record that ED Charge Nurse #5 documented the change in the patient's condition, prior to arrival to L&D. As the patient arrived via EMS to the ED with a GCS of 14.

4:26 P.M.- the patient and EMS staff arrived to L&D triage. Pt. presented to L & D with no response to verbal stimuli but responds to chest sternal rub, and report received from EMS staff. The patient's fasting blood sugar level was 325 (normal blood sugar level 60-100.). The patient's oxygen saturation was 96%, on 4 liters of oxygen.

4:29 P.M.- Vital Signs L & D staff unable to obtain a blood pressure. "Heavy large amount of blood noted under the patient's Perineum, bottom, blood continues to trickle out of patient's vagina. Dried blood noted on patient's chest, legs and feet. The patient was on continuous cardiac monitoring and was tachycardic, and O2 increase to 12 liters and on a non-rebreather mask. "EMS remains at bedside, EMT states due to patients' condition, we will stay since there is no physician present yet."

4:30 P.M.- Monitor Mode- External Palpitation. The on-call OB/MD was called, US was needed. 4:32 P.M.- Unable to obtain a blood pressure; FHR (Fetal Heart Rate) Baseline Unable to find fetal heart tones, MD already aware and enroute. EFM (electronic fetal monitor) applied.

4:33- Orders received for OB/MD # 1 to draw stat labs and notify Anesthesiology of patient's status.

4:35 P.M.- Anesthesiology notified of patient's status and possible need for C-section.

4:38 P.M.- Nurse and OBMD #1 at bedside. Called and spoke to Blood Bank to initiate mass transfusion protocol

4:39 P.M. - unable to obtain Blood pressure

4:44 P.M. Anesthesiology notified of Placenta abruption and intrauterine Fetal demise

4:45- P.M.- Pt. complain of back pain and able to speak a few words and now somewhat responsive

4:48 P.M.- Pulse 86 and Oxygen saturation was 79% (Normal 93%-100%)

4:51: Pulse was 116 and Oxygen saturation was 100%

4:54- IV line Started by Anesthesia

5:00 P.M.- Consent signed by (Patient #13's) mother for C-Section

5:03 P.M. EFM disconnected and Patient taken to L & D OR via labor bed.

5:50 P.M.-called and spoke to bed placement at Hospital B to transfer patient for DIC (Disseminated Intravascular Coagulation-a serious condition affecting the blood's inability to clot and stop bleeding).



5:59 P.M.- OB/MD #1 on the phone with Hospital B for hospital transfer to tertiary Care Center. Pt. remains in L&D OR for continuing care and stabilizing care. Anesthesiology, L &D nurses present for continuing post- partum care

6:04 P.M.- Hospital B accepted the patient.

6:45 P.M.- telephone report given to Hospital B Surgical ICU (Intensive Care Unit) RN

7:05 P.M.- patient transferred from Labor and Delivery Operating Room to Hospital B's surgical ICU per helicopter ambulance.

The post-operative report from Hospital A dated 7/22/22 for Patient #13 was reviewed. The post-operative note revealed in part, "Pre-op diagnosis- 37 weeks intrauterine Pregnancy, placental abruption, and Hypovolemic shock (an emergency condition in which severe blood loss, or other fluid loss makes the heart unable to pump enough blood to the body). Primary Surgeon OB/MD #1. Procedure: Primary low segment Transverse Cesarean Section (C-Section). Description of Procedure: Patient presented to Labor and Delivery with symptoms of a complete placental abruption and a fetal demise, Because of the continued excessive bleeding a decision was made to proceed with an emergent C-section. The patient was stabilized by Anesthesia. The baby was delivered and noted to be near term demise with complete blanching of the skin. There was no pulse noted in the umbilical cord. The baby was handed off to the waiting pediatric nurse."

Delivery information on Baby A dated 7/22/2022 was reviewed. The delivery information revealed that Baby A was delivered on 7/22/22 at 5:17 P.M. The method of delivery was via C-Section, presentation was Cephalic (Head), and Cephalic Position was Vertex. The Gestational age of the fetus at delivery was documented as 34.0 weeks. Baby A was delivered stillborn, and weighed 6 pounds and 1 ounce.

An interview was conducted on 8/23/2022 at 2:45 P.M., with the OB(Obstetrical)/ Nurse Director #1. OB/Director stated that if a patient presents to the ED with complaints of greater that 20 weeks, the patient is brought to the Labor and Delivery Unit. The patient will be evaluated by an RN qualified to perform Medical Screening Examinations. The patient is evaluated by the RN to rule out labor, and the OB/MD physician on- call be notified. She also stated that the facility does not have in-house OB physicians. The facility only has 24/7 on-call OB/Physicians.

