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Based on review of hospital policy and procedure,medical staff rules and regulations, medical record reviews, staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 2 of 4 sampled DED obstetrical patients (Patient #7 and #4) who presented to the hospital for evaluation and treatment and were discharged to another acute care hospital; and 1 of 1 DED patients who presented to the hospital for evaluation and treatment and was transferred to an acute care psychiatric unit at another hospital (Patient #4).

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

2. The hospital's Dedicated Emergency Department (DED) physician failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize a patient's Emergency Medical Condition (EMC) for 2 of 4 sampled DED obstetrical patients (Patient #7 and #4) who presented to the hospital for evaluation and treatment and were discharged to another acute care hospital; and 1 of 1 DED patients who presented to the hospital for evaluation and treatment and was transferred to an acute care psychiatric unit at another hospital (Patient #4).

~ cross refer to §489.24(d)(1-3) Stabilizing Treatment, Tag A2407.

3. The hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer by: 1) failing to obtain permission from the receiving hospital to transfer 2 of 4 DED obstetrical patients that were discharged to another hospital (Patients #7 and #4), 2) failing to complete a written physician's certification for transfer documenting the medical benefits and/or increased risks associated with the transfer for the specific Emergency Medical Condition (EMC) of the patient in 2 of 4 DED obstetrical patients that were discharged to another hospital (7# and #4), 3) failing to send to the receiving hospital all medical records related to the emergency condition for 2 of 4 DED obstetrical patients that were discharged to another hospital (Patients #7 and #4), 4) failing to ensure the DED physician orders and certifies the appropriate mode and personnel for transfer of 1 of 1 DED patients transferred to an acute care psychiatric unit at another hospital (Patient #9).

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

Based on hospital policy and procedure review, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 2 of 4 sampled DED obstetrical patients (Patient #7 and #4) who presented to the hospital for evaluation and treatment and were discharged to another acute care hospital; and 1 of 1 DED patients who presented to the hospital for evaluation and treatment and was transferred to an acute care psychiatric unit at another hospital (Patient #4).

The findings include:

