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Based on policy review, document review, medical record review, and interview, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA). This failure potentially placed all patients at increased risk for adverse outcomes.

Findings include:

The facility failed to ensure there was on-call obstetric coverage and/or that the on-call obstetrician presented to the hospital when notified for three of seven patients (A-2404), the facility did not ensure that an appropriate medical screening examination was performed for two of seven patients (A-2406), and the facility did not provide an appropriate transfer for two of seven patients (A-2409).

Cross Reference:

489.20 (r) (2) and 489.24 (j) (1-2)- On Call Physicians
489.24 (a) & 489.24 (c)-Medical Screening Exam
489.24 (e) (1)-(2)- Appropriate Transfer

Based on policy review, medical record review, document review, and interview, the facility failed to ensure there was on-call obstetric coverage for Patient #1 and failed to ensure that the on-call obstetrician presented to the hospital when notified for two of seven pregnant patients (Patients #24 and #27). Failure to ensure obstetric coverage has the potential for a delay in care, inadequate care, and/or an adverse patient outcome.

Findings include:

Review of the policy "Medical Screening Exam, Stabilization, and Transfers From the Emergency Department" last revised November 2022 indicated that if the emergency department physician or attending physician feels a consultation by a specialist is necessary to further assess or stabilize an individual with an emergency medical condition, the appropriate on-call physician will be notified and expected to respond in a timely manner. Urgent calls are to be answered within 15 minutes and all others within one hour. The medical screening examination includes a history and physical examination/evaluation, appropriate testing within the capabilities of the hospital including the use of on-call physicians as appropriate to determine if an individual has an emergency medical condition.

Review of the policy "Medical, Dental and Podiatric Staff Rules and Regulations," last revised 12/19/22 indicated that the on-call provider should respond to calls from the emergency department within 15 minutes and must arrive to the hospital to evaluate the patient within 30 minutes of the call for emergent conditions.

Review of the emergency department medical record dated 11/19/23 for Patient #1 revealed the following:
- At 07:42 PM, Patient #1 arrived ambulatory with complaints of being in labor.
- At 07:49 PM, the triage assessment revealed that Patient #1 reported a full-term pregnancy and had been in labor since yesterday. Patient #1 had complaints of "a lot of bleeding." Patient #1 denied having any prenatal care. Patient #1 was triaged as a level two.
- At 07:55 PM, a medical screening examination by Staff (M), Physician revealed Patient #1 had no prenatal care and stated that her last use of heroin was approximately one hour ago. Orders were placed for laboratory studies. Fetal heart tones were obtained by the nurse. According to the on-call schedule, there was no obstetrician on-call. Staff (P), Pediatrician was called to the bedside. Staff (J), Obstetric Registered Nurse, performed a vaginal speculum exam that revealed an intact amniotic sac (fluid filled sac that contains and protects a fetus) within the vaginal canal. Patient #1 was fully dilated (opening in the cervix) and effaced (stretching and thinning of the cervix). "Given this state Patient #1 cannot be transferred." Further attempts were made to contact the obstetricians, but neither of them could be contacted. A call was placed to the labor and delivery hotline at the recipient hospital. Patient #1's presentation, history, and current state was discussed with the provider at the recipient hospital. Patient #1 was not a candidate for transfer until after delivery. Recommendations (by the recipient hospital hotline provider) were given to provide supportive care through delivery. The recipient hospital provider stated to call back with any other concerns. Staff (L), General Surgeon (on-call), was called in for surgical backup if Patient #1's condition declined. Staff (L), General Surgeon felt that Patient #1's membranes should be ruptured. At 08:50 PM, the membranes were ruptured (by Staff L) with clear fluids noted. Immediately after, a prolapse of the umbilical cord (the umbilical cord connects the developing fetus with the mother to provide nutritents/oxygen and to remove waste. Umbilical cord prolaspse is when the cord slips out of the vagina before the fetus, and is an obstetrical emergency) was noted. An emergent caesarean section (surgical removal of the infant) was needed. The on-call anesthesia staff were notified to come in. A call was placed to the labor and delivery hotline at the recipient hospital again. The recipient hospital provider requested that a dose of ceftriaxone (antibiotic) be given and recommended an emergent caesarean section (surgical removal of the infant).
- At 08:00 PM, the nursing supervisor attempted to call the obstetrician's, but they were not available to come in. The general surgeon and pediatrician were called in. Staff (L), General Surgeon, ruptured the amniotic membranes. The umbilical cord and a leg (infant) immediately protruded from the vagina (the infant's position was feet first or breech instead of head first. Potential complications for an infant with a breech presentation are injury, the head getting stuck or trapped, and the umbilical chord flattening or twisting causing nerve or brain damage due to lack of oxygen). Manual reduction (staff manually moving and reducing cord compression to maintain oxygenation) of the umbilical cord and leg were performed. Patient #1 was taken to the operating room at 08:55 PM.
- At 09:29 PM, Patient #1 delivered a limp, cyanotic (bluish discoloration, apneic (lack of breathing) infant (Patient #2) via caesarean section (surgical removal of the infant).

