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Based on medical record review, policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination and stabilization within its capability and capacity for one (P#1) of 20 sampled patients when P#1 presented to the Emergency Department (ED) on April 3, 2024 with a complaint of 38 weeks pregnant with "vaginal leaking all night with contractions starting 4am." Specifically, the facility failed to ensure that P#1 had a pelvic exam conducted to determine cervical dilation, effacement, station, and fetal presentation. Additionally, the facility failed to ensure that P#1 and her unborn child were stabilized prior to transfer, including but not limited to how advance in labor P#1 was and the presentation of the unborn child, to ensure the risk of delivering en route were minimized.

Findings included:

Cross-refer to C-2406 as it relates to the facility's failure to provide an appropriate medical screening exam within its capability and capacity to determine if an emergency medical condition existed.

Cross-refer to C-2409 as it relates to the facility's failure to ensure stabilizing treatment prior to transfer, including but not limited to how advance in labor P#1 was and the presentation of the unborn child, to ensure the risk of delivering en route were minimized.

Based on review of medical records, policy and procedures, and staff interviews it was determined that the facility failed to ensure that one (P#1) one of 20 sampled patients received an appropriate medical screening exam within the facility's capability and capacity to determine if a medical emergency condition existed. On April 3, 2024, P#1 presented to the facility's emergency department (ED) with complaints of 38 weeks pregnant with "vaginal leaking all night with contractions starting 4am." The facility failed to ensure that P#1 had a pelvic exam to determine cervical dilation, effacement, station, and fetal presentation.

Findings included:

A review of Patient (P) #1's medical record revealed that P#1 was admitted to the Emergency Department (ED) on 4/3/24 at 8:33 a.m. with the chief complaint of 38 weeks pregnant with "vaginal leaking all night with contractions starting 4am."

A review of the hospital document titled "ED Note Physician" dated 4/3/24 at 8:38 a.m., written by Nurse Practitioner (NP) BB, revealed that P#1 was 38 weeks pregnant and stated her last two children were delivered one week earlier than their due dates. NP BB documented "...pt [patient] presents ... via ems [Emergency Medical Services] in active labor." On arrival to the ED, P#1's contractions were every four minutes, lasting 45 seconds to one minute. P#1 stated she had vaginal leaking all night, and contractions had started at 4:00 a.m. The physical exam revealed that P#1's abdomen was "soft, diffuse abdominal pain, labor pains, contractions every 5 minutes lasting 355[sic]-45 seconds [35 to 45]..." There was no documentation that an exam to determine cervical dilation, effacement, station, and fetal presentation was completed.

P#1 was transferred via an ambulance to a receiving facility (Hospital B) on 4/3/24 at 9:39 a.m.

A review of Hospital B's History and Physical (H&P) Note dated 4/3/24 at 11:12 a.m. revealed that P#1 presented with complete dilation of the cervix (last stage of labor before birth), 100% effacement, fetal station +1, with fetal presentation documented as breech (confirmed by bedside ultrasound at Hospital B).

An interview was conducted on 4/9/24 at 11:10 a.m. with Registered Nurse (RN) EE in the facility's staff training room. RN EE stated P#1 had been hurting since 4:00 a.m. (at home). RN EE said that NP BB came in to see P#1 and went straight to call the receiving facility. RN EE stated that NP BB said he did not check how far P#1 was dilated because he (NP BB) did not want to rupture the membranes and further complicate issues. RN EE also stated that there was no wetness on P#1's bed, but when she (RN EE) did an external vaginal examination, there was a little bit of wetness, which she tested, and the result of the test was safe (nitrozine test negative for fluid collected outside of P#1's vagina).

A telephone interview was conducted on 4/9/24 at 11:30 a.m. with Registered Nurse (RN) FF in the facility's staff training room. RN FF stated that P#1 came directly to Trauma 1, and she (P#1) stated that contractions started earlier. RN FF explained that the facility's policy was that nursing staff did not check the cervix.

A telephone interview was conducted on 4/9/24 at 11:45 a.m. with Nurse Practitioner (NP) BB in the facility's staff training room. NP BB stated that P#1 presented with contractions every three to five minutes. NP BB said that he only did a visual examination of P#1's vagina based on his (NP BB) experience not to insert anything into the vagina if there was no imminent delivery to prevent further complications.

