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Based on interview, policy review, and record review, the hospital had a failure to provide stabilization for one patient (#4) of 30 Emergency Department (ED) and Obstetric (OB) records reviewed. This had the potential to affect all patients who were in need of stabilization. The hospital's ED average monthly census over the past six months was 1500. The OB Department averaged 40 patients each month.

Please refer to A-2407 for details.

Based on interview and record review, the hospital failed to provide stabilization for one patient (#4) of 30 Emergency Department (ED) and Obstetric (OB) records reviewed. This failure had the potential to affect all patients who required stabilization. The hospital's ED average monthly census over the past six months was 1500. The OB Department averaged 40 patients each month.

Findings included:

Review of the hospital's policy titled, "Lebanon Labor EMTALA," dated 01/23/20, showed that if the hospital determines that an individual has a medical emergency, it must stabilize the condition or provide for an appropriate transfer. The decision to transport is determined by factors that may include but are not limited to gestational age less than 36 weeks, the stage of labor, the medical status of the mother or the fetus (unborn child), and the availability of services required. The transferring physician certifies in writing that the benefits expected from the treatment at another facility outweigh the increased risks to the individual or unborn child from the transfer. The hospital is obligated to assure and document that the patient has been provided information regarding the hospital's obligation for examination and treatment, the risks/benefit ratio of the proposed transfer, and a signed informed consent.

Review of Ambulance #1's report, dated 09/14/20, showed that an ambulance was dispatched to a residence for a 21-year-old female who was suffering from abdominal pain. The ambulance arrived at the scene at 6:58 PM, and the crew documented that Patient #4 was pregnant, complained of lower abdominal pain that radiated to her back, and that she had a sensation to push and "pee". The ambulance arrived at the hospital's OB unit on 09/14/20, at 7:27 PM.

Review of the medical record, showed that Patient #4, a 21-year-old uninsured female pregnant at 23 weeks, 5 days gestation arrived at the hospital's obstetrical unit on 9/14/2020 at 7:30 PM in active preterm labor and placed in outpatient observation (not admitted to the hospital as an inpatient). At 9:08 PM, OB physician I documented under "OB History and Physical" that patient # 4 "is feeling a regular pelvic cramping but states that it is severe in nature." Further documentation showed "Of note, the patient has (sic) not a current patient of the Mercy OB/GYN system and has an outside provider and (sic) Rolla." Under "Physical Exam" OB physician I documented he performed a sterile vaginal exam and that the patient had "Bulging amniotic membranes, unable to fully evaluate cervix." OB physician I performed a speculum exam and documented "Unable to complete based on bulging membranes." Under "Assessment/Plan" OB physician I documented "Advanced preterm labor" - "Patient with exam findings consistent with advanced cervical dilation and bulging fetal membranes." "High risk of imminent delivery." Further documentation showed OB physician I ordered a medication (Procardia) to suppress patient # 4's premature labor, a medication (BMZ 12 mgn) used to mature lung function in fetuses at risk for preterm delivery, an antibiotic medication (Ancef ) to prevent group B streptococcus infection in a newborn, an infusion of magnesium sulfate to aid in slowing preterm labor and to prevent injuries to a preterm baby's brain, and then began the process of arranging transfer to Hospital B's Labor and Delivery unit located 150 miles away.

At 10:45 PM OB physician I documented that patient # 4 "has advanced cervical dilation and is currently not actively contracting" and that Hospital B had agreed to accept the transfer at 10:22 PM. Under "Details of Transfer" OB physician I documented that the ambulance transporting patient # 4 to Hospital B was equipped with basic life support equipment (meaning the ambulance did not have the appropriate equipment for managing advanced life support or a preterm delivery). Under "Transfer Benefits" OB physician I documented that Hospital B had an available Neonatal Intensive Care Unit (NICU), and under "Transfer Risks" OB physician I documented "Delivery en route, Miscarriage, Worsening vaginal bleeding, Progression of labor, Fetal demise, Increased pain."

Review of Ambulance #2's report, dated 09/14/20, indicated that the ambulance crew arrived at Patient #4's bedside on the hospital OB unit at 11:39 PM. The ambulance crew documented that the Registered Nurse (RN) stated the patient was 23-weeks pregnant and presented on 09/14/20, at 7:30 PM with complaint of contractions, and that this was her first pregnancy. The RN stated that Patient #4 was on Magnesium Sulfate (a medication used to prevent seizures in pregnancy) and Lactated Ringers (intravenous fluid that contains electrolytes) infusion. "RN states patient is in stable condition & has had no recent contractions, however, upon making patient contact patient started to c/o (complain of) having contractions." "RN made visual inspection to find no crowning." Further documentation showed that at 36.9 miles into the 150 miles transport, at 12:22 AM on 9/15/2020 patient # 4 precipitously delivered in the ambulance forcing the ambulance crew to emergently divert to the closest hospital (Hospital D, a military health system hospital).