Review of the Obstetrical/Gynecological on-call schedule for November 2023 (no date), revealed Staff (N), Obstetrician, was scheduled to be on-call for 11/19/23.

Review of the Obstetrical/Gynecological on-call schedule for November 2023 with a revision date of 11/13/23, revealed that no physician was on-call for the date of 11/19/23.

Interview on 11/30/23 at 08:43 AM with Staff (K), Registered Nurse, stated there was a lot of trouble with the on-call schedule. One obstetrical on-call schedule identified there was no provider on call and another schedule identified there was a provider on for 11/19/23.

Interview on 11/30/23 at 12:41 PM with Staff (R), Registered Nurse Supervisor, stated there were two on-call schedules. One schedule identified there was obstetrical coverage while the other schedule identified no coverage. Staff (R) made multiple attempts to get a hold of both obstetrical providers with no success.

Review of the emergency department medical record dated 03/11/22 revealed that at 07:05 PM, Patient #24 presented to the facility emergency department with the complaint of abdominal pain with uterine contractions (is part of the birthing process where there is a tightening feeling across the stomach, back, and/or thighs) every five to seven minutes that started at 09:00 AM. Patient #24 had an estimated due date of 03/21/22 and was scheduled for a cesarean section on 03/14/22 at another hospital. At 07:05 PM, the initial nursing assessment noted Patient #24 having uterine contractions every one to three minutes that last for 40-60 seconds. At 08:01 PM, a nursing note indicated that Patient #24 was discharged from the facility per telephone conversation with Staff (O), Obstetrician, who instructed Patient #24 to drive their personal vehicle directly to another hospital. At 08:01 PM, Patient #24 left the facility via personal vehicle. (There in no evidence that Staff (O), Obstetrician, who was on-call, came to the hospital to perform an emergency medical screening examination and evaluate Patient #24 to see if an emergency condition existed).

Review of the emergency department medical record dated 04/22/23 revealed that at 12:00 AM, Patient #27 arrived ambulatory to the facility with a complaint of premature rupture of membranes and abdominal pain. Patient #27 was leaking amniotic fluid since 11:00 PM. At 12:00 AM, an amnisure test was positive for amniotic fluid. At 12:27 AM, a vaginal examination was performed by Staff (V), Obstetric Registered Nurse, who indicated there was no cervical dilation (the cervix was closed), there was thick effacement (the cervix had no thinning), and the baby was at a high station (how far the baby has descended in the pelvis). Patient #27 was 29 weeks, six days gestation (age). Patient #27 had two prior cesarian sections (surgical removal of the infant). At 12:30 AM, the registered nurse called Staff (O), Obstetrician with an assessment of Patient #27 indicating that per Patient #27, the fetus was in a known breech (infants buttocks or lower extremity entering the pelvis first instead of head first) presentation and was being monitored for pre-eclampsia (pregnancy induced high blood pressure). Staff (O) gave instructions over the phone for Patient #27 to get in their car and drive to another hospital approximately 55 minutes away immediately. At 12:45 AM, Patient #27 was discharged with their husband. (There in no evidence that Staff (O), Obstetrician, who was on-call, came to the hospital to perform an emergency medical screening examination and evaluate Patient #27 to see if an emergency condition existed).