Review of facility policy "EMTALA Policy, Reference #336" revealed "Policy: The CMS ....(EMTALA) regulations are followed for emergency medical screening treatment, transfer and physician on-call roster policy for ....Regional Medical Center. ...A. Presenting for Care and Medical Screening Examination (Procedure) 1. Any individual who comes to the Emergency Department requesting examination or treatment shall be provided an appropriate medical screening examination. (Points to Remember) 1. An individual will be considered to have come to the Emergency Department if the individual is on hospital premises ....and is requesting care for which may be an emergency condition. This includes pregnant patients who present to OB having contractions. (Procedure) 2. The medical screening examination shall include use of ancillary services routinely available to the Emergency Department. The medical screening examination must be similar for patients presenting with similar symptoms. (Points to Remember) 2. The (Hosptial A) capability to provide medical screening examination includes use of ancillary services and the services of on-call physicians. Hospital services which are routinely utilized by emergency room staff (such as laboratory and radiology) are also utilized in the screening examination regardless of the patient ' s ability to pay. The medical screening examination must be performed according to one standard of care. (Procedure) 3. When providing a medical screening examination, the hospital shall not discriminate against any individual because of diagnosis, financial status, race, color, national origin, or handicap. (Points to Remember) 3. The medical screening examination should not be delayed to obtain financial information during the registration process. (Procedure) 4. The purpose of the medical screening examination is to determine if an individual is experiencing an emergency medical condition. (Points to Remember) 4. An emergency medical condition is a condition manifesting symptoms (including severe pain, psychiatric disturbances, and/or symptoms such as substance abuse) which, in the absence of immediate medical attention, is likely to cause serious dysfunction or impairment to a bodily organ or function or serious jeopardy to the health of the individual or unborn child. A pregnant woman who is having contractions is considered to be in an emergency medical condition if there is not enough time to safely transfer the woman prior to delivery or a transfer would pose a threat to the woman or her unborn child. (Procedure) 5. If an individual presents to the Emergency Department and requests care or treatment and the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform a screening examination appropriate to determine that the individual does not have an emergency medical condition. (Points to Remember) 5. A screening examination is required but is expected to be much more focused and narrow in scope. (Procedure) 6. A medical screening examination may be performed by a physician on the medical staff, medical assistants and obstetrical nurses who are approved by the ....Medical Center Board of Trustees (Points to Remember) 6. Regardless of who performs the medical screening examination, a physician must be responsible for the patient at all times. The medical screening examination is not triage. No obstetrical patient will be released from the facility without a verbal telephone report to the physician and a physician order unless the physician is present and writes the order.
1. Closed DED (Dedicated Emergency Department) Labor and Delivery medical record review of patient #7 revealed a 34 year old pregnant female at 38 weeks gestation who is a gravida 2 (2nd pregnancy) para 0 (no pregnancy carried to 20 weeks). The record review revealed a cerclage (stitch around the cervix to prevent miscarriage or preterm birth) had been removed at 36 weeks gestation (2 weeks prior).
Review revealed the patient was from out of town visiting relatives, and received her prenatal care at another facility 155 miles away (Hospital B). The patient presented to the DED (Dedicated Emergency Department) Labor and Delivery on 10/18/15 at 0230 with complaints of "a gush of fluid at 0145 along with a few strong contractions - contractions less now." Nursing documentation revealed "...placed on EFM (electronic fetal monitor - device to record fetal (baby) heart rate and uterine activity (contractions) ...0250 ...irritability type contractions noted ...0330 - exam (vaginal exam to check cervix for dilation) done - perineum wet - nitrazine + (a test performed to determine presence of amniotic fluid) ...cervix FT (the diameter of a fingertip) / 90% (percentage of effacement - thinning of the cervix) / -1 (station - the relationship of the fetal head to the mother's internal pelvic structure)...Patient and family request to be allowed to leave to go to (Hospital B) where patient plans to deliver. Discussed patients exam and FHR (fetal heart rate) strip with MD #1 - approval given for D/C (discharge) @ 0405. Patient discharged by wheelchair - escorted to vehicle by OB staff."
Telephone interview with MD #1 11/4/15 at 1005 revealed "...the patient did not want us to continue to care for her. She was here visiting family and wanted to go to her primary MD. She declined treatment. I did not transfer her because I didn't think I needed to transfer. It didn't seem like an OB emergency. I thought it was reasonable to go to her primary provider and would have arranged for transfer if the patient were at risk ...I briefly thought about calling (Hospital B), but didn't think it was a serious deal ...I didn't think her request to leave was unreasonable ...we could have sent her records but didn't think to do that. I don't know what the protocol is at (Hospital A) ...I did not sit down and discuss risks of leaving and traveling to (Hospital B)..." Interview further revealed MD #1 did not come in to the Labor and Delivery unit to examine Patient #7. Interview revealed that the risks associated with ruptured membranes could be possible infection, cord prolapse (the umbilical cord drops out of the uterus with or before the presenting part), and fetal heart decelerations (fetus (baby) heart rate drops below normal).
Interview with RN #2 11/4/15 at 1040 revealed "...the patient wanted to get checked and then go to (Hospital B) ...by her dilation (FT/90%/-1) and strip the patient was not in labor ...the patient asked if she could drive herself and MD #1 said she didn't have a problem with it ..." RN #2 further stated that (Hospital B) was not called and a copy of the patient's medical record was not sent with the patient to (Hospital B). Interview further revealed that due to Patient #7 having a cerclage removed, she could potentially deliver the baby very quickly, and that other risks could include prolapsed cord or hemorrhage (loss of blood). Interview revealed, "I would have felt better if she had been transported. This patient should have been transferred, not discharged."
2. Closed DED (dedicated emergency department) Labor and Delivery medical record review of patient #4 revealed a 20 year old pregnant female at 36 weeks gestation who is a gravida 1 (1st pregnancy) admitted to the Labor and Delivery unit on 8/1/15 at 0430 with complaint of "labor-like pain that awoke her about an hour ago..." Nursing documentation revealed "...gets PNC (prenatal care) in (town 37 miles away) ...contr (contractions) 2-3 (minutes apart) 30-40 (seconds) mild ...SVE (sterile vaginal exam) FT (cervix diameter of the fingertip) thick (not effaced (thin)) -1 (station - relationship of the fetal head to the mother's internal pelvic structure) ...with exam gush of fluid (amniotic fluid), nitrazine + ..." Review of MD orders written 8/1/15 at 0520 revealed "...get amnisure (test to verify amniotic membrane rupture) ROM (rupture of membranes) test ...may be discharged so she can go to (hospital C) to see her doctor ..." Further review of nursing documentation revealed "...0555 amnisure positive for ROM ...0605 told can go to (Hospital B) if desires. Pt and family want to go to (Hospital B) ...Pt's mother __ feels confident in taking her daughter to (Hospital C) by private car. Told (patient #4) could have her baby here if she wants. But (patient #4) wants her doctor to deliver her baby ...pt and family anxious to be on their way to (town where Hospital B is located) ...0620 uterine activity - contraction frequency 2-3 (minutes apart) 20-40 (seconds) mild ...0630 ...give instructions to go straight to (Hospital C), do not go home first. Left Labor and Delivery by wheelchair..."
Interview with RN #1 11/4/15 at 0915 revealed "...I would have made a note in the chart if the physician had seen the patient. It is not documented so the physician must not have come ...I give the physician the information and the physician makes the determination ...possible risks for this patient with ruptured membranes include infection and prolapsed cord...(Hospital C) was not called and we did not send a copy of her medical record ..."
Interview with MD #2 11/4/15 at 1130 revealed "...there was not a medically indicated transfer ...I knew the patient to be responsible and felt comfortable that she was safe to travel to (Hospital C) ...the family felt strongly about going to (Hospital C) ...I did not discuss the risks / benefits of traveling to (Hospital C) with ruptured membranes ...the risks associated with traveling to (Hospital C) with ruptured membranes could include car problems, the patient was not in labor ...I did not feel I could certify that this was a medically necessary transfer ..."