A review of the hospital's policy titled "Triage in the Emergency Department," last revised February 2024, revealed that Emergency Medical Treatment and Labor Act (EMTALA) law stated, "If you had an emergency or are in labor, you had the right to receive, within the capabilities of this hospital's staff and facilities: 'An appropriate Medical Screening Examination Necessary Stabilization Treatment (including treatment for an unborn child) and, if necessary, an appropriate transfer to another facility..."

Cross Refer to C2409.

Based on review of medical records, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that one (P#1) of 20 patients received stabilizing treatment prior to transfer, including but not limited to how advance in labor P#1 was and the presentation of the unborn child, to ensure the risk of delivering en route were minimized.

Findings included:

A review of Patient (P) #1's medical record revealed that P#1 was admitted to the Emergency Department (ED) on 4/3/24 at 8:33 a.m. with the chief complaint of 38 weeks pregnant with "vaginal leaking all night with contractions starting 4am."

A review of a hospital document titled "ED Note Physician" dated 4/3/24 at 8:38 a.m., written by Nurse Practitioner (NP) BB, revealed that P#1 was 38 weeks pregnant and she stated that her last two children were delivered one week earlier than their due dates. On arrival to the ED, P#1's contractions were every four minutes, lasting 45 seconds to one minute. There was no documentation that an exam to determine cervical dilation, effacement, station, and fetal presentation was completed.

On 4/3/24 at 9:31 a.m., P#1 was transferred from Hospital A to Hospital B.

A review of the "Hospital Transfer Authorization" document revealed that the reason for the transfer was "labor (services not available)." A review of the form failed to reveal that a selection for P#1's condition was made. The options to select included: "1. Individual was stabilized within reasonable medical probability, no material deterioration of the individual condition or the condition of the mother and unborn child(ren) was likely to result from transfer.
2. The individual's condition had not been stabilized; however, the individual would benefit from a higher level of care which outweighed the risk associated with the transfer. 3. The individual was in active labor. However, the expected benefits of transfer outweighed the potential risk to the mother and/or unborn child(ren)."

An interview was conducted on 4/9/24 at 11:10 a.m. with Registered Nurse (RN) EE in the facility's staff training room. She said P#1 stated she had been hurting since 4:00 a.m. (at home). RN EE said that NP BB came in to see P#1 and went straight to call the receiving facility. RN EE stated that NP BB said he did not check how far P#1 was dilated because he (NP BB) did not want to rupture the membranes and further complicate issues.

A telephone interview was conducted on 4/9/24 at 11:30 a.m. with Registered Nurse (RN) FF in the facility's staff training room. RN FF stated that P#1 came directly to Trauma 1, and she (P#1) stated that contractions started earlier. RN FF stated that P#1 requested to be taken to the other (receiving) facility. RN FF explained that the facility's policy was that nursing staff did not check the cervix.

A telephone interview was conducted on 4/9/24 at 11:45 a.m. with Nurse Practitioner (NP) BB in the facility's staff training room. NP BB stated that P#1 presented with contractions every three to five minutes. NP BB said that he only did a visual examination of P#1's vagina based on his (NP BB) experience not to insert anything into the vagina if there was no imminent delivery to prevent further complications.

A review of the hospital's policy titled "Transfer of Patients: from (Hospital A) to Other Facilities ..." effective July 2023, revealed "To ensure (Hospital A) complies with Emergency Medical Treatment and Active Labor Law (EMTALA), provides continuity of care between hospitals, assures proper medical screening and assure patients medical condition is stabilized prior to transport, assures patient safety in transport ...IV. Procedures for Transfers of Patients from (Hospital A) to other facilities ...The physician or physician extender completes and signs the certification of transfer (Patient Agreement for Transfer Form) to include summary of the medical risks and medical benefits of transfer ...The patient cannot be transferred unless Form is completed. Reason for unstable transfer must be documented in the risks and benefits section ..."

A review of the receiving facility's (Hospital B) History and Physical (H&P) Note dated 4/3/24 at 11:12 a.m. revealed that P#1 presented with complete dilation of the cervix (last stage of labor before birth), 100% effacement, fetal station +1, with fetal presentation documented as breech (confirmed by bedside ultrasound at Hospital B). A continued review revealed that the unborn baby was in a breech presentation (buttocks or lower extremity delivering first), and a need for a stat (now) cesarean delivery secondary to breech presentation was discussed with P#1. Documentation revealed that upon immediate transfer to the operating room (OR), grossly ruptured membranes had occurred with thick meconium fluid. Documentation revealed that upon arrival to the OR, a breech vaginal delivery had to be performed due to P#1's advanced nature.

Cross Refer to C2406.