HospitalInspections.org

Based on physician interview, nurse midwife interview, additional emergency room staff interview, medical record review and review of policy and procedures, the hospital failed to provide an appropriate transfer for one of 20 sampled patients, Patient #1. The physician verbalized that the discharge plan for patient #1 was to proceed directly to her primary obstetrician at a local hospital about 46 miles away.

The findings include:

The hospital failed to contact or provide medical records upon discharge to Patient #1, Patient #1's primary physician, and the receiving hospital. The physician verbalized that Patient #1 declined transfer, however, the hospital did not maintain a written transfer certification signed by the physician documenting the medical benefits reasonably expected from medical treatment at another facility outweigh the risk and benefits of transfer.

Cross Refer to A2409.

Based on physician interview, nurse midwife interview, additional emergency room staff interview, medical record review and review of policy and procedures, the hospital failed to provide an appropriate transfer for one of 20 sampled patients, Patient #1. The physician verbalized that the discharge plan for patient #1 was to proceed directly to her primary obstetrician at a local hospital about 46 miles away. The hospital failed to contact or provide medical records upon discharge to the patient, patient's primary physician, and the receiving hospital. The physician verbalized that Patient #1 declined transfer, however, the hospital did not maintain a written transfer certification signed by the physician documenting the medical benefits reasonably expected from medical treatment at another facility outweigh the risk and benefits of transfer.

The findings include:

On 02/22/2024 during review of Patient #1 medical record, staff C (physician) note dated 01/18/2024, 08:06am physician at bedside, discussed with patient (#1) and partner, pain out of proportion to stage of spurious labor, no clinical evidence of abruption. SVE (sterile vaginal exam) performed cervix is closed. Staff C discussed findings with patient #1, if pain is that severe, then recommend a cesarean section as no cervical change in over 8hrs. Patient #1 does not want cesarean section, our lab does not have Factor 8 available which will be necessary if we are to perform the cesarean section here. Patient #1 following consultation will go to Tertiary Care Center and discuss with patient #1's primary obstetrician about delivery options.

Documentation reviewed in Patient #1's medical record was inconsistent with interviews with Physician C and CNMs (Certified Nurse Midwife) A and B, who all reported during interview they understood the patient would leave the hospital and travel by personal vehicle directly to the tertiary care center where the Maternal Fetal Medicine specialist who was Patient #1's primary obstetrician (OB) was located and where she planned to deliver. No documentation or interview indicated the facility staff contacted Patient #1's primary OB physician to discuss the plan of care, contacted the tertiary care center hospital to let them know Patient #1 was traveling there by personal vehicle, provided the patient with copies of records to provide when she arrived at the tertiary care center, or provided Patient #1's medical records to the receiving hospital (Tertiary Care Center). No documentation of transfer was included in Patient #1's medical record. Furthermore, Patient #1's medical record did not contain documentation that the risks and benefits of declining the recommended cesarean section, transferring to the Tertiary Care Center (approximately 46 miles away), or discharging home and continuing the pregnancy were explained to Patient #1.
No documentation of Patient #1 signing an "Against Medical Advice" or "Partial Refusal of Care" form or being asked to sign these in relation to declining the recommendation of a cesarean section and/or transferring via personal vehicle to the tertiary care center hospital were contained in the medical record.

Patient #1's medical record did not indicate education including the risk factors associated with uterine rupture. According to WebMD (accessed on 02/26/2024 at 5:32pm under the title "Uterine Rupture: What are Its Symptoms and How Is It Treated?" at webmd.com), "uterine rupture is most common among pregnant women who previously delivered a baby via a cesarean section. Some of the warning signs include sudden, severe uterine pain.

On 02/22/2024 at approximately 02:37pm an interview was conducted with staff A (certified nurse midwife/CNM). Staff A on duty for patient #1 and monitored her care during her stay till end of shift on 01/18/2024 approximately 06:45am. Patient #1 was a previous cesarean section, had a lot of pain out of the ordinary, we treated her pain and I felt uncomfortable and wanted staff C (physician) to come see her, and he responded. Patient #1 had pain with contractions, pain was in the right lower quadrant after contraction, the uterus did relax on palpation, I sat with her at times just holding the monitor on. Patient #1 said she had seen her obstetrician the day before and discussed a VBAC (vaginal birth after cesarean) and that was her plan for delivery. Staff A added, I had no other issues with the fetal heart strip, just hard to keep patient#1 on the monitor, fetal movement was positive.

On 02/23/2024 at approximately 10:20am an interview was conducted with staff G (Director of Women's and Children's). On 01/18/2024 a call was received from another facility inquiring about patient #1, the labor nurse for patient #1 answered the call and discussed the ultrasound and BPP report with the hospital staff nurse. Patient #1's record was reviewed by staff G and standard of care was met as the conclusion.