22798

3. Closed DED record of Patient #9 revealed a 22 year-old female who presented to Hospital A on 10/17/2015 at 1638 via private vehicle with suicidal ideation. Record review revealed Patient #9 was medically screened by a DED physician at 1647 and was involuntary committed for depression with psychotic features and posttraumatic stress syndrome. Review revealed a Telepsychiatry consult was ordered at 1701. Review of ED Nursing Notes revealed on 10/18/2015 at 0949 (16 hours and 48 minutes later) "Telepsych consult started..." Review revealed at 1045 "...telepsych recommendations rec'd and reviewed by Dr. ..." Review revealed at 1145 "Per (name) with (Hospital D), pt assigned to bed 2221...." Record review revealed an "Emergency Transfer Form...Transfer patient to the services of (MD at receiving hospital) and (Hospital D) who have accepted the patient for transfer. Diagnosis: Bipolar I disorder depressed with psychotic features. Reason for Transfer: (checked) Specialty/Treatment not available. Psychiatry...". Record review revealed the DED physician at Hospital A signed the "Physician's Certification for Transfer" on 10/18/2015 at 1045 and reassessed Patient #9 at 1330. Record review revealed no documentation the physician ordered the mode of transport/qualified personnel to Hospital D for Patient #9. Record review revealed a nurse's note on 10/18/2015 at 1410, "(County Law Enforcement) present to transport pt to (Hospital D)...".
Interview on 11/04/2015 at 1120 with DED Administrative Staff # 1 revealed , "IVC (involuntary commitment) patients are always transported by law enforcement". Interview further revealed there was not a space on the hospital's "Emergency Transfer Form" for the DED physician to order mode of transport and qualified personnel needed for the transport. Interview confirmed the DED physician did not order the mode of transport needed to transport Physician #9 from Hospital A to Hospital D.