Review of the Obstetrical/Gynecological on-call schedule revealed that Staff (O), Obstetrician, was scheduled to be on-call for 03/11/22 and 04/23/23.

Interview on 12/13/23 at 02:30 PM with Staff (B), Chief Nursing Officer, stated during this time, obstetrical triage was conducted by a nurse when a laboring patient presented to the facility.

Based on policy review, medical record review, and interview, the facility did not ensure that an appropriate medical screening examination was performed for two of seven patients (Patients #24 and #27). Failure to provide an appropriate medical screening examination has the potential for an adverse patient outcome.

Findings include:

Review of the policy "Medical Screening Exam, Stabilization, and Transfers From the Emergency Department" last revised November 2022, indicated that all persons who present to the emergency department requesting examination or treatment will be provided a medical screening exam by qualified medical personnel. All presenting individuals will be afforded a medical screening exam based upon their priority as determined by the triage nurse. No individual presenting to the emergency department shall be denied a medical screening exam. The medical screening examination includes a history and physical examination/evaluation of the individual and appropriate testing within the capabilities of the hospital, to determine if the individual has an emergency medical condition. Completion of appropriate documentation is required. An emergency medical condition is manifested by acute symptoms of sufficient severity that can result in placing the health of the individual, pregnant woman and/or unborn child in serious jeopardy, serious impairment of bodily function, serious dysfunction of any bodily organ/part: or in respect to a pregnant woman who is having contractions, inadequate time for a safe transfer to another hospital before delivery.

Review of the emergency department medical record dated 03/11/22 revealed that at 07:05 PM, Patient #24 presented to the facility emergency department with the complaint of abdominal pain with uterine contractions (is part of the birthing process where there is a tightening feeling across the stomach, back, and/or thighs) every five to seven minutes that started at 09:00 AM. Patient #24 had an estimated due date of 03/21/22 and was scheduled for a cesarean section on 03/14/22 at another hospital. At 07:05 PM, the initial nursing assessment noted Patient #24 having uterine contractions. At 08:01 PM, a nursing note indicated that Patient #24 was discharged from the facility per telephone conversation with Staff (O), Obstetrician, who instructed Patient #24 to drive their personal vehicle directly to another hospital (approximately 55 minutes away). At 08:01 PM, Patient #24 left the facility via personal vehicle. (There was no evidence to indicate Patient #24 received an emergency medical screening examination by a physician while in active labor (the first stage of giving birth or labor to an infant. The cervix, the female reproductive organ that connects the vagina to the uterine cavity, dilates or opens from six to 10 centimeters, and contractions become stronger, closer together, and regular).

Review of the emergency department medical record dated 04/23/23 revealed that at 12:00 AM, Patient #27 arrived ambulatory to the facility with a complaint of premature rupture of membranes and abdominal pain. Patient #27 was leaking amniotic fluid since 04/22/23 at 11:00 PM. At 12:00 AM, an amnisure test was positive for amniotic fluid. At 12:27 AM, a vaginal examination was performed by Staff (V), Obstetric Registered Nurse, indicated there was no cervical dilation (the cervix was closed), there was thick effacement (the cervix had no thinning), and the baby was at a high station (how far the baby has descended in the pelvis). Patient #27 was 29 weeks, six days gestation (age). Patient #27 had two prior cesarian sections (surgical removal of the infant). At 12:30 AM, the registered nurse called Staff (O), Obstetrician with an assessment of Patient #27 indicating that per Patient #27, the fetus was in a known breech (the infants buttocks or lower extremity entering the pelvis first instead of the head) presentation and was being monitored for pre-eclampsia (pregnancy induced high blood pressure). Staff (O) gave instructions over the phone for Patient #27 to get in their car and drive to another hospital (approximately 55 minutes away) immediately. At 12:45 AM, Patient #27 was discharged with their husband. (There was no evidence to indicate Patient #27 received an emergency medical screening examination by a physician).

Interview on 12/13/23 at 02:30 PM with Staff (S), Vice President of Quality, verified these findings.