A group interview was conducted on 8/23/2022 from 2:50 P.M. to 3:00 P.M. with the OB Nurse Director, OB/RN#1 and OB/RN #2, during an observational tour of the L&D unit. They all stated that if a patient presents to the ED via ambulance, they will come in the ED via the ambulance bay. They continued to state that usually the ambulance will call and let us know they are on the way. They stated that if an Obstetrical patient presents to the ED unresponsive, the patient is taken care of in the ED medically. The ED staff will go down and assess fetal status. Further interview with the OB/Director and OB/RN #1 and OB/RN #2 stated that if the Obstetrical patient is unresponsive, this takes precedence, and the patient would remain in the ED in order to determine why the patient is unresponsive.

An interview was conducted with the VP (Vice President) of Quality on 8/24/2022 at 9:39 am. The VP of Quality stated that the facility did a Root Cause Analysis to look at all of the contributing factors and actions of the case related to Patient #13. She further stated that it was an unusual case of fetal demise. The VP of quality stated that there were a lot of triggers and identifiers such as: a.) no documentation of an examination performed by the ED provider regarding Patient #13 on 7/22/22; b.) House Supervisor not notified that Patient #13 was coming in the door; c.) Intraosseous vascular (IO) access EMTs', and staff not familiar with the use of IO's; d.) OB Algorithm was not followed; and e.) We need more drills on mass blood transfusions.

Interviews were conducted on 8/24/2022 at 10:13 A.M., to 11:00A.M., with OB/RN #3 and RN #4 (Information Lead computer navigator). OB/RN#3 reviewed the Electric Health Record (EHR) with the surveyor. They both stated that according to medical record review, that on 7/22/22 at 4:16 P.M., Patient #13 was enroute to the ED via EMS. They also stated that the EMS staff informed the ED staff that Patient #13 had not received any pre-natal care. They both stated that on 7/22/2022 patient #13 was not triaged by OB/RN Charge Nurse #5. OB/RN #3 stated the patient should have been triaged. She also stated if the ED staff does not know the patient's due date, the ED provider has to evaluate the patient to see how far along the patient is in her pregnancy. OB/RN #3 stated that the ED provider has to determine if the patient is less than 20 weeks or greater than 20 weeks pregnant prior to coming to the L&D unit. OB/RN #3 stated Patient #13 was treated in L&D with EMS Staff present. She stated that someone from L&D was supposed to come from L&D to assist in the ED because the patient (#13) was so unstable. She stated that if we do not know if the patient was less than 20 weeks, then the ED staff has to find out gestational age. OB/RN stated that a medical screening examination should have been performed by the ED physician/provider on 7/22/22 when Patient #13 presented to the ED. However, the only documentation regarding an assessment of the patient's Fundal height of the uterus done by the ED physician in the ED was documented by an OB staff nurse in L&D. She stated that the ED called L&D and informed L&D, the patient's fundal height was 37. OB/RN #3 stated that an Ultra Sound was done in L&D. The results of the revealed that Patient #13 was 34 weeks pregnant. She further stated according to review of the medical record, upon the patients' arrival to the L&D unit, no L&D staff accompanied the patient from the ED to the L&D unit She also stated that no Vital Signs were not done in the ED by ED staff members. Additionally, no orders came with the patient from ED/MD #1.

An interview was conducted with the OB/MD #1 on 8/24/2022 at 12:00 noon. He stated that he/she received a call form L&D that they had received a pregnant patient, bleeding and no gestational age. He stated that when he arrived to the L&D unit Patient #13 was critically ill, and had lost a significant amount of blood. He stated that he assessed the patient in the L&D triage room, and determined the patient was more than 20 weeks. He stated that an Ultrasound was ordered and completed. He stated that from the Ultrasound report it was determined the patient was 37 weeks pregnant, and there was no fetal heartbeat. He also stated that an IV access was established. He continued to state that a Massive Transfusion protocol was initiated because the patient had lost a considerable amount of blood. He stated the patient was given blood, platelets and clotting factors from uncross-matched blood. He stated that Anesthesiologist #1 was on the L&D unit to assist with the care of this patient. He stated that once Anesthesiologist #1 assisted with the patient's care, the patient became more arousable and her blood pressure, started to come up. He stated the patient needed a C-Section to evacuate the baby and the placenta. He stated the patient's uterus was bleeding profusely. He further stated that in order to save Patient #13's life we did an emergency C-Section. He stated that during the surgery, from the findings in the uterus wall he felt the patient was going into DIC. He stated that he ordered Fresh Frozen Plasma, platelets and blood. He further stated that their facility does not store platelets in their blood bank, and that it would take approximately 3 hours for the platelets to arrive at their facility. He stated as the patient continued to bleed and if they had to wait for the platelets it would cause a delay in her treatment. He said that since Wilson Medical Center did not have Platelets readily available, and in his clinical judgement it was best to transfer the patient to a tertiary care center (Specialized care provided by specialty facility) The OB/MD #1 stated that he communicated with the ICU MD at Hospital B, and was informed it would be most appropriate to get the patient moved as soon as possible. He stated the patient was transferred safely via air ambulance to Hospital B.

