HospitalInspections.org

Based on document review and staff interview, the Critical Access Hospital (CAH)'s administrative staff failed to ensure the emergency department (ED) staff followed their policies and provided all available stabilizing treatment to 2 of 32 patients (Patient #10 and Patient #26) who requested emergency medical care at the CAH's ED from 3/1/17 to 9/25/17. The CAH administrative staff identified an average of 812 patients per month who presented to the CAH's ED and requested emergency medical care.

Failure to follow the CAH's policies resulted in the CAH ED staff transferring Patient #26 to another hospital while she was in active labor and nearly delivered a baby in the ambulance. The failure to follow the policies also resulted in the CAH ED staff transferring Patient #10 to another hospital for inpatient services available at the CAH.

Findings include:

1. Review of the policy "EMTALA Guidelines," reviewed 08/2017, revealed in part, "Stabilize ... With respect to a woman in labor, stabilization includes delivery of the child and placenta." The policy lacked a requirement for the CAH staff to provide all appropriate treatment within the capabilities available at the facility to stabilize the patients' medical conditions.

2. Review of Patient #26's medical record revealed she presented to the CAH's ED on 8/13/17 for a possible urinary tract infection. Patient #26 did not know she was pregnant. The CAH staff decided to transfer Patient #26 to Recipient Hospital A while Patient #26 was in active labor. Patient #26 began experiencing further contractions in the ambulance and the paramedics in the ambulance diverted to Recipient Hospital B, where Patient #26 delivered her baby a short time after arriving at Recipient Hospital B.

Please refer to C-2407 for additional information.

3. Review of Patient #10's medical record revealed Patient #10 presented to the CAH's ED via ambulance on 7/26/17 for nausea and severe pressure wounds. The ED Physician decided to transfer Patient #10 to Recipient Hospital A (over an hour's drive away) without determining if the CAH could provide care to Patient #10.

Please refer to C-2407 for additional information.

I. Based on document review and staff interviews, the critical access hospital (CAH) failed to provide stabilizing treatment to 1 of 31 patients (Patient #26) who presented to the CAH with an emergency medical condition, between 3/1/17 and 9/25/17, when the CAH staff knew Patient #26 was in labor and the CAH staff failed to provide required stabilizing treatment by failing to deliver the baby at the CAH. The CAH staff identified an average census of 2.5 OB patients per day.

Failure to provide appropriate stabilizing treatment, including delivering the baby, resulted in the ambulance carrying Patient #26 to divert to another hospital so Patient #26 could deliver the baby in a hospital instead of the ambulance.

Findings include:

1. Review of Patient #26's medical record revealed she presented to the CAH's Emergency Department (ED) on 8/13/17 at 1:30 PM complaining of a urinary track infection. The CAH staff examined Patient #26 and determined she was pregnant when her water broke in the ED. The ED staff transported Patient #26 to the CAH's inpatient OB unit (department of hospital that delivers babies) for further OB care. Registered Nurse (RN) B called Obstetrician D (a physician specialized in care of pregnant patients and delivering babies). Obstetrician D had RN B examine Patient #26. RN B determined Patient #26 was in labor. RN B informed Obstetrician D of these findings and Obstetrician D gave telephone orders for medications to slow Patient #26's labor. During the examination, RN B determined Patient #26 was approximately 32 weeks along in her pregnancy (out of a full term pregnancy at 40 weeks). When Obstetrician D arrived at the hospital, approximately one hour later, he arranged to transfer Patient #26 to Recipient Hospital A for access to specialized care for Patient #26's premature baby. Obstetrician D ordered additional medications to slow the progress of Patient #26's labor prior to transfer.

Prior to transporting Patient #26 on 8/13/17 at 3:31 PM to Recipient Hospital A, Obstetrician D documented Patient #26's cervix was dilated to 5 centimeters, 100 percent effaced, and at a -1 to -2 station (Patient #26's cervix was half way dilated to the full 10 cm, already fully thinned, and the baby's head was near Patient #26's cervix).

2. Review of the Prehospital Care (Ambulance) Report, dated 8/13/2017 at 3:59PM, revealed Patient #26 began screaming and starting to push to deliver the baby 20 minutes after leaving the CAH. Paramedic E instructed his paramedic partner to find the closest hospital that could deliver a baby and divert to the hospital. The paramedics diverted to Recipient Hospital B, with the same obstetrical capabilities as the sending hospital. Recipient Hospital B staff delivered Patient #26's baby and placenta (stabilizing the emergency medical condition).