On 02/23/2024 at approximately 10:52am a telephone interview was conducted with staff C (physician). Staff C said, I came in to see patient #1 as staff A (Certified Nurse Midwife) had called to report patient #1 has had no cervical change, and still having pain. Staff C ordered an ultrasound and saw patient#1 at the bedside. Staff C performed a sterile vaginal exam, the cervix was still closed, no change from when patient #1 came in. Patient #1 was in pain, staff C offered patient #1 a cesarean section and discussed this with patient #1 and her husband. Patient #1 was planning a VBAC (vaginal birth after cesarean) at her local hospital. Patient #1 had met with her obstetrician the day before and discussed the risks of VBAC in detail and plan was to VBAC later that month. Staff C informed patient #1 her cervix was unchanged, and had been contracting at home from yesterday afternoon, and did not think patient#1 was a good candidate for VBAC. Patient #1 declined the cesarean section. Staff C stated in the interview he offered to transfer the patient to the other hospital as it is a Tertiary Care Center, as patient #1's obstetrician is there. Patient #1 declined this, added it will be faster by personal car. Patient #1 added I would prefer to VBAC and go there. According to the interview,Staff C attempted to discuss risk factors of a VBAC, and patient #1 stated the risks were discussed with her obstetrician and she knew the risks already.

On 02/23/2024 at approximately 12:15pm an interview was conducted with staff B (certified nurse midwife/CNM). Staff B came on duty at 06:45am on 01/18/2023, received hand off report from staff A (CNM). Staff A reported that patient#1's pain was outside of her labor, history of a prior cesarean section and requested staff C (physician) to assess patient #1. Staff B was at bedside with staff C during assessment, the ultrasound was completed and reported as 8/8 for biophysical profile (BPP, test measures baby's heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid around the baby ). Patient #1 stated the risks and benefits of VBAC had been discussed the day before with her obstetrician and scheduled to have the VBAC at a local hospital in a few weeks. Staff C offered to transfer patient #1 to the other hospital and patient #1 refused the cesarean section and the transfer, patient #1 wanted to go there by personal car. Staff B did not disagree with staff C's decision, patient#1 was not in good labor, had a reactive fetal heart strip, a reassuring BPP of 8/8. Staff B added, patient #1 was in a stable condition at discharge.

On 2/22/2024 at approximately 12:38pm an interview was conducted with staff J (Emergency Services Director) explained that a "partial refusal of care" would include an example of when the patient is willing to transfer but refuses transportation because they don't want to pay for an ambulance.

Policy review conducted on 02/22/2024 revealed, EMTALA Transfer Policy dated 5/1/2019 with an expiration date of 5/1/2033. On page 4 of 16, paragraph 2. D. "Transfers for High Risk Deliveries. A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE (medical screening exam) and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer even if a transfer agreement is in place. In addition, a physician certification that the benefits of transfer outweigh the risks of transfer is required for the transfer of the woman in labor. Paragraph 2. G. "Women in Labor. For a woman in labor, a transfer may be made only if the woman in labor or her representative requests the transfer, or if a physician signs a certification that the benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the individual or the woman in labor who requests transfer to another facility may not be discharged against medical advice to go to the other facility. The risks associated with such a disposition must be thoroughly explained to the patient and documented. If the patient still insists on leaving to go to the other facility, the facility should take all reasonable steps to obtain the patient's request in writing and take all steps to have the patient transported using qualified personnel and transportation equipment. Transporting a woman in labor by privately-owned vehicle is not an appropriate form of transportation.

The hospital's EMTALA - MSE and Stabilization Policy effective 4/1/2018, approved 4/1/2018, expiration 4/1/2033 titled Florida - EMTALA Medical Screening Examination and Stabilization Policy. e. Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual's signs and symptoms: ...ii. Pregnant Women: The medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membranes (i.e., ruptured, leaking and intact), to document whether or not the woman is in labor. A woman experiencing contractions is in true labor unless a physician, certified nurse-midwife or other QMP acting within his or her scope of practice as defined by the hospital's medical staff bylaws and State medical practice acts, certifies in writing that after a reasonable time of observation, the woman is in false labor. The recommended timeframe for such physician certification of the QMP's determination of false labor should be within 24 hours of the MSE, however, the medical staff bylaws, rules and regulations can provide guidance on the timeframe. Page 10 of 15 Procedure 6. Refusal to Consent to Treatment: a. Written Refusal - Partial Refusal of Care or Against Medical Advice. If a physician or QMP has begun the MSE or any necessary treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice, after being informed of the risks and benefits and the hospital's obligations under EMTALA, reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individuals refusal to sign the Partial Refusal of Care or the Against Medical Advice Form (see Informed Refusal for Partial Refusal of Care and AMA form - English or Informed Refusal for Partial Refusal of Care and AMA form - Combined English and Spanish). The medical record must contain a description of the screening and the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. 7. Stabilizing Treatment Within Hospital Capability. The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED (dedicated emergency department) has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an EMC of a woman in labor, that the woman has delivered the child and placenta; ...8. When EMTALA obligations End - The hospital's EMTALA obligation ends when a physician or QMP has made a decision: a. That no EMC exists (even though the underlying medical condition may persist): b. That an EMC exists and the individual is appropriately transferred to another facility; or c. Than an EMC exists and the individual is admitted to the hospital for treatment to relieve or eliminate the EMC; or d. That an EMC exists and the individual has been provided treatment which relieves or eliminates the EMC and discharged.