HospitalInspections.org

Based on document review and staff interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure an OB patient in active labor was appropriately transferred. (A-2409)

A. Based on document review and interview, it was determined that for 1 of 6 (Pt. #1) obstetrical (OB) patient records reviewed for transfer to another facility, the Hospital failed to ensure an OB patient in active labor was appropriately transferred. This has the potential to affect all Emergency Department (ED) and OB patients being transferred.

Findings include:

1. The Hospital's policy titled, "Cobra Compliance on Patient Screening and Transfer (approved 01/21/22)," was reviewed on 02/03/23 at approximately 11:00 AM. The policy stated on page #3, "V. Transfers... a. When Patient Has an EMC (Emergency Medical Condition) or is in Active Labor- No patient suffering from an EMC or active labor shall be transferred until stabilized, unless in the medical judgment of the responsible physician the hospital is incapable of providing reasonably necessary or anticipated care for the patient, or, in the case of active labor, the mother and/or unborn child, and maintain the stability of the patient(s).... c. Requirements Prior to Transfer - No patient shall be transferred pursuant to the above until the responsible physician has: i. Obtained advanced acceptance by the receiving facility... ii. Determined that the receiving facility has available space and qualified personnel to treat the condition of the patient.... vi. Personally conveyed his/her medical assessment of the patient to the responsible physician at the receiving hospital by two-way voice communication.... ix. Informed Consent 1. When possible, the responsible physician or physician designee shall obtain written informed consent from the patient... x. Documentation 1. Physician's Certificate of Transport (COBRA FORM/PCT) Must be completed on all patients transferring and/or going to higher level of care... Definitions: 'Active Labor' means labor or impending labor.... A woman experiencing contractions is considered to be in active labor unless a physician certifies, after a reasonable observation period, the woman is in false labor."

2. The clinical record of Pt. #1 at Hospital A was reviewed on 02/02/23. Pt. #1 presented to Hospital A's emergency department (ED) on 01/26/22, at 6:03 PM for "OB check." Pt was taken to OB and the "OB Triage" record at 6:23 PM by OB RN (E #3) stated, "Complaint: contractions every 10 minutes that started around 2:00 PM. Intake Pain Scale - 5... Subjective Assessment.. Fetal Movement: Present, Contractions: Present, ROM (Rupture of Membranes): Unknown... Objective Assessment Uterus: Soft, Non-tender.. Pain Type: Cramping, Back Pain... Skin Temperature: Warm, Dry, Cheeks flushed." The following was noted in the record.

- At 6:28 PM OB Triage note by E #3 stated, "(Pt) states baby breech as of last week and scheduled for primary c/s (cesarean section) on 2-7 at (Hospital B)." A urine specimen was collected at 6:30 PM. An Amnisure test (checks for the presence of amniotic fluid to assess for rupture of membranes) was collected at 6:36 PM which indicated the membranes had not ruptured.

- At 6:36 PM, OB triage note stated, "Cervical Exam - Dilatation: 0.0, Effacement 25, Station -4 not engaged."

- At 7:00 PM, OB triage note by OB RN (E #4) stated, "Uterine Activity - .. Contraction Frequency 6-10 (minutes), Contraction Duration: 80-130 (seconds), Contraction Quality: Moderate.. Fetal Assessment - FHR (Fetal Heart Rate) Baseline Range 120... Variability: Moderate (6 to 25 beats per minute)."

- At 7:45 PM, OB Triage note by E #4 stated "Patient states that (Pt) no longer feels contractions but is no feeling low abdominal cramping and still has the constant back pain."

- At 7:57 PM, the record indicated OB MD (E # 5) was notified of "patients chief complaint on arrival, complaints now, vitals, lab results, FHTs, contractions and SVE (sterile vaginal exam)." The record also stated "Orders received: Yes Recheck (Pt) cervix now and give 2 liters of LR (Lactated Ringers - intravenous solution for hydration) over 2 hours. If the patient is still complaining of pain then recheck (Pt) cervix again after the 2 liters is complete."

- At 8:00 PM, the record stated, " Uterine Activity - Contraction frequency - 2 minutes, Contraction Duration: 70-80 seconds, Contraction quality Moderate."

- At 8:10 PM the record stated, "Cervical Exam - Dilatation: outer os 3 cm (centimeter) inner os closed, Effacement: THICK, Station -4.