Based on policy and procedure review, medical record reviews, staff and physician interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize a patient's Emergency Medical Condition (EMC) for 2 of 4 sampled DED obstetrical patients (Patient #7 and #4) who presented to the hospital for evaluation and treatment and were discharged to another acute care hospital; and 1 of 1 DED patients who presented to the hospital for evaluation and treatment and was transferred to an acute care psychiatric unit at another hospital (Patient #4).

The findings include:

Review of facility policy "EMTALA Policy, Reference #336" revealed "Policy: ...C. Stabilization and Treatment Beyond the Capability of the Emergency Department (Procedure) 1. A patient experiencing an emergency medical condition must be stabilized prior to being discharged or transferred. (Points to Remember) 1. A patient is considered to be stabilized when the treating physician has determined with reasonable clinical confidence that the patient's emergency medical condition has been resolved. ..."

1. Closed DED (dedicated emergency department) Labor and Delivery medical record review of patient #7 revealed a 34 year old pregnant female at 38 weeks gestation who is a gravida 2 (2nd pregnancy) para 0 (no pregnancy carried to 20 weeks). The record review revealed a cerclage (stitch around the cervix to prevent miscarriage or preterm birth) had been removed at 36 weeks gestation (2 weeks prior).
Review revealed the patient was from out of town visiting relatives, and received her prenatal care at another facility 155 miles away (Hospital B). The patient presented to the DED (Dedicated Emergency Department) Labor and Delivery on 10/18/15 at 0230 with complaints of "a gush of fluid at 0145 along with a few strong contractions - contractions less now." Nursing documentation revealed "...placed on EFM (electronic fetal monitor - device to record fetal (baby) heart rate and uterine activity (contractions) ...0250 ...irritability type contractions noted ...0330 - exam (vaginal exam to check cervix for dilation) done - perineum wet - nitrazine + (a test performed to determine presence of amniotic fluid) ...cervix FT (the diameter of a fingertip) / 90% (percentage of effacement - thinning of the cervix) / -1 (station - the relationship of the fetal head to the mother's internal pelvic structure)...Patient and family request to be allowed to leave to go to (Hospital B) where patient plans to deliver. Discussed patients exam and FHR (fetal heart rate) strip with MD #1 - approval given for D/C (discharge) @ 0405. Patient discharged by wheelchair - escorted to vehicle by OB staff."
Telephone interview with MD #1 11/4/15 at 1005 revealed "...the patient did not want us to continue to care for her. She was here visiting family and wanted to go to her primary MD. She declined treatment. I did not transfer her because I didn ' t think I needed to transfer. It didn't seem like an OB emergency. I thought it was reasonable to go to her primary provider and would have arranged for transfer if the patient were at risk ...I briefly thought about calling (Hospital B), but didn't think it was a serious deal ...I didn ' t think her request to leave was unreasonable ...we could have sent her records but didn't think to do that. I don't know what the protocol is at (Hospital A) ...I did not sit down and discuss risks of leaving and traveling to (Hospital B) ..." Interview further revealed MD #1 did not come in to the Labor and Delivery unit to examine Patient #7. Interview revealed that the risks associated with ruptured membranes could be possible infection, cord prolapse (the umbilical cord drops out of the uterus with or before the presenting part), and fetal heart decelerations (fetus (baby) heart rate drops below normal).
Interview with RN #2 11/4/15 at 1040 revealed "...the patient wanted to get checked and then go to (Hospital B) ...by her dilation (FT/90%/-1) and strip the patient was not in labor ...the patient asked if she could drive herself and MD #1 said she didn't have a problem with it ..." RN #2 further stated that (Hospital B) was not called and a copy of the patient's medical record was not sent with the patient to (Hospital B). Interview further revealed that due to Patient #7 having a cerclage removed, she could potentially deliver the baby very quickly, and that other risks could include prolapsed cord or hemorrhage (loss of blood). Interview revealed, "I would have felt better if she had been transported. This patient should have been transferred, not discharged."