3. During an interview on 9/27/17 at 8:40AM, RN A revealed the CAH had the capacity and capabilities to deliver Patient #26's baby. The CAH staff knew Patient #26 was pregnant and experiencing regular contractions. RN A stated "We gave [Patient #26] medications to show down the child birth [process]. Obstetrician D [arrived at the CAH] about 45 minutes [after Patient #26 arrived]. Obstetrician D told the nures on the phone that he would transfer [Patient #26]. [Obstetrician D only [lives] within half a mile [of the CAH]. Right before [the ambulance] left, [Patient #26's cervix] was at 5 centimenters (cm), and her contractions had slowed way down. [RN B's name] checked [Patient #26 and determined Patient #26's cervix was dilated] at 5 cm and 90 % [effaced]. [Obstretician D] said to send [Patient #26]. He had talked to the doctor at [Recipient Hospital A] and knew [Patient #26] was having contraction." RN A stated Patient #26 was in active labor because Patient #26's contractions were lessening after the nurses increased the magnesium sulfate (a medication to slow down contractions). RN A stated "you can't have a baby if you aren't contracting." RN A acknowledged Recipient Hospital B had similar abilities to handle premature babies as the CAH.


4. During an interview on 9/27/17 at 1:30PM, Paramedic E stated he was afraid of delivering the baby in the ambulance and lacking the necesary equipment to care for a premature baby and the mother. Paramedic E stated "I kept track of contractions and monitored [Patient #26's labor]. Before we hit Highway 14, [Patient #26] started to say she felt she had to have a BM. It prompted me to take a look [and see if he could see the baby's head, which was not present yet]. That is when I told my partner to put on the [emergency] lights. I saw [Patient #26's labia was] bulging, [manually checked the baby] and could feel the baby's head just inside of the vagina, [Recipient Hospital B] was 20 minutes away and [Recipient Hospital A] was 35 minutes. I called [Recipient Hospital B] and told them what we had, let them know we were rerouting to them ... I was nervous ...5 cm, 100% effaced, -1 to -2 station, I don't recall for sure that I was told that [information before we left the CAH]."

On 9/27/17 at 3:00PM Paramedic F expressed she was extremely nervous about delivering the baby without proper equipment and was afraid of the mother and the baby dying. Paramedic E stated "We started driving and maybe 20 minutes into the trip I could hear [Patient #26] start to scream, [her] contractions were coming faster and faster ... It was nerve racking because she was in labor, if we would have known how close [to delivering the baby] we wouldn't have [left the CAH]. The doctor and nurses [at the CAH] were okay with the transfer, it changed so fast ...After 5cm it could go either way ... That girl was lucky to have [Recipient Hospital B] there."

5. During an interview on 9/27/17 at 12:20 PM, RN C revealed the CAH delivered premature babies in the past as RN C stated "We have delivered if they can't get transferred to a [larger hospital with the ability to care for premature babies] in the past ... [We] contact a facility with a neonatal care unit. We have to transfer the babies there."

6. During an interview on 9/27/17 at 11:00 AM, Obstetrician D revealed Patient 26 was having contractions. Obstetrician D also indicated he can deliver premature babies and has done so in the past." I'm the only OB/GYN doctor here. I end up getting a lot of the high risk patients. I am trained and feel comfortable doing that. Once the baby is born I am done [and have someone else care for the mother and baby]. I have to consider other doctors." Obstetrician D stated if he felt there was not enough time to transfer Patient #26 to a bigger hospital, he would have delivered the baby at the CAH and requested a team of specialized nurses with training to care for premature babies travel to the CAH and transport the baby to a hospital with the specialized capability to care for premature babies. Obstetricain D stated "in my mind, the benefits ouweighed the risks. In my opinion, I would have done the samething again" (thus potentially resulting in a pregnant woman delivering a premature baby in an ambulance without sufficient staff to provide care for the baby).

7. During an interview on 9/26/17 at 12:30 PM, Recipient Hospital B's Family Practice (FP) Physician I and FP Physician J discussed the dangers of transferring a patient in active labor. FP Physician I stated the sending CAH staff transferred Patient #26 in active labor. She was not stable, especially with a 33 week gestation baby. The risk of a premature baby dying during the transfer was very high. I would question this transfer. The EMS staff with the patient said they felt uncomfortable and then diverted to our hospital from their planned destination. The patient would have delivered the baby in the ambulance if they had continued to Recipient Hospital A. For the mother, she had any of the normal risks associated with an ambulance transfer, including possible uncontrolled bleeding after the delivery. There are more risks to the baby. There are only two people in the ambulance, so they would not have the experience and equipment to support a preterm baby. All they could do is keep the baby warm and continue to drive to the hospital. I wouldn't be comfortable letting a patient who is 33 weeks pregnant and in active labor transferring to another hospital."