- At 8:18 PM the first fluid bolus was started.

- At 9:00 PM Pt #1's record indicated, "Contraction Frequency: 3-11 minutes, Contraction Duration: 60-80 seconds.

- At 9:16 PM the 2nd liter of intravenous fluids were infusing.

- At 9:20 PM the record stated, "Uterine Activity - Dilatation: Unchanged from 8:10 PM check.

- At 9:35 PM, an OB Triage note by E #4 "Doctor Notified - Notified of the unchanged cervix. Also that the patient states that if this is labor (Pt) wants to deliver at (Hospital B) just in case the baby needs the NICU (Neonatal Intensive Care Unit). Orders Received: Yes. (E #5) was fine with discharging the patient as long as she goes to (Hospital B) to be evaluated there. IV (intravenous) fluids can be stopped and discontinue the IV. Patient is stable to go to (Hospital B) by personal vehicle."

- At 9:40 PM the OB Triage Note stated, "Uterine Activity.. Contraction Frequency: 3-8 minutes, Contraction Duration: 50-90 seconds, Contraction Quality: Moderate."

- At 9:45 PM, the record stated, "Discharge Instructions reviewed with the patient. the patient is to go to (Hospital B) from leaving here. Patient verbalized understanding. Patient states that (Pt's) (Family member) is getting (Pt) bags and will be coming to get (Pt) and take (Pt) to (Hospital B)."

- At 10:00 PM, Pt #1 was discharged.

- The clinical record lacked documentation of nurse-to-nurse and/or physician-to-physician communication made with the receiving hospital (Hospital B) to accept Pt. #1's transfer. The clinical record also lacked documentation of any completed transfer forms.

3. The clinical record of Pt. #1, from Hospital B, was reviewed on 02/02/23. Pt. #1 presented to Hospital B's ED on 01/26/23, at 11:01 PM. The OB nursing note at 11:02 PM stated, "Remarks: Patient presents to triage with contractions every 2 minutes. Baby is known to be breech. (OB MD, MD #2) at bedside. SVE. Breech presentation confirmed by BSUS (bedside ultrasound)." The following was noted in the record.

- Pt #1's OB History and Physical was completed by MD #2 at 11:18 PM stated, "(Pt) is a ... G2P1001 (Gravida- Pregnancies, Para- births, 1001 - 1 term pregnancy, no pre-term, no abortion, 1 living child) at 37 weeks 5 days... who is being admitted for cesarean delivery due to breech malpresentation in the setting of spontaneous labor.... This pregnancy has been complicated by: High Risk NIPT (Noninvasive Prenatal Testing) for Trisomy 21, bilateral fetal ventriculomegaly (enlarged ventricles in the brain).... Objective... SSE (sterile speculum exam): 5/90/0 (dilatation:5, effacement: 90, station: 0). contractions: every 2-3 minutes."

- Nursing Note indicated Pt #1 was transferred to OR on 01/27/23 at 12:01 AM.

-The Brief Operative Note completed by MD #2 stated, "Procedure: Primary low transverse cesarean section... Complications: Terminal fetal bradycardia (low heart rate) following spontaneous rupture of membranes necessitating splash prep."

- Pt #1's clinical record indicated Pt #1's baby was admitted to the NICU at birth and Pt #1 was discharged on 1/30/23.

4. An interview was conducted with OB RN (E #3) on 02/02/23, at approximately 11:45 AM. E #3 stated, "Pt complained of contractions since 2:00 PM. (Pt) was unsure if it was labor so (Pt #1) drove self here to get checked out. (Pt #1) was scheduled for a c-section at (Hospital B) because (Pt) had testing at 28 weeks which indicated a high probability of Trisomy 21 and (Pt #1) wanted to be able to be with the baby if it needed higher level of care. (Pt #1) stated as of the last ultrasound, the baby was breech. I obtained vital signs, placed the patient on the fetal monitor, collected a urine and checked an Amnisure. (Pt #1) was having contractions about 10 minutes apart. I did a vaginal exam. When you've previously delivered a baby, the external os (outside opening of the cervix) does not completely close. So, I could insert one finger into the external ox, which would be expected. The inner os was closed. It didn't surprise me that the inner os was closed as the baby was said to be breech so there would not be pressure on the os to make it open. The patient had asked me about decelerations (of baby's heart rate which could indicate stress on the baby) because she had some variable ones previously. I told (Pt #1) that everything looked okay. I gave report to the oncoming nurse. Before I left, the nurse called down the hall to me and re-verified my cervical os findings. The nurse said she was able to insert 3 fingers (indicating 3 cm dilation) into the external os. It was indicating the patient was progressing. I then left as my shift was over."