2. Closed DED (dedicated emergency department) Labor and Delivery medical record review of patient #4 revealed a 20 year old pregnant female at 36 weeks gestation who is a gravida 1 (1st pregnancy) admitted to the Labor and Delivery unit on 8/1/15 at 0430 with complaint of "labor-like pain that awoke her about an hour ago ..." Nursing documentation revealed "...gets PNC (prenatal care) in (town 37 miles away) ...contr (contractions) 2-3 (minutes apart) 30-40 (seconds) mild ...SVE (sterile vaginal exam) FT (cervix diameter of the fingertip) thick (not effaced (thin)) -1 (station - relationship of the fetal head to the mother's internal pelvic structure) ...with exam gush of fluid (amniotic fluid), nitrazine + ..." Review of MD orders written 8/1/15 at 0520 revealed "...get amnisure (test to verify amniotic membrane rupture) ROM (rupture of membranes) test ...may be discharged so she can go to (hospital C) to see her doctor ..." Further review of nursing documentation revealed "...0555 amnisure positive for ROM ...0605 told can go to (Hospital B) if desires. Pt and family want to go to (Hospital B) ...Pt's mother __ feels confident in taking her daughter to (Hospital C) by private car. Told (patient #4) could have her baby here if she wants. But (patient #4) wants her doctor to deliver her baby ...pt and family anxious to be on their way to (town where Hospital B is located) ...0620 uterine activity - contraction frequency 2-3 (minutes apart) 20-40 (seconds) mild ...0630 ...give instructions to go straight to (Hospital C), do not go home first. Left Labor and Delivery by wheelchair ..."
Interview with RN #1 11/4/15 at 0915 revealed "...I would have made a note in the chart if the physician had seen the patient. It is not documented so the physician must not have come ...I give the physician the information and the physician makes the determination ...possible risks for this patient with ruptured membranes include infection and prolapsed cord...(Hospital C) was not called and we did not send a copy of her medical record ..."
Interview with MD #2 11/4/15 at 1130 revealed "...there was not a medically indicated transfer ...I knew the patient to be responsible and felt comfortable that she was safe to travel to (Hospital C) ...the family felt strongly about going to (Hospital C) ...I did not discuss the risks / benefits of traveling to (Hospital C) with ruptured membranes ...the risks associated with traveling to (Hospital C) with ruptured membranes could include car problems, the patient was not in labor ...I did not feel I could certify that this was a medically necessary transfer ..."


22798

3. Closed DED record of Patient #9 revealed a 22 year-old female who presented to Hospital A on 10/17/2015 at 1638 via private vehicle with suicidal ideation. Record review revealed Patient #9 was medically screened by a DED physician at 1647 and was involuntary committed for depression with psychotic features and posttraumatic stress syndrome. Review revealed a Telepsychiatry consult was ordered at 1701. Review of ED Nursing Notes revealed on 10/18/2015 at 0949 (16 hours and 48 minutes later) "Telepsych consult started..." Review revealed at 1045 "...telepsych recommendations rec'd and reviewed by Dr. ..." Review revealed at 1145 "Per (name) with (Hospital D), pt assigned to bed 2221...." Record review revealed an "Emergency Transfer Form...Transfer patient to the services of (MD at receiving hospital) and (Hospital D) who have accepted the patient for transfer. Diagnosis: Bipolar I disorder depressed with psychotic features. Reason for Transfer: (checked) Specialty/Treatment not available. Psychiatry...". Record review revealed the DED physician at Hospital A signed the "Physician's Certification for Transfer" on 10/18/2015 at 1045 and reassessed Patient #9 at 1330. Record review revealed no documentation the physician ordered the mode of transport/qualified personnel to Hospital D for Patient #9. Record review revealed a nurse's note on 10/18/2015 at 1410, "(County Law Enforcement) present to transport pt to (Hospital D)...".
Interview on 11/04/2015 at 1120 with DED Administrative Staff # 1 revealed , "IVC (involuntary commitment) patients are always transported by law enforcement". Interview further revealed there was not a space on the hospital's "Emergency Transfer Form" for the DED physician to order mode of transport and qualified personnel needed for the transport. Interview confirmed the DED physician did not order the mode of transport needed to transport Physician #9 from Hospital A to Hospital D.