An interview was conducted on 8/24/2022 at 12:28 P.M. with ED/RN #5. ED/RN #5. As ED/RN#5 was the ED Nursing Supervisor was on duty, when patient #13 presented to the ED on 7/22/2022. She also stated EMS staff had given her report via the radio regarding Patient#13's status. She stated that when pregnant patients present to the ED we have to determine if they are greater than 20 weeks and is appropriate to go upstairs to the L&D unit. She stated that she asked the patient what was the date of her last menstrual cycle. She continued to state that Patient #13 did not know the date of her last menstrual cycle. She also stated that if a Pregnant trauma presented to the ED, we will check the patient out in the ED prior to sending the patient to L&D. ED/RN Charge Nurse #5 also verified that she did not do Vital Signs, no quick fundal height or gravida assessment, on the patient #13 because there is no place to document this information in the Electronic Health Record.

A telephone interview was conducted on 8/24/22 at 4:13 P.M., with ED/MD #1. ED/Physician #1 was given the patient's name and date of incident- 7/22/22. She stated that she did not remember the patient, and would have to get access remotely to review the patient the patient's medical record. She stated that if a patient is pregnant and is greater than 20 weeks the patient goes straight up to L&D. She stated that EMS will usually get the Estimated Delivery Date. She stated that if she performs a complete medical screening examination, the L&D nurse will not take the patient unless the ED physician makes the determination the patient is greater than 20 weeks. There was no documentation in the EHR that a brief History and Physical was done by ED physician #1. ED physician #1 failed to document in the EHR an assessment/examination of patient #13 on 7/22/22, prior to patient leaving the ED and going to the L&D unit. On 8/29/2022 at 2:31 p.m., a telephone interview was conducted with the Chief Medical Officer requesting to have ED. MD #1 call the surveyor, regarding review of patient #13's medical chart for the ED 7/22/22 visit. A follow-up telephone call was not received back from ED/MD#1.


On 8/24/2022 at 1250 P.M., and 8/25/2022 at 3:54 P.M., the video surveillance dated 7/22/22 4:11:09 for Patient #13 was reviewed with CMS surveyor and the Chief Medical Officer. The video surveillance review revealed the ambulance pulled up in the hospital's ED bay area. Three EMT's were observed hurriedly trying to get the patient into the ED. During the review of the video we were only able to see the back of the EMS ambulance gurney raised in semi-fowlers position.

Further review revealed no documentation in the medical record that the ED emergency room staff ED/RN Charge Nurse #5 triaged the patient, did not obtain vital signs; nor documentation of a clinical assessment of Patient #13's presenting signs and symptoms upon arrival to the ED. There was also no documentation in the medication record for Patient #13 that a brief history and medical screening examination was provided by ED Physician #1 that was within the capability and capacity of the hospital ED prior to the patient going to L&D.