II. Based on document review and staff interviews, the critical access hospital's (CAH) administrative staff failed to ensure the emergency department (ED) staff provided all available stabilizing treatment, including inpatient admission, to 1 of 25 patients (Patient #10) who presented to the E D between 3/1/2017 and 9/25/17. The hospital's administrative staff identified an average of approximately 20 inpatients per month that received care from the wound nurse.

Failure to provide an inpatient admission to the CAH resulted in the Emergency Department (ED) staff transferring Patient #10 to a hospital over 60 miles away for care while the CAH could provide inpatient care to Patient #10.

Findings include;

1. Review of Patient #10's medical record revealed Patient #10 presented to the CAH's ED on 7/26/17 at 3:34 PM. Patient #10 was recently discharged from Recipient Hospital A to home. Patient #10's home health nurse summoned Emergency Medical Services (EMS) staff to transport Patient #10 to the CAH's ED. The EMS staff documented Patient #10 weighted approximately 570 pounds. The CAH's wound nurse (a nurse with specialized training in treating wounds such as pressure sores) documented Patient #10 had multiple pressure wounds, including on Patient #10's buttocks.

ED Physician AA documented Patient #10 was in the ED 4 days prior and seen by ED Physician AA. ED Physician AA documented Patient #10 was morbidly obese, recently discharged from Recipient Hospital A, and was nauseated. Patient #10's family could not adequately provide care to Patient #10 at home.

Patient #10's medical record lacked evidence that Patient #10 required services unavailable at the CAH.

2. During an interview on 9/26/17 at 4:00 PM, ED Physician AA stated she transferred Patient #10 to Recipient Hospital A because Patient #10 was morbidly obese, required surgical care of the pressure sores, and the CAH lacked the capability to handle patient who were morbidly obese.

3. During an interview on 9/27/17 at 10:00 AM, the Wound Nurse stated she had treated Patient #10 for many years, due to Patient #10's chronic medical conditions predisposing Patient #10 to develop pressure wounds. The Wound Nurse saw Patient #10 at home, stated Patient #10 did not look well, and required a physician's examination for further diagnostic testing and care.

The Wound Nurse stated that she was comfortable providing wound care to Patient #10 and could provide inpatient wound care to Patient #10 if required. If Patient #10 required inpatient hospitalization, the CAH staff could call an outside vendor and obtain rental bariatric equipment (equipment specially designed for patients over 500 pounds) within about 2 hours, including a specialty bed needed for patients with pressure wounds.

4. Review of the Surgical On-Call schedule for 7/26/17 revealed the CAH staff could call General Surgeon CC and Certified Registered Nurse Anesthetist BB (CRNA, a nurse with advanced training to administer the medications to put people to sleep during surgery) if a patient required surgical care at the CAH.

5. During an interview on 9/27/17 at 10:40 AM, CRNA BB stated he previously provided anesthesia to Patient #10 (administered medication to put Patient #10 to sleep for surgery). CRNA BB stated he could provide anesthesia to Patient #10 if Patient #10 required surgery. CRNA BB stated the machine used to administer anesthesia to patients could breathe for bariatric patients, such as Patient #10.

6. During an interview on 9/27/17 at 9:30 AM, General Surgeon CC stated he knew Patient #10 for many years and previously provided care to Patient #10. General Surgeon CC stated he could provide care for Patient #10's wounds, and had previously cared for Patient #10's wounds.

7. Observations during a tour of the Operating Rooms on 9/27/17 at 3:05 PM revealed 3 operating room tables. The operating room tables' manufacturers rated the tables to handle patients between 600 to 700 pounds.

8. During an interview on 9/27/17 at 2:30 PM, Certified Nurse's Aide (CNA) DD stated after ED Physician AA decided to transfer Patient #10 to Recipient Hospital A, CNA DD called an ambulance service that had ambulances specially equipped for bariatric patients. The ambulance service had an ambulance stationed in Indianola, approximately 1 hour's drive away from the hospital.

9. During an interview on 9/26/17 at 4:20 PM, the Director of Clinics stated the CAH staff admitted Patient #10 to the CAH on 8/26/17 for inpatient hospice care. The CAH staff obtained a special bariatric bed and mattress for Patient #10 to use during the hospitalization. The CAH nursing staff cared for Patient #10 until they died on 8/27/17.