Review of a 9/15/2020 air ambulance trip report dispatched to Hospital D at 7:14 AM showed that patient # 4 "was being transported by ground ambulance to an outside hospital (Hospital B) and precipitously delivered a 23 week fetus in an ambulance prior to arrival." "Patient arrived to the outside hospital (Hospital D) 10 minutes later and had an estimated blood loss of greater than 500 mls (1/2 liter)." Further documentation showed a critical care transport team transported patient # 4 and her newborn baby to Hospital E for further stabilizing treatment.

Review of the hospital provided emailed documents dated 11/09/20, at 5:04 PM, showed that OB nursing staff had successfully completed the Neonatal Resuscitation Program (NRP) curriculum of the American Academy of Pediatrics and American Heart Association for resuscitating infants who are not breathing or have a pulse at the time of delivery and/or immediately afterwards.
- Staff H, Primary OB RN, was NRP certified with an expiration date of 11/30/2020.
- Staff J, RN, was NRP certified with an expiration date of 06/30/2021.
- Staff M, Secondary OB RN, was NRP certified with an expiration date of 09/30/2022.

During an interview on 09/16/20 at 4:45 PM, Staff F, OB and Nursery Manager, stated that she would not have let Patient #4 be transferred with a bulging bag and complete dilation of the cervix. She had called Hospital C (60 miles away), in the past, and they had sent the Neonatal Intensive Care Unit (NICU, unit for premature and ill newborns) team, when a baby had been delivered at the hospital and needed resuscitation.

During an interview on 09/17/20 at 9:34 AM, Staff L, experienced OB/GYN, (on staff at the hospital for eight years and had a total of 35 years of experience, but not involved in Patient #4's care) stated that in his professional opinion, Patient #4 should not have been transferred. He had heard about Patient #4 being transferred, and he had discussed the event with Staff I, OB/GYN, the morning after the transfer occurred.

During a telephone interview on 09/23/20 at 11:05 AM, Staff U, OB RN, Hospital B, stated that:
- She was the labor and delivery Charge Nurse on 09/14/20 and spoke to Staff I, OB/GYN, when he called about a patient that he wanted to transfer.
- Staff I, OB/GYN, told her that Patient #4 was a first time 23-week-pregnant female with a bulging bag.
- Staff I, OB/GYN, stated that he was unsure of the cervical dilation due to the bulging bag, and was concerned about amniotomy (artificial rupture of the amniotic sac) upon exam, but the bag had not moved down since his initial exam.
- Staff I, OB/GYN, stated that Patient #4 had been contracting and said, "I don't have anything for neonatal resuscitation and I can't deliver her here."
- She was concerned about Patient #4 riding in an ambulance, and told Staff I, OB/GYN, that she was concerned about a high-risk delivery, and offered the NICU team. She gave Staff I, OB/GYN, the contact information for the high-risk specialty service, in case the resuscitation team was needed.
- Staff N, MFM, called Staff U, OB RN, Hospital B, to discuss the report of Patient #4 that she had received from Staff I, OB/GYN, because Staff N, MFM, thought the transport would be safe.
- She told Staff N, MFM, she was concerned that the transport of Patient #4 would not be safe because when she asked Staff I, OB/GYN, about checking the dilation of the cervix and the bulging bag, he had told her that he was unsure of the cervical dilation due to the bulging bag.

During an interview on 09/17/20 at 7:54 AM, Staff I, OB/GYN, stated that:
- He examined Patient #4 and she was completely dilated with a bulging bag of water.
- Staff K, Pediatrician (a specialty physician focused on the care of babies, children, adolescents, and young adults), stated that babies usually go to Hospital B if they were 23 weeks. The cut off for resuscitation was 23 weeks at the hospital.
- There was no contact made with Hospital C, which was 60 miles away, and had a NICU. Staff K, Pediatrician, told him that Hospital C did not do 23-week resuscitations and they could not handle a 23-week baby.
- He called the OB floor at Hospital B, and spoke to the Generalist OB, who did not accept the transfer, because Patient #4 was a high-risk delivery, and that was not his expertise.
- He called Staff N, MFM, on call at Hospital B, who specialized in high-risk deliveries, and asked, "What would you do with a 23 week pregnant patient who has a bulging bag of water?", and Staff N, MFM, said he could transfer Patient #4 to Hospital B.
- He offered to keep Patient #4 overnight, and then transport, but Staff N, MFM, told him he would not need to do that. He could transfer Patient #4 now.
- He called Labor and Delivery at Hospital B, and spoke to Staff U, RN, who told him he could not transfer Patient #4. He told Staff U, RN, that Staff N, MFM, recommended the transfer, and there were no other options. This hospital did not have the capabilities to care for a 23-week old baby that would require a stay in the NICU.
- He called to speak with the NICU Physician, (whose name he did not recall) at Hospital B, and requested them to send a crew of NICU doctors.
- The NICU Physician called back and stated that it was not feasible to have a NICU team sitting there when they had no idea when Patient #4 would deliver. His recommendation was to transfer Patient #4 to where the NICU doctors were located at Hospital B.
- He spoke to Staff N, MFM, again, stating that Staff U, RN, told him he could not transfer Patient #4, even though she had recommended transfer, and the NICU Physician recommended transfer. Staff N, MFM, told him that she would call and get Hospital B to accept the transport.