Based on policy and procedure review, closed medical record reviews, staff and physician interviews, the hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer by: 1) failing to obtain permission from the receiving hospital to transfer 2 of 4 DED obstetrical patients that were discharged to another hospital (Patients #7 and #4), 2) failing to complete a written physician's certification for transfer documenting the medical benefits and/or increased risks associated with the transfer for the specific Emergency Medical Condition (EMC) of the patient in 2 of 4 DED obstetrical patients that were discharged to another hospital (7# and #4), 3) failing to send to the receiving hospital all medical records related to the emergency condition for 2 of 4 DED obstetrical patients that were discharged to another hospital (Patients #7 and #4), 4) failing to ensure the DED physician orders and certifies the appropriate mode and personnel for transfer of 1 of 1 DED patients transferred to an acute care psychiatric unit at another hospital (Patient #9).

The findings include:

Review of facility policy "EMTALA Policy, Reference #336" revealed "Policy: ...C. Stabilization and treatment Beyond the Capability of the Emergency Department ...1. A patient experiencing an emergency medical condition must be stabilized prior to being discharged or transferred. A patient is considered to be stabilized when the treating physician has determined with reasonable clinical confidence that the patient's emergency medical condition has been resolved ...E. Patient Transfers to a Medical Facility 1. A patient in an emergency medical condition may be transferred to another medical facility before stabilization if: after being informed of the risks of transfer and the hospital's treatment obligations, the individual requests to be transferred; or based on the information available at the time of transfer, the physician determines that the medical benefits to be received at another medical facility outweigh the risk to the patient of being transferred (including in the case of a woman in labor, the risks to the unborn child) and a certification to this effect is signed by the physician. 2. Appropriate steps shall be taken and treatment provided to minimize the risks associated with the transfer. __ (named facility) must provide the medical treatment necessary to stabilize the patient and reduce the risk of transfer within its capacity. The care and condition of the individual must be documented in the medical record. A copy of the medical record including test results, consent forms, and physician transfer certification must be provided, to the receiving hospital. 3. When a patient requests a transfer, the physician shall discuss the risks associated with the transfer and the services that would be provided if the patient is not transferred. If the patient continues to request a transfer, reasonable steps must be taken to obtain written confirmation of this request from the patient. If the patient requests the transfer against the advice of the physician, this shall be noted in the patient's transfer form. If the patient refused to sign the form, all pertinent information shall be recorded in the patient's medical record. 4. When a physician initiated the transfer, the Emergency Department or on-call physician shall complete the Transfer Certification Form which must include the summary of the risks and benefits of transfer (Form A-262B). For units other than ED (emergency department) and OB (obstetrics/Labor and Delivery), Transfer Form A-262A should be completed. Reasonable steps shall be taken to secure the written consent of the patient for the transfer. If the patient refuses to sign the form, all pertinent information shall be recorded in the medical record. If the patient refuses a transfer that is recommended by a physician, steps shall be taken to obtain this refusal in writing and the same shall be documented in the patient's medical record. 5. In all cases of patient transfer, consent of the receiving hospital and physician must be obtained and documented in the patient's medical record before transfer. This consent is to include that the receiving hospital has available space and qualified personnel to provide treatment to the patient. The patient's condition must be documented in the medical record prior to transfer ...7. Copies of the patient's medical record including, but not limited to, symptoms, preliminary diagnosis, treatment provided, test results, and informed written consent or transfer certification shall be sent with the patient to the receiving hospital. 13. The nurse caring for the patient at this facility should give a report to the nurse at the receiving facility prior to transport ..."
1. Closed DED (dedicated emergency department) Labor and Delivery medical record review of patient #7 revealed a 34 year old pregnant female at 38 weeks gestation who is a gravida 2 (2nd pregnancy) para 0 (no pregnancy carried to 20 weeks). The record review revealed a cerclage (stitch around the cervix to prevent miscarriage or preterm birth) had been removed at 36 weeks gestation (2 weeks prior).