Review of the Labor and Delivery EMTALA Log dated 7/22/2022. The Log revealed that the patient arrived to the L&D unit at 4:26 P.M. The reason for the visit was listed as "EMS Field abruption" (Placental Abruption- a serious condition where the placenta separates from the wall of the uterus before birth. If this happens the baby may not get enough oxygen and patient may have pain and bleeding; and requires prompt medical treatment)
The LD (Labor Delivery) Flow sheet for Patient #13 RN dated 7/22/22, revealed the following:
4:14 PM- L & D Charge RN #7 documented - ED registration to call patient up, as the patient was brought to the hospital via EMS, L and D staff informed ED registration that patient #13 needed to be triaged and evaluated by the ED physician for an EDC (expected date of confinement (expected date of delivery). The Registrar will register patient to the ED.
4:15 P.M.- ED RN Charge Nurse#5 called back and stated that she looked pregnant and the patient was not actively bleeding at present. The L&D RN Charge Nurse#7 discussed the obstetrical Triage Algorithm with the ED Charge Nurse #5 and stated ED needs to confirm pregnancy/EDC. ED Charge Nurse #5 stated the ED Doctor #1 was in with the patient now. L & D RN Nurse#7 informed ED Charge Nurse #5 that pregnancy needs to be confirmed may get "Fundal Height."
4:20 P.M.- ED Charge Nurse#5 called back and stated "Fundal Height was 37", and the EMS staff was bringing her up to L & D, and the patient was slightly responsive to stimuli and patient has 2 (two) IO's (Intraosseous lines) per EMS. There was no documentation in the medical record that ED Charge Nurse #5 documented the change in the patient's condition, prior to arrival to L&D. As the patient arrived via EMS to the ED with a GCS of 14.

4:26 P.M.- the patient and EMS staff arrived to L&D triage. Pt. presented to L & D with no response to verbal stimuli but responds to chest sternal rub, and report received from EMS staff. The patient's fasting blood sugar level was 325 (normal blood sugar level 60-100.). The patient's oxygen saturation was 96%, on 4 liters of oxygen.
4:29 P.M.- Vital Signs L & D staff unable to obtain a blood pressure. "Heavy large amount of blood noted under the patient's Perineum, bottom, blood continues to trickle out of patient's vagina. Dried blood noted on patient's chest, legs and feet. The patient was on continuous cardiac monitoring and was tachycardic, and O2 increase to 12 liters and on a non-rebreather mask. "EMS remains at bedside, EMT states due to patients' condition, we will stay since there is no physician present yet."
4:30 P.M.- Monitor Mode- External Palpitation. The on-call OB/MD was called, US was needed. 4:32 P.M.- Unable to obtain a blood pressure; FHR (Fetal Heart Rate) Baseline Unable to find fetal heart tones, MD already aware and enroute. EFM (electronic fetal monitor) applied.

4:33- Orders received for OB/MD # 1 to draw stat labs and notify Anesthesiology of patient's status.

4:35 P.M.- Anesthesiology notified of patient's status and possible need for C-section.
4:38 P.M.- Nurse and OBMD #1 at bedside. Called and spoke to Blood Bank to initiate mass transfusion protocol
4:39 P.M. - unable to obtain Blood pressure
6:44 P.M. Anesthesiology notified of Placenta abruption and intrauterine Fetal demise
4:45- P.M.- Pt. complain of back pain and able to speak a few words and now somewhat responsive
4:48 P.M.- Pulse 86 and Oxygen saturation was 79% (Normal 93%-100%)
4:51: Pulse was 116 and Oxygen saturation was 100%
4:54- IV line Started by Anesthesia
5:00 P.M.- Consent signed by (Patient #13's) mother for C-Section
5:03 P.M. EFM disconnected and Patient taken to L & D OR via labor bed.
5:50 P.M.-called and spoke to bed placement at Hospital B to transfer patient for DIC (Disseminated Intravascular Coagulation-a serious condition affecting the blood's inability to clot and stop bleeding).
5:59 P.M.- OB/MD #1 on the phone with Hospital B for hospital transfer to tertiary Care Center. Pt. remains in L&D OR for continuing care and stabilizing care. Anesthesiology, L &D nurses present for continuing post- partum care
6:04 P.M.- Hospital B accepted the patient.
6:45 P.M.- telephone report given to Hospital B Surgical ICU (Intensive Care Unit) RN
7:05 P.M.- patient transferred from LD OR to Hospital B surgical ICU per helicopter ambulance.

The post-operative report from Hospital A dated 7/22/22 for Patient #13 was reviewed. The post-operative note revealed in part, "Pre-op diagnosis- 37 weeks intrauterine Pregnancy, placental abruption, and Hypovolemic shock (an emergency condition in which severe blood loss, or other fluid loss makes the heart unable to pump enough blood to the body). Primary Surgeon OB/MD #1. Procedure: Primary low segment Transverse Cesarean Section (C-Section). Description of Procedure: Patient presented to Labor and Delivery with symptoms of a complete placental abruption and a fetal demise, Because of the continued excessive bleeding a decision was made to proceed with an emergent C-section. The patient was stabilized by Anesthesia. The baby was delivered and noted to be near term demise with complete blanching of the skin. There was no pulse noted in the umbilical cord. The baby was handed off to the waiting pediatric nurse."

