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Based on clinical record review and interview, it was determined the Facility failed to provide an appropriate transfer for three (#1, #8 and #9) of nine (#1, #4, #7, #10, #14, #15, #17, #18 and #20) patients transferred in that the facility failed to send copies of the patient's medical records to the receiving facility and failed to transfer three (#1, #8 and #9) of (#1, #4, #7, #10, #14, #15, #17, #18 and #20) patients via qualified personnel and transportation equipment. The failed practice placed the patients at risk of delivery during personal transport to the receiving Facility and had the potential to affect all patients presenting in labor that require transfer to another facility. The findings follow:

A. Review of Patient #1's clinical record on 06/23/14 revealed the following:

1. Registered Nurse OB (Obstetrics) Triage note dated 06/11/14 at 0450 revealed, "Gestational age (weeks): 34; Chief Complaint: SROM (spontaneous rupture of membranes) at 0400; Contractions: Irregular; Contractions: 7-10 min (minutes); Rupture of membranes: ruptured; Comments: Pt (patient) arrives via WC (wheelchair) with c/o (complaints of) SROM around 0400, pt states she had a large gush of clear to pink tinged fluid, denies and vag (vaginal) bleeding, rates pain at 2 on 0/10 scale, abd (abdomen) soft nontender to palp (palpation), EFM (external fetal monitor) applied, findings as per flowsheet, pt states she has been going to (Named Facility) for a cancerous cervical tumor and was to go to an appointment today for a follow up with an oncologist and discuss possible having a C-Section (cesarean-section) tomorrow, light VE (vaginal exam) done, unable to determine cervical dilation due to size of tumor, clear fluid noted upon exam, small black spots of black DC (discharge) noted on exam glove and a foul odor coming from vagina, pt oriented to room, call light in reach, family at bedside, no request at this time; Dilation: unable to determine due to size of cervical tumor."
2. Registered Nurse OB Triage note dated 06/11/14 at 0540 revealed, "Dr. (named), pt status report given, new orders received and noted."
3. Physician telephone order dated 06/11/14 at 0539 revealed, "DC c (with) inst (instructions) to go to (named facility) for further treatment."
4. Registered Nurse OB Triage note dated 06/11/14 at 0547 revealed, "DC inst given, pt and family verbalized understanding, monitors off for pt to dress."
5. Registered Nurse OB Triage note dated 06/11/14 at 0600 revealed, "Pt to personal vehicle via WC, family to take pt to (Named Facility) for further care under primary OB (obstetrician) physician."
6. Discharge Summary Teaching/Instructions/Referrals dated 06/11/14 at 0541 revealed, "Go directly to (Named Facility) for further treatment under primary care physician."

B. Review of Patient #8's clinical record on 06/23/14 revealed the following:
1. Registered Nurse OB Triage note dated 04/27/14 at 0550 revealed, "Gestational age (weeks): 41.2; Chief complaint: 'I'm in labor'; Contractions: q (every) 3-4 min per pt; Rupture of membranes: denies; Pain scale: 9; Pain presence: intermittent; Dilation: 1.5; Effacement (%): 70; Station: - (negative) 3; Membrane status: bulging; cervix, consistency: soft; Triage summary: Pt presents ambulatory from home with c/o 'I'm in labor.' States she's been hurting since Friday, but the ctx (contractions) became worse at 0100. Abd soft/nontender to palpation, EFM applied. SVE with cervix 1.5/70/-3 with normal show. Pt has been seeing a doctor in (Named Town). Oriented to room."
2. Registered Nurse OB Triage note dated 04/27/14 at 0604 revealed, "Dr. (named) notified of pt status, FHTs (fetal heart tones), ctx, SVE, and bloody show. New orders noted to discharge pt to drive to (Named Hospital)."
3. Physician telephone order dated 04/27/14 at 0609 revealed, "Discharge c instructions to go to (Named Hospital)."
4. Registered Nurse OB Triage note dated 04/27/14 at 0618 revealed, "Discharged ambulatory in stable condition with family member with instructions to drive straight to (Named Hospital). Pt states she will try to get there."
5. Discharge Summary Teaching/Instructions/Referrals dated 04/27/14 at 0609 revealed, "Report to (Named Hospital)."

C. Review of Patient #9's clinical record on 06/23/14 revealed the following:
1. Registered Nurse OB Triage note dated 04/21/14 at 0500 revealed, "Gestational age (weeks): 32.3; Chief complaint: SROM; Contractions: irregular; Rupture of membranes: ruptured; Comments: pt arrives amb (ambulatory) with c/o SROM around 0315 this a.m., pt states she had a big gush of clear fluid with some abd tightening noted, denies any pain or vag (vaginal) bleeding at this time, pt states she is visiting family and requesting that if any way possible we transfer/allow her to go to her primary care OB in Bossier City, LA, due to insurance and physician preference, pt reassured we would do whatever possible but most important was fetal and maternal well being, VE done cx (cervix) 1cm (centimeter)/thick/ballotable, mod (moderate) amount clear fluid noted with VE, abd soft nontender to palp, EFM applied, findings per flowsheet, SO (significant other) at bedside, no request at this time."
2. Registered Nurse OB Triage note dated 04/21/14 at 0520 revealed, "Dr. (named) called and notified of pt status and request, new orders received and noted."
3. Physician telephone order dated 04/21/14 at 0520 revealed, "Discharge pt to go straight to hospital in Shreveport."
4. Discharge Summary Teaching/Instructions/Referrals dated 04/21/14 at 0524 revealed, "Go directly to health care facility in Bossier City, LA for further OB care under primary OB physician."

D. The findings were confirmed in an interview with the Director of Quality and Risk Management on 06/23/14 at 1430.




Based on clinical record review and interview, it was determined the physician failed to sign the certification stating the risks and benefits of the transfer to another Facility for four (#7, #17, #20 and #21) of nine (#1, #4, #7, #10, #14, #15, #17, #18 and #20) patients. The failed practice did not ensure the physician agreed with the stated risks and benefits of the transfer. This failed practice the potential to affect all obstetrical patients emergently transferred from the Facility. The findings follow:

A. Review of patient #7's clinical record on 06/23/14 revealed the patient was transferred from the Facility on 04/24/14. Review of the Patient Transfer Form revealed the physician signature was blank.

B. Review of patient #17's clinical record on 06/23/14 revealed the patient was transferred from the Facility on 03/22/14. Review of the Patient Transfer Form revealed the physician signature was blank.

C. Review of patient #20's clinical record on 06/23/14 revealed the patient was transferred from the Facility on 05/22/14. Review of the Patient Transfer Form revealed the physician signature line had a Registered Nurse's signature/Physician's name. There was no evidence the physician signed the form.

D. Review of patient #21's clinical record on 06/23/14 revealed the patient was transferred from the facility on 02/26/14. Review of the Patient Transfer Form revealed the physician signature was blank.

E. The findings were confirmed in an interview with the Chief Nursing Officer on 06/23/14 at 1530.