Review revealed the patient was from out of town visiting relatives, and received her prenatal care at another facility 155 miles away (Hospital B). The patient presented to the DED (Dedicated Emergency Department) Labor and Delivery on 10/18/15 at 0230 with complaints of "a gush of fluid at 0145 along with a few strong contractions - contractions less now." Nursing documentation revealed "...placed on EFM (electronic fetal monitor - device to record fetal (baby) heart rate and uterine activity (contractions) ...0250 ...irritability type contractions noted ...0330 - exam (vaginal exam to check cervix for dilation) done - perineum wet - nitrazine + (a test performed to determine presence of amniotic fluid) ...cervix FT (the diameter of a fingertip) / 90% (percentage of effacement - thinning of the cervix) / -1 (station - the relationship of the fetal head to the mother's internal pelvic structure)...Patient and family request to be allowed to leave to go to (Hospital B) where patient plans to deliver. Discussed patients exam and FHR (fetal heart rate) strip with MD #1 - approval given for D/C (discharge) @ 0405. Patient discharged by wheelchair - escorted to vehicle by OB staff."
Telephone interview with MD #1 11/4/15 at 1005 revealed "...the patient did not want us to continue to care for her. She was here visiting family and wanted to go to her primary MD. She declined treatment. I did not transfer her because I didn ' t think I needed to transfer. It didn't seem like an OB emergency. I thought it was reasonable to go to her primary provider and would have arranged for transfer if the patient were at risk ...I briefly thought about calling (Hospital B), but didn't think it was a serious deal ...I didn ' t think her request to leave was unreasonable ...we could have sent her records but didn't think to do that. I don't know what the protocol is at (Hospital A) ...I did not sit down and discuss risks of leaving and traveling to (Hospital B) ..." Interview further revealed MD #1 did not come in to the Labor and Delivery unit to examine Patient #7. Interview revealed that the risks associated with ruptured membranes could be possible infection, cord prolapse (the umbilical cord drops out of the uterus with or before the presenting part), and fetal heart decelerations (fetus (baby) heart rate drops below normal).
Interview with RN #2 11/4/15 at 1040 revealed "...the patient wanted to get checked and then go to (Hospital B) ...by her dilation (FT/90%/-1) and strip the patient was not in labor ...the patient asked if she could drive herself and MD #1 said she didn't have a problem with it ..." RN #2 further stated that (Hospital B) was not called and a copy of the patient's medical record was not sent with the patient to (Hospital B). Interview further revealed that due to Patient #7 having a cerclage removed, she could potentially deliver the baby very quickly, and that other risks could include prolapsed cord or hemorrhage (loss of blood). Interview revealed, "I would have felt better if she had been transported. This patient should have been transferred, not discharged."
2. Closed DED (dedicated emergency department) Labor and Delivery medical record review of patient #4 revealed a 20 year old pregnant female at 36 weeks gestation who is a gravida 1 (1st pregnancy) admitted to the Labor and Delivery unit on 8/1/15 at 0430 with complaint of "labor-like pain that awoke her about an hour ago ..." Nursing documentation revealed "...gets PNC (prenatal care) in (town 37 miles away) ...contr (contractions) 2-3 (minutes apart) 30-40 (seconds) mild ...SVE (sterile vaginal exam) FT (cervix diameter of the fingertip) thick (not effaced (thin)) -1 (station - relationship of the fetal head to the mother's internal pelvic structure) ...with exam gush of fluid (amniotic fluid), nitrazine + ..." Review of MD orders written 8/1/15 at 0520 revealed "...get amnisure (test to verify amniotic membrane rupture) ROM (rupture of membranes) test ...may be discharged so she can go to (hospital C) to see her doctor ..." Further review of nursing documentation revealed "...0555 amnisure positive for ROM ...0605 told can go to (Hospital B) if desires. Pt and family want to go to (Hospital B) ...Pt's mother __ feels confident in taking her daughter to (Hospital C) by private car. Told (patient #4) could have her baby here if she wants. But (patient #4) wants her doctor to deliver her baby ...pt and family anxious to be on their way to (town where Hospital B is located) ...0620 uterine activity - contraction frequency 2-3 (minutes apart) 20-40 (seconds) mild ...0630 ...give instructions to go straight to (Hospital C), do not go home first. Left Labor and Delivery by wheelchair ..."
Interview with RN #1 11/4/15 at 0915 revealed "...I would have made a note in the chart if the physician had seen the patient. It is not documented so the physician must not have come ...I give the physician the information and the physician makes the determination ...possible risks for this patient with ruptured membranes include infection and prolapsed cord...(Hospital C) was not called and we did not send a copy of her medical record ..."
Interview with MD #2 11/4/15 at 1130 revealed "...there was not a medically indicated transfer ...I knew the patient to be responsible and felt comfortable that she was safe to travel to (Hospital C) ...the family felt strongly about going to (Hospital C) ...I did not discuss the risks / benefits of traveling to (Hospital C) with ruptured membranes ...the risks associated with traveling to (Hospital C) with ruptured membranes could include car problems, the patient was not in labor ...I did not feel I could certify that this was a medically necessary transfer ..."