5. A telephone interview was conducted with OB RN (E #4) on 02/02/23, at approximately 2:00 PM. E #4 stated, "I got report and was told the patient had an essentially closed outer os and the inner os was closed. Pt had stated (Pt #1) was feeling some contractions but complained more of cramping. I measured and the inner os was still closed and the outer os was at a 3. I noticed a changed and called (MD #1) at updated (MD #1). (MD #1) ordered 2 boluses of fluid and said to recheck the patient after the first fluid bolus. After the first fluid bolus, I checked and there was no change. Pt was still complaining of cramping. I called the physician again to update with that information. MD #1 asked me to ask (Pt #1) if (Pt #1) felt was in labor. (Pt #1) didn't know if (Pt#1) was in labor, just felt crampy. MD #1 then asked if (Pt #1) would ultimately want to deliver at this hospital with a possibility of baby transferring to (Hospital B) or if (Pt #1) wanted to just deliver at (Hospital B). (Pt #1) wanted to deliver at (Hospital B) and be with the baby at (Hospital B). (MD #1) felt (Pt #1) was stable for discharge and was to go straight to (Hospital B) for further evaluation. (Pt #1) was discharged with (family member) to go straight to (Hospital B). The patient was discharged so there was no transfer papers. All communication with MD #1 was via the phone. MD #1 was not present at the hospital. Normally, the OB physicians will come in and evaluate patients if there is a need to transfer. The physician will make the calls and get an accepting physician. Then we will arrange for transport. Most of the time (Hospital B) will send an ambulance or helicopter for transport as that is where transfer 99% of the time."

6. A interview was conducted with the OB MD (MD #1) on 02/02/23, at approximately 2:30 PM. MD #1 stated, "I had seen this patient prenatally in the office. (Pt #1) had testing done early and was aware there was a high probability of Trisomy. The plan was to deliver at (Hospital B) due to the Trisomy. When (Pt #1) came in the nurse called me and said (Pt #1) is contracting but not dilated. The external os was open, which could be normal from previous delivery. We knew the baby was breech and there was a scheduled c-section at (Hospital B). I was under the impression, (Pt #1) was having contractions but not in active labor. I instructed the nurse to give IV fluids and recheck. After the re-check there was no change. If (Pt #1) wanted to deliver here we would watch (Pt #1). Otherwise, (Pt #1) could go to (Hospital B). I don't recall if I told (E #4) to have (Pt #1) go directly to (Hospital B). I might have told (E #4) that. All communication with the OB nurse was by phone. The OB nurses are trained to do an assessment. If there are concerns, the physicians will come in to evaluate and make the decision to transfer in conjunction with the specialist at the receiving facility. In the past, we've had stable patients that may have underlying problems that may have opted to go home and then would go to the other hospital if things changed. I did not have any communication with (Hospital B). In reflecting on this situation, it would be an EMTALA (Emergency Medical Treatment and Labor Act) violation. I've spoken with (CEO - with previous ER experience) and the OB nurses. We went over the rules and expectations regarding EMTALA violations.

7. An interview with the Chief Nursing Officer (E #5) was conducted on 02/03/23 at approximately 9:00 AM. E #5 stated, "(Hospital B) legal called (Hospital A) legal to notify us of a concern related to EMTALA. I called OB to ask what they knew about the situation. (Day shift RN - E #6) was aware of the pt and got me the triage record I requested. (E #6) did not directly care for the pt but was aware of the pt. I asked if we sent the pt without calling (Hospital B). E #6 said that (MD #1) said because (Pt #1) didn't progress it was okay to discharge and send to (Hospital B). I explained to the OB staff that because (Pt #1) was discharged and sent directly to (Hospital B) there should have been communication with (Hospital B) and transfer forms completed. As we were discussing the situation, we realized a difference in the definition of 'Active Labor' between the American College of Obstetricians and Gynecologists and EMTALA regulations. Active Labor is anyone having contractions. In this situation there should have been communication with (Hospital B) and transfer forms completed and there was not."