HospitalInspections.org

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the emergency department (ED) staff followed their policies and provided all available stabilizing treatment to 1 of 1 patient who presented to the Emergency Department (ED) between 6/1/17 and 12/4/17 with an obstetrical complaint (Patient #3). The CAH's administrative staff identified an average of 428 patients per month who presented to the ED and requested emergency medical care.

Failure to follow the CAH's policies and provide all available stabilizing treatment, including administration of tococlytics (anti-contraction medications to prolong pregnancy for women in preterm labor) or delivery of the baby, resulted in the CAH staff sending a pregnant patient who was actively in labor 20 miles to another CAH without assurance there was sufficient time to effect a safe transfer. The failure to provide all available stabilizing treatment could have resulted in the patient delivering the baby in the ambulance, and the ambulance staff lacking the ability to adequately provide care to a very pre-term baby.

Findings included:

1. Review of the policy "EMTALA (Transfer & Emergency Examination)" revised 01/2016, revealed in part, "A pregnant woman experiencing contractions shall be provided a medical screening examination.... If there are signs and symptoms of labor, this examination shall be designed to determine [if there is] ... inadequate time to affect a safe transfer prior to delivery or transfer may pose a threat to the health or safety of the woman [or] the unborn child." "If a pregnant woman is ... determined to be in labor, this condition cannot be 'stabilized' as defined by EMTALA. Accordingly, no transfer may be made of such a patient..."

2. Review of Patient #3's medical record revealed Patient #3 presented to the CAH's ED on 11/26/17 at 11:41 PM complaining of abdominal pain. ED Registered Nurse (RN) A noted Patient #3 was 26 weeks pregnant and experiencing labor like cramps. ED Physician B determined Patient #3 was in active labor. The CAH staff decided to transfer Patient #3 to Recipient Hospital A while Patient #3 was in active labor. Patient #3 delivered her very premature baby shortly after arriving at Recipient Hospital A.

Please refer to C-2407 for additional information.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 patients who presented to the Emergency Department (ED) between 6/1/17 to 12/4/17 with an obstetrical complaint (Patient #3) received appropriate stabilizing treatment. The CAH's administrative staff identified an average of 428 ED patients per month who presented and requested emergency medical care.

Failure to provide all available stabilizing treatment, including administration of tocolytics (anti-contraction medications that prolong pregnancy for women in premature labor) or delivery of the baby, resulted in the CAH staff sending a pregnant patient who was actively in labor 20 miles to another CAH without assurance there was sufficient time to effect a safe transfer. The failure to provide all available stabilizing treatment could have resulted in the patient delivering the baby in the ambulance, and the ambulance staff lacking the ability to adequately provide care to a very pre-term baby.

Findings included:

1. Review of the policy "EMTALA (Transfer & Emergency Examination)" revised 01/2016, revealed in part, "A pregnant woman experiencing contractions shall be provided a medical screening examination.... If there are signs and symptoms of labor, this examination shall be designed to determine [if there is] ... inadequate time to affect a safe transfer prior to delivery or transfer may pose a threat to the health or safety of the woman [or] the unborn child." "If a pregnant woman is ... determined to be in labor, this condition cannot be 'stabilized' as defined by EMTALA. Accordingly, no transfer may be made of such a patient..."

2. Review of Patient #3's medical record revealed Patient #3 presented to the CAH's ED on 11/26/17 at 11:41 PM complaining of abdominal pain. ED Registered Nurse (RN) A noted Patient #3 was 26 weeks pregnant and experiencing labor like cramps. ED Physician B determined Patient #3 was in active labor. Initially, ED Physician B determined Patient #3 was fully dilated (her cervix was fully open and ready to deliver the baby). ED Physician B had requested a neonatal transport team (nurses specially trained to care for very young babies and trained to transport them to nurseries specially equipped to treat very young babies) to fly via helicopter to the hospital to care for Patient #3's baby that ED Physician B expected to deliver the baby at the CAH. ED Physician B contacted the obstetrical staff at Recipient Hospital A. ED Physician B rechecked Patient #3's cervix, and determined Patient #3's cervix was only 3 centimeters (cm) dilated (out of a possible 10 cm). ED Physician B then determined Patient #3 could safely transfer to Recipient Hospital A. ED RN A notified the neonate specialty transport team to divert from the CAH to Recipient Hospital A.

3. During an interview on 12/5/17 at 1:42 PM, RN A revealed Patient #3 came into the ED complaining of labor like abdominal pain. Patient #3 had several other children and was currently 25 weeks pregnant (normal pregnancies last 40 weeks, thus Patient #3's baby was 15 weeks/4 months premature). Patient #3 obtained her prenatal care at Recipient Hospital A. ED Physician B examined Patient #3 and felt she was going to deliver very quickly. RN A contacted other nurses at the CAH, and requested help providing care to Patient #3. ED Physician B originally told RN A that Patient #3's cervix was fully open and ready to deliver the baby. The ED nurses began gathering supplies needed for the delivery. RN A spoke with staff at Specialty Hospital B and requested the hospital staff send a team of specialized nurses by helicopter to transport Patient #3's baby. Specialty Hospital B staff told RN A they could come, but would take 45 minutes to arrive.

RN A revealed the CAH staff had requested the staff from the helicopter ambulance service located on the CAH's property to assist with Patient #3's care. The helicopter staff told RN A they could not safely transport Patient #3 in the helicopter while she was in active labor.

ED Physician B examined Patient #3 again, and determined that Patient #3's cervix was actually not fully dilated. ED Physician B determined the CAH staff should transfer Patient #3 to Recipient Hospital A (18 miles away, 22 minutes travel by ground ambulance), since Patient #3 had received her prenatal care at Recipient Hospital A. The CAH's ground ambulance transported Patient #3 to Recipient Hospital A, with the helicopter ambulance staff riding along in the CAH's ground ambulance to provide additional assistance and monitoring for Patient #3.

4. During an interview on 12/6/17 at 7:05 PM, ED Physician B revealed he works rarely at the CAH and was not familiar with the local nursing staff or the staff at Recipient Hospital A. ED Physician B acknowledged the CAH nursing staff was not comfortable with providing pregnancy care to Patient #3 or deliver Patient #3's baby. The CAH staff do not normally deliver babies, but ED Physician B stated the CAH had the equipment to deliver Patient #3's baby.

Patient #3 told ED Physician B that she normally delivered her babies very quickly. ED Physician B stated he had delivered over 700 babies in his career as a physician and stated he was comfortable delivering Patient #3's baby, even with Patient #3's baby being 15 weeks premature. However, the CAH nursing staff did not feel they could provide care for Patient #3's baby after delivery. ED Physician B chose to send Patient #3 to Recipient Hospital A by ground ambulance since ED Physician B felt the nurses and physicians at Recipient Hospital A had more comfort and experience delivering babies. ED Physician B instructed Specialty Hospital B's air ambulance with the nurses specializing in treating newborn babies to divert to Recipient Hospital A.