Delivery information on Baby A dated 7/22/2022 was reviewed. The delivery information revealed that Baby A was delivered on 7/22/22 at 5;17 P.M. The method of delivery was via C-Section, presentation was Cephalic (Head), and Cephalic Position was Vertex. The Gestational age of the fetus at delivery was documented as 34.0 weeks. Baby A was delivered stillborn, and weighed 6 pounds and 1 ounce.

An interview was conducted on 8/23/2022 at 2:45 P.M., with the OB(Obstetrical)/ Nurse Director #1. OB/Director stated that if a patient presents to the ED with complaints of greater that 20 weeks, the patient is brought to the Labor and Delivery Unit. The patient will be evaluated by an RN qualified to perform Medical Screening Examinations. The patient is evaluated by the RN to rule out labor, and the OB/MD physician on- call be notified. She also stated that the facility does not have in-house OB physicians. The facility only has 24/7 on-call OB/Physicians.

A group interview was conducted on 8/23/2022 from 2:50 P.M. to 3:00 P.M., during an observational tour on the L & D unit with the OB Nurse Director, OB/RN#1 and OB/RN #2. They all stated that if a patient presents to the ED via ambulance, they will come in the ED via the ambulance bay. They continued to state that usually the ambulance will call and let us know they are on the way. They stated the patient was registered in the ED. They stated that if an Obstetrical patient presents to the ED unresponsive, the patient is taken care of in the ED medically. The ED staff will go down and assess fetal status. Further interview with the OB/Director and OB/RN #1 and OB/RN #2 stated that if the Obstetrical patient is unresponsive, this takes precedence, and the patient would remain in the ED in order to determine why the patient is unresponsive.

An interview was conducted with the VP (Vice President) of Quality on 8/24/2022 at 9:39 am. The VP of Quality stated that the facility did a Root Cause Analysis to look at all of the contributing factors and actions of the case related to Patient #13. She further stated that it was an unusual case of fetal demise. The VP of quality stated that there were a lot of triggers and identifiers such as: a.) no documentation of an examination performed by the ED provider regarding Patient #13 on 7/22/22; b.) House Supervisor not notified that Patient #13 was coming in the door; c.) Intraosseous vascular (IO) access EMTs', and staff not familiar with the use of IO's; d.) OB Algorithm was not followed; and e.) We need more drills on mass blood transfusions.

Interviews were conducted on 8/24/2022 at 10:13 A.M., to 11:00A.M., with OB/RN #3 and RN #4 (Information Lead computer navigator). OB/RN#3 reviewed the Electric Health Record (EHR) with the surveyor. They both stated that according to medical record review, that on 7/22/22 at 4:16 P.M., Patient #13 was enroute to the ED via EMS. They also stated that the EMS staff informed the ED staff that Patient #13 had not received any pre-natal care. They stated the patient was registered in the ED log. They both stated that on 7/22/2022 patient #13 was not triaged by OB/RN Charge Nurse #5. OB/RN #3 stated the patient should have been triaged. She also stated if the ED staff does not know the patient's due date, the ED provider has to evaluate the patient to see how far along the patient is in her pregnancy. OB/RN #3 stated that the ED provider has to determine if the patient is less than 20 weeks or greater than 20 weeks pregnant prior to coming to the L&D unit. OB/RN #3 stated Patient #13 was treated in L&D with EMS Staff present. She stated that someone from L&D was supposed to come from L&D to assist in the ED because t

Based on observations, review of medical records, policy and procedure review, bed census reports, and CMS (Centers for Medicare and Medicaid Services) form Hospital /CAH (Critical Access Hospital) database worksheet-Version 2, and staff interviews it was determined the facility failed to provide medical treatment within its capacity that minimizes the risk of the individual's health for 1 (#19) of 27 Emergency Department medical records reviewed. As this resulted in an inappropriate transfer for the Patient #19 who was involuntary committed for inpatient hospitalization for an emergency psychiatric condition.