22798

3. Closed DED record of Patient #9 revealed a 22 year-old female who presented to Hospital A on 10/17/2015 at 1638 via private vehicle with suicidal ideation. Record review revealed Patient #9 was medically screened by a DED physician at 1647 and was involuntary committed for depression with psychotic features and posttraumatic stress syndrome. Review revealed a Telepsychiatry consult was ordered at 1701. Review of ED Nursing Notes revealed on 10/18/2015 at 0949 (16 hours and 48 minutes later) "Telepsych consult started..." Review revealed at 1045 "...telepsych recommendations rec'd and reviewed by Dr. ..." Review revealed at 1145 "Per (name) with (Hospital D), pt assigned to bed 2221...." Record review revealed an "Emergency Transfer Form...Transfer patient to the services of (MD at receiving hospital) and (Hospital D) who have accepted the patient for transfer. Diagnosis: Bipolar I disorder depressed with psychotic features. Reason for Transfer: (checked) Specialty/Treatment not available. Psychiatry...". Record review revealed the DED physician at Hospital A signed the "Physician's Certification for Transfer" on 10/18/2015 at 1045 and reassessed Patient #9 at 1330. Record review revealed no documentation the physician ordered the mode of transport/qualified personnel to Hospital D for Patient #9. Record review revealed a nurse's note on 10/18/2015 at 1410, "(County Law Enforcement) present to transport pt to (Hospital D)...".
Interview on 11/04/2015 at 1120 with DED Administrative Staff # 1 revealed , "IVC (involuntary commitment) patients are always transported by law enforcement". Interview further revealed there was not a space on the hospital's "Emergency Transfer Form" for the DED physician to order mode of transport and qualified personnel needed for the transport. Interview confirmed the DED physician did not order the mode of transport needed to transport Physician #9 from Hospital A to Hospital D.

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