Review of Hospital Licensure data showed that Hospitals C and E, located approximately 60 miles from Mercy Hospital Lebanon had a 28 bed and 46 bed respectively, Level III Neonatal Intensive Care unit (Level IV is the highest level) capable of providing care to premature and critically ill infants. Hospital E's capabilities include a neonatal transport team that provides transport for critically ill newborns to its NICU.

During an interview on 09/17/20 at 7:35 AM, Staff H, Primary OB RN, stated that:
- She performed a vaginal exam and documented that Patient #4 was fully dilated with a bulging bag.
- Staff I, OB/GYN, had approval from Staff N, MFM, Hospital B, to transfer Patient #4.
- Staff U, RN, from Hospital B, called back and said that they would not take Patient #4.
- Staff N, MFM, called back and said it was okay to transfer Patient #4, even though Staff U, RN, said that it was not okay.
- She would not normally transport a fully dilated patient, because they can deliver at any time, but Hospital B said they would take Patient #4.

During a telephone interview on 09/17/20 at 10:08 AM, Staff M, Secondary OB RN, stated that:
- She heard Staff I, OB/GYN, call Staff N, MFM, and speak to her about transferring Patient #4.
- She heard Staff I, OB/GYN, speaking with Staff U, RN, from Hospital B, who did not want him to send Patient #4.
- She heard Staff I, OB/GYN, speaking with the Staff N, MFM, again, who told him to transfer Patient #4.
- Hospital D, called to get report on Patient #4, who had given birth en route to Hospital B, and this hospital was not aware that Patient #4 had delivered en route.

During an interview on 09/17/20 at 8:38 AM, Staff K, Pediatrician, stated that:
- Staff I, OB/GYN, had examined Patient #4 and had discovered that she had bulging membranes and was fully dilated.
- He heard that Patient #4's contractions were not consistent.
- He witnessed the discussions that Staff I, OB/GYN, had with the generalist OB on call and Staff N, MFM, at Hospital B, and he was aware that the Staff N, MFM, had accepted the transfer of Patient #4.

During a telephone interview on 09/17/20 at 1:28 PM, Staff N, MFM, Hospital B, stated that:
- She received a call on 09/14/20, at 8:52 PM from Staff I, OB/GYN, stating that he had an urgent consult.
- Patient #4 was 23 weeks pregnant and had a bulging bag of water, but she was not aware of the cervical dilation.
- She then called the Hospitalist (physician whose primary professional focus in the general medical care of hospitalized patients) to inform them of the transfer, and Staff U, RN, was with the Hospitalist at that time.
- At about 10:00 PM, she received another call from Staff I, OB/GYN, stating that he was having issues transferring Patient #4, because Staff U, RN, Hospital B, had told him he could not transfer Patient #4.
- She then called Staff U, RN, discussed Patient #4, and informed Staff U, RN, that she had accepted the transfer of Patient #4.
- She offered the NICU team, but Staff I, OB/GYN, declined, saying that the labor slowed and there was enough time to transfer.
- When asked if Patient #4 was stable for transfer, her response was that she could not speak to that because it was hard to predict with a bulging bag of fluid.

During a telephone interview on 09/21/20 at 8:41 PM, Staff Q, Paramedic, Ambulance #1, stated that:
- Patient #4 was at her home, tearful, and stated she could not walk, so he carried her to the Emergency Medical System (EMS) cot.
- Patient #4 was having contractions and he instructed her to tell him when it started and when it stopped.
- En route to the hospital, Patient #4 stated that she had to go to the bathroom, which was a possible sign of active labor, and wanted to push. He informed Patient #4 that was not a good idea.

During a telephone interview on 09/23/20 at 9:02 AM, Staff S, Paramedic, Ambulance #2, stated that:
- He was told that Patient #4 was a first-time pregnant, 21-year old female who, at the time, was not having any contractions.
- Patient #4 was transferred to the EMS cot and complained of pain. Patient #4 was examined by a nurse, who stated that there was no crowning.
- He was not aware of the extent of cervical dilation for Patient #4.
- Patient #4 complained that, "the baby was going to come".
- He monitored Patient #4 in the ambulance, but did not have equipment available to monitor the baby. He did not have a cardiac monitor or oxygen for the baby.
- While en route, he delivered the baby who had a weak cry and was breathing. He suctioned the baby and gave her to Patient #4 to keep warm, until they arrived at Hospital D.