The findings were:

The medical record for patient #19 was reviewed. The medical record revealed that patient #19 was brought to the ED by her mother on 8/22/22 at 12:56 P.M. The Emergency Department (ED) Registered Nurse (RN) documented the patient's stated complaint details was listed as, "Pt. (Patient) presented ED complaint SI (suicidal Ideation) and depression. Pt. States last night she was driving through stop signs and stoplights in hopes someone hit her. Pt. reports taking pills in the past." Further documentation revealed the patients' vital signs were Blood Pressure 153/97 (normal 120/80); Pulse/Heart rate- 121 (Normal 60-100), Respirations 18; Pulse oximetry 95% on Room Air; and Temperature: 97.2 F (Fahrenheit). The CSSRS (Columbia Suicide Severity Rating Scale-Assessment tool that evaluates suicidal severity) (https://cssrs.Columbia.edu), Patient #19's Suicide Risk Level was "High Risk ...Response Protocol: High Risk Notify Charge Nurse. Priority: Emergency." The patient's signs and symptoms related to the psychiatric complaint was Anger, Suicidal Thoughts, Hostility. Documentation also revealed the Psychiatric Ideation was Suicidal, Inappropriate Behavior and uncooperative. Neurologically the patient was awake alert and oriented x 3.

Review of the Emergency Room Provider Record dated 8/22/22 at 2:10 P.M. revealed that Patient #19 was seen and evaluated by the ED provider. The ED provider documented the patient had a history of Bi-polar disorder (mental illness that causes dramatic shifts in a person's mood, energy, and ability to think clearly-https: www.nami.org). The patient is also on Trileptal (medication used to treat seizures, and it is used as a mood stabilizer to treat symptoms of bi-polar), and also receives ECT (Electroconvulsive Therapy also electroshock therapy, a short-term treatment for sever manic or depressive episodes, particularly when symptoms involve serious suicidal or psychotic symptoms. https://www.webnd.com) at Hospital B. The patient reported to the ED provider as having bruising and trying to stop medication. The patient also reported to the ED provider that she had been manic (extremely elevated and excitable moods) for the past few weeks, and had only slept 5 hours in the past 10 days. The patient also reported she has ongoing suicidal ideations, and had attempted suicide multiple times. The patient informed the ED provider that she had taken pills a few days ago but woke up. The patient reported to the ED provider that she tried to crash her car on yesterday, but had no injuries. The ED provider documented that Patient #19 continues to want to kill herself, denied homicidal ideations, auditory and visual hallucinations.

The physical examination revealed in part, "Psych (Psychiatric) Mildly Hyperactive and Cooperative). The section of the note titled MDM (Medial Decision Making) revealed in part, "Patient presents for a psychiatric evaluation. Admits to mania ... Patient seen by psychiatry and IVC (Involuntary Commitment is the legal process by which a person is confined in a psychiatric hospital because of a treatable mental disorder, against his or her wishes. (https://www.ncbi,nlm.nih.org) and was enacted by myself. Discussed with Hospital B by psychiatry and will be transferred there on Wednesday ...Pt. to be transitioned to the behavioral health locked area in the Emergency Department secondary to attempt to elopement." Further review revealed that at 6:44 p.m., the ED provider documented under "Additional Comments" that Patient #19 was severely agitated, wanting to speak with the attending psychiatrist, and wanting to leave the ED, and she is a danger to others. The patient was treated with Haldol, Benadryl and Ativan. The ED provider documented in part, "Impression: Primary Impression Mania. Additional Impressions: Suicidal ideations and Agitation. Disposition type: Hospitalize."


The form "Affidavit and Petition for Involuntary Commitment for Patient #19 dated 8/22/22 was reviewed. IVC revealed in part, "1. Mentally ill and dangerous to self or others, or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness ...The facts upon this opinion is based are as follows: Patient with a history of bi-polar disorder is manic ...Suicidal ideation, suicide attempts x 2 prior to admission. Cont'd (Continued) Suicidal Thoughts. Danger to self ," The IVC form was signed by the ED attending physician on 8/22/22.


Review of the Psychiatric Consult Note revealed that Patient #19 had been evaluated in the ED by PA-C #1 on 8/22/22. Documentation by PA-C#1 revealed that Patient #1 was awake alert and oriented, cooperative and elevated in their interview on 8/22/22. Further review revealed the patient wanted to go to Hospital B. According to the medical record the patient has received ECT therapy for the past 1.5. years, most recent 1 month ago from Hospital B. The patient reported wrecking her car driving 90 miles an hour swiping another car as a suicide attempt. The patient also reported overdosing on multiple tablets prior to coming to the ED. Documentation by the PA-C#1 of the patient's mental examination revealed in part, Appearance: Poorly groomed, Attitude: Cooperative guarded, Mood: elevated; Affect: Congruent mood, Insight and Judgement: Impaired; Attention: Limited, Thought Content: Self destructive Ideation; and SI/HI (suicidal ideation/homicidal ideation): Denied. The PA-C recommendation was to continue Involuntary Commitment status.