Based on policy review, medical record review, and interview, the facility did not provide an appropriate transfer for two of seven patients (Patients #24 and #27). Failure to provide an appropriate transfer has the potential for an adverse patient outcome.

Findings include:

Review of the policy "Medical Screening Exam, Stabilization, and Transfers From the Emergency Department" last revised November 2022, indicated that if a medical transfer is necessary, the transferring hospital must provide treatment within its capacity which minimizes the risks to the woman in active labor and the risks to the unborn child. The transferring hospital should obtain agreement from a receiving facility that it will accept the transfer and provide appropriate treatment. All medical records related to the emergency condition must be sent with the individual at the time of transfer. The transferring hospital must provide or ensure that the transfer is safely affected with qualified personnel and transportation equipment.

Review of the emergency department medical record dated 03/11/22 revealed that at 07:05 PM, Patient #24 presented to the facility emergency department with the complaint of abdominal pain with uterine contractions (is part of the birthing process where there is a tightening feeling across the stomach, back, and/or thighs) every five to seven minutes that started at 09:00 AM. At 07:05 PM, the initial nursing assessment noted Patient #24 having uterine contractions every one to three minutes that last for 40-60 seconds. At 08:01 PM, a nursing note indicated that Patient #24 was discharged from the facility per telephone conversation with Staff (O), Obstetrician, who instructed Patient #24 to drive their personal vehicle directly to another hospital (approximately 55 minutes way). Patient #24's father asked if it was safe for Patient #24 to travel to another hospital by car instead of an ambulance. The nurse stated that Staff (O), Obstetrician, did not think a transfer via ambulance was necessary, but that "they are more than welcome to call for an ambulance to take them if they prefer." Patient #24 and their father declined at that time. At 08:01 PM, Patient #24 left the facility via personal vehicle. Discharge documentation was provided to Patient #24, but no transfer documentation was found in the medical record (No medical screening examination was performed. Patient #24 was discharged from the hospital with instructions to go to another hospital approximately 55 minutes away by private vehicle instead of being transferred via ambulance, in active labor (the first stage of giving birth or labor to an infant. The cervix, the female reproductive organ that connects the vagina to the uterine cavity, dilates or opens from six to 10 centimeters, and contractions become stronger, closer together, and regular). The hospital did not contact the receiving hospital/physician for notification and/or acceptance of the transfer, and there was no evidence that medical records and/or documentation were sent with Patient #24).

Review of the emergency department medical record dated 04/23/23 revealed that at 12:00 AM, Patient #27 arrived ambulatory to the facility with a complaint of premature rupture of membranes and abdominal pain. Patient #27 was leaking amniotic fluid since 04/22/23 at 11:00 PM. At 12:00 AM, an amnisure test was positive for amniotic fluid. At 12:27 AM, a vaginal examination was performed by Staff (V), Obstetric Registered Nurse, who indicated there was no cervical dilation (the cervix was closed), there was thick effacement (the cervix, a female reproductive organ that connects the vagina to the uterine cavitiy, had no thinning), and the baby was at a high station (how far the baby has descended in the pelvis). Patient #27 was 29 weeks, six days gestation. Patient #27 had two prior cesarian sections (surgical removal of an infant). At 12:30 AM, the registered nurse called Staff (O), Obstetrician with an assessment of Patient #27 indicating that per Patient #27, the fetus was in a known breech (the infants buttocks or lower extremity entering the pelvis first instead of the head) presentation and was being monitored for pre-eclampsia (pregnancy induced high blood pressure). Staff (O), Obstetrician, gave instructions for Patient #27 to get in their car and drive to another hospital (approximately 55 minutes away) immediately. At 12:45 AM, Patient #27 was discharged with their husband. Discharge documentation was provided to Patient #27, but no transfer documentation was found in the medical record (No medical screening examination was performed. Patient #27 was discharged from the hospital with instructions to go to another hospital approximately 55 minutes away by private vehicle instead of being transferred via ambulance, with pregnancy complications. The hospital did not contact the receiving hospital/physician for notification and/or acceptance of the transfer, and there was no evidence that medical records and/or documentation were sent with Patient #27).

Interview on 12/13/23 at 02:30 PM with Staff (B), Chief Nursing Officer, verified these findings.