The PA-C #1 documented on 8/22/22 (Monday) that Patient #19 psychiatrist at Hospital B has been treated by their psychiatrists, and recommended to continue the patient on Seroquel (medication used to treat sudden episodes of sudden episodes of mania or depression. https://www.webmd.com) and Trileptal. Further documentation revealed that Hospital B was willing to accept the patient to their facility so that she can receive ECT, but will not be able to take the patient until Wednesday 8/24/2022.

On Tuesday 8/23/22 (the patient remained in the hospital's ED Crisis Intervention Unit) PA-C #1 documented the patient was re-evaluated. Documentation also revealed that the nurse reported the patient was elevated, hyperverbal but able to de-escalate, and the patient had taken a shower and flooded bathroom. The recommendation was to continue the IVC. An addendum note was added by PA-C #1 revealed the psychiatrist at hospital was notified; was advised that the psychiatrist at Hospital B would be the person to make arrangements for the patient's transfer to hospital B.

On Wednesday 8/24/222 (Patient #19 remained in the hospital's ED Crisis Intervention Unit). PA-C #1 documented Patient #19 was re-evaluated and the patient continues with elevated mood, insight is fairly poor, and slept poorly on last night. Documentation also revealed the nurse reported the patient was elevated and hyperverbal on last night. The patient took a shower and flooded the bathroom floor. The PA-C#1 documented the psychiatrist at Hospital B was called and a message was left to contact PA-C #1.

On Thursday 8/25/2022 (Patient #19 remained in the hospital's ED Crisis Intervention Unit). PA-C #1 documented the nurse reported the patient was seen on the unit with her top off and required room re-direction. The PA-C#1 documented the patient continued with elevated mood, and continue to coordinate patient's transfer to hospital B. PA-C #1 recommended continuation of the Involuntary commitment.

The ED Summary report dated 8/25/2022 at 10:35 A.M., was reviewed. Documentation by Hospital A staff revealed that hospital B was called inquiring about the transfer of Patient #19 to Hospital B for further treatment. Further documentation revealed in part, "They were advised they did not have a bed assignment for the patient "(Pt. #19). Hospital A Staff documentation also revealed Hospital B was called and spoke with someone, and was informed that Patient #19 was not listed or assigned a bed, the only thing seen in the patient's record was an appointment for today (8/25/2022) with the psychiatrist at Hospital B. Documentation also revealed that Hospital B's psychiatric unit was called by Hospital A staff to find out the process to get patient a bed assignment, "they (Hospital B) said (said) they no longer direct (directly) accept patients they have to come in thru the hospital (Hospital B), and COVID test done within 48 hours of acceptance." Continued documentation by Hospital A staff informed Hospital B staff that "Hospital B psychiatrist (MD Name) had accepted the patient and wanted the patient there to continue ECT treatment. She said the patient will have to go thru the Emergency Department and then be transferred from there. I called Hospital B physicians back and notified them of the above." Documentation also revealed that Hospital A staff called Hospital B staff to give report, and Hospital B staff informed Hospital staff A staff they were not aware of the patient was coming from Hospital A's ED. Further documentation by Hospital A staff was informed by Hospital B staff, would call the psychiatrist at Hospital B. On 8/25/22 at 4:03 P.M., negative COVID test results and IVC papers were faxed to Hospital B. Documentation by hospital Staff A revealed that Hospital B physicians called at 10:08 P.M. to inform Hospital B that they will not be able to pick up patient #19 until tomorrow morning.

On 8/26/2020 (patient #19 remained on the ED Crisis Intervention Unit) PO-C #1 documented patient remains discharged focus, bizarre thought processes, and mood remains elevated, and seems to be calmer today. Further documentation revealed the ED staff continues to work to coordinate transferring the patient to Hospital B. The Patient was still on an IVC status as of 8/26/2022. According to review of the ED Summary Report dated 8/26/2022 at 1:28 P.M., the RN documented the patient's transfer disposition was noted to be transferred to Hospital B. Documentation also revealed the ED nurse in the Crisis Intervention Unit gave report to Hospital B on 8/26/22 at 2:00 P.M. Patient #19 left the ED Crisis Intervention unit on 8/26/2022 at 3:00 P.M. in a wheel chair accompanied by a county deputy, to be transported to Hospital B's Behavior Health Unit.

The facility's Policy titled, "LL.027, EMTALA -Transfer Policy", Origination 11/10/2003, Approved 12/2/2021, Effective 12/2/2021. The policy revealed in part, "3. There are four requirements of an appropriate transfer must be met before a patient can be transferred to a second facility: a. The transferring hospital must, within its capability, provide treatment to minimize the risks to the health of the individual."

The facility's policy titled, Emergency Medical Treatment and Labor Act (EMTALA), 13.0, Origination 7/2001, Approved 2020, Effective 04/2020, Last revised 4/2020. The policy revealed in part, "Appropriate Transfer: An appropriate transfer is defined as: WMC (Wilson Medical Center) has provide medical treatment within its capacity, that minimizes the risk to the patient's health."


The facility's policy titled, "Admission, Continued Stay and Discharge Criteria- Psychiatric Inpatient Department" Origination 1/2019, Effective 11/2020, and Last revised 11/2020. The policy revealed in part, "Policy Statement It is the policy of Wilson Medical Center Behavioral Health to admit only individuals 18 years older who are functionally impaired to the point where inpatient treatment is medically necessary to assure safety due to risk of harm to self and others and/or inability to are for themselves related to their mental illness.
a. Admission Criteria- There is evidence of actual or potential danger to self or others or severe psychosocial dysfunction as evidenced by at least one of the following: "1. Suicide attempt which is serious by degree of lethality and intentionality, or suicidal ideation with a plan and means."


On 8/25/2022 at 11:55 A.M., Patients were observed on the outside of the nursing station walking around the unit. During this same time an interview was conducted with the Behavioral Health Director, and she stated that that one patient was to be discharged today.


An interview was conducted on 8/25/2020 at 3:00 P.M. with PA-C #1. He stated that Patient #19 has been in the ED for several days since she presented to the ED. He stated the patient met criteria for admission because the patient was having increased mania, bizarre behaviors, slept 3 hours briefly, little sleep for the past 10 days. The concern is about the patient's behaviors non-compliant with medications, anxious, paranoid, and 2 suicidal attempts lately motor vehicle accident with the intention of killing herself. He stated that the Behavioral Health Unit on the 6th floor is at capacity, and the unit was having staffing issues. PA-C #1 was informed by the surveyor that BHU on the 6th floor had 24 beds. He stated that he did not know the date that Patient #19 would be transferred to Hospital B, but he patient needs ECT treatment that is why the patient is being held in the ED-Crisis Intervention Unit. He also stated that Patient #19 was receiving medications while in the ED Crisis Intervention Unit.

Review of the CMS form 286 titled "Hospital/CAH (Critical Access Hospital) Updated 07/22 was reviewed. The section of the form titled "Services Provided" revealed the facility provided the following psychiatric services: Emergency Psychiatry, Adolescent and Geriatric Psychiatry.

The Bed Census report (which included Staffing) dated 8/22/22 through 8/26/22 was requested from the BHU via email on 9/21/2022.
The BHU bed Census e-mail report revealed the following:

8/22/22- 8 patients- Day: 1 RN 1 CNA (Certified Nursing Assistant) Night: 2 RN 1 CNA;
8/23/22-9 patients- Day: 1 RN 1 CNA- Night: 2 RN 2 CNA;
8/24/22-10 patients- Day: 2 RN Night: 1 RN LP 1 CNA.
8/252/22-BHU Bed Nurse Unit Census revealed the census was 10 patients - Day: 1 RN Night: 1 RN 1 LPN 1 CNA (A copy of this bed census report was received during the investigation) and;
8/26/22- (e-mail) 7 patients- Day: 2 RN 1 CNA- Night: 1 RN 2 CNA.

The facility failed to provide treatment within its capability to minimize the risks of the health of the individual (Pt. #19). The facility failed to ensure that their policies and procedures were followed as evidenced by failing to admit Patient #19 to their BHU from 8/22/22 through 8/25/2022, the facility had available in-patient psychiatric beds. The patient met the criteria for admission to the psychiatric unit, she had attempted suicide twice, trying to overdose on pills and utilized a car/vehicle with the intent to kill/injure herself. Additionally, the patient was involuntary committed and required inpatient hospitalization. Despite the facility having open psychiatric beds the week of 8/22/22 through 8/26/2022, Patient #19 stayed in the hospital's ED Crisis Intervention Unit for 5 days, before transferring the patient to Hospital B for Electroconvulsive Therapy.



NC00191444