HospitalInspections.org

Based on review of facility A's (Candler Hospital ) medical record for patient #1 who presented to the facility's Labor and Delivery Unit on 07/12/17, facility B's medical record for the patient and the newborn infant, Transfer Center recordings, ambulance run sheet, the facility's Joint Medical Staff Rules & Regulations and Departmental Rules, policies and procedures, staff interviews, Paramedic interview, EMT interview, query of births less than 32 weeks' gestation and Patient abstract form, it was determined that the facility failed to provide stabilizing treatment and failed to appropriately transfer 1 (#1 and #22) of 22 sampled patients.

Cross refer to tag A-2407 as it relates to failure to provide stabilizing treatment.

Cross refer to tag A-2409 as it relates to failure to provide an appropriate transfer.

Based on review of medical records, ambulance trip reports, query of births less than 32 weeks' gestation, the facility's Joint Medical Staff Rules & Regulations and Departmental Rules, policies and procedures, patient abstract form, staff interviews, Paramedic and EMT interviews, it was determined that the facility failed to provide stabilizing treatment as required that was within the capability of the hospital's dedicated emergency department for 1 (#1) of 22 sampled patients.

Findings were:

Medical Record from Candler Hospital (Hospital A)

Review of the Patient #1 ' s medical record revealed that Patient #1 was transported from home to the Labor and Delivery (L&D) Unit by EMS on 07/12/17. The ambulance trip report noted that Patient #1 was six (6) months pregnant and that Patient #1 had been experiencing vaginal spotting for one (1) hour and cramping for over 12 hours.

Review of the external uterine contraction monitor strips revealed that the monitor was applied to Patient #1 on 07/12/17 at 1:10 p.m. and remained on during the patient's hospitalization except when it was removed for an ultrasound. The monitor strips not only monitored Patient #1's contractions but also the fetal heart rate.

The L&D triage (assessment by a nurse to determine patients' priority of need) assessment was completed by an L&D Registered Nurse (Nurse #7). Nurse #7 noted that Patient #1 arrived at the L&D unit on 07/12/17 at 1:13 p.m. with complaints of lower pelvic pain. Nurse #7 noted that this was Patient #1's second pregnancy and that Patient #1 had previously delivered one (1) live infant. Nurse #7 also noted that the Patient #1's due date was 10/08/17 and that the patient's gestational age (age of fetus/baby) was 27.3 days. Nurse #7 noted that when he/she performed the vaginal examination at 1:13 p.m., Patient #1's cervix was dilated to six (6) centimeters (cm), effacement (thinning of the cervix in preparation for delivery) was 100%, and the baby was at 2+ station (positive numbers indicate the baby has begun to enter the birth canal).

Review of Physician #2's orders dated 07/12/17 and the Medication Administration Record for Patient #1 revealed the following:
Magnesium Sulfate 20 grams (gm) was ordered and administered intravenously (IV) at 1:31 p.m.
Lactated Ringers (LR) 1,000 milliliter (ml) bag was ordered and administered IV at 1:34 p.m.
Ultrasound to be performed at bedside was ordered at 2:00 p.m.

Review of the TBAT: Outpatient Triage Orders revealed that Patient #1 was diagnosed with an intrauterine pregnancy, gestational age 27.3 days. The box for Admit to Outpatient Observation was not checked. The box for LR 1,000 ml IV with a #18 gauge intracath at 999 ml/hour was checked. Written on this form was "Transfer to (name of receiving facility B), V.O. (verbal order) Dr.". There was no physician's name written, no nurse's signature, no date or time, and no physician's co-signature.

A screen shot of Patient #1's activity on 07/12/17 from 1:15 p.m. until 1:35 p.m. revealed that Patient #1 was admitted to Inpatient Services at 1:35 p.m. However, the Patient Abstract form revealed the patient was admitted for Observation at 1:35 p.m.

At 1:37 p.m., documentation indicated that Patient #1 received an assessment in L&D, but there were no additional notes found. At 1:38 p.m., Nurse #7 noted that a 20-gauge intravenous (a catheter inserted into a vein to administer medications and fluids) catheter was inserted into the patient's right wrist. At 1:39 p.m., Nurse #7 noted that the external uterine contraction monitor noted that Patient #1 was having contractions every one (1) to three (3) minutes lasting 30-40 seconds in duration and that the contractions were regular and mild in intensity. Nurse #7 also noted that the fetal heart tones by Doppler (equipment used to monitor fetal heart rate) were 160 (normal 120-160) beats per minute. At 1:44 p.m., Nurse #7 noted that Physician #2 was transferring Patient #1 to the receiving facility (facility B) and that Magnesium Sulfate (medication used to stop or delay delivery) and Lactated Ringers (intravenous fluids) had been ordered.

Documentation revealed that Patient #1 was registered and that Patient #1 signed consents for treatment on 07/12/17 at 1:50 p.m.

Review of Physician #2's history and physical note dated 07/12/17, confirmed that Patient #1 was pregnant with a second baby and that the patient had previously delivered one baby. The physician noted that Patient #1's due date was 10/08/17 and that Patient #1 had been admitted to triage with complaints of pain and vaginal bleeding that had started the previous night. Physician #2 noted that the attending nurse, (Nurse#7) had initially reported that Patient #1's gestation was 22 weeks. Physician #2 noted that he/she instructed Nurse #7 to examine Patient #1 and call him/her back. Physician #2 noted that Nurse #7 reported that Patient #1 was dilated six (6) cm and that after reviewing Patient #1 ' s office records it was determined that Patient #1 was 27.3 weeks pregnant. Physician #2 noted that he/she gave orders for Magnesium Sulfate to be administered and for Patient #1 to be transferred to the receiving facility (B). Physician #2 noted that his/her examination revealed bulging fetal membranes into the vagina but not through the vaginal opening. Physician #2 noted that a call was made to the receiving facility's (B) Transfer Center and that he/she was informed that the Transfer Center would have the on-call physician (Physician #13) call to discuss the transfer. Physician #2 noted that in the meantime Patient #1 had been released to the EMTs (Emergency Medical Technicians) by the attending nurse (Nurse #7) and was being transported to the elevator. Physician #2 noted that because the travel time was only several minutes, he/she allowed the transport to continue because he/she believed that the transfer would be accepted. Physician #2 noted that Patient #1 had already been advised of the risk of delivery en route, and of the risks and benefits of transfer. Physician #1 further noted that to return Patient #1 to her room would add to the patient's anxiety. Physician #2 noted that the facility's (B) on-call physician (Physician #13) called and advised against transferring Patient #1 because the baby was in a breech presentation. Physician #2 noted that an attempt was made to have Patient #1 returned, but that Patient #1 was already at the receiving facility (B) after a three (3) minute transport. Physician #2 noted that Patient #1 was subsequently taken to the receiving facility's (B) L&D and arrived two (2) minutes later for a total time of five (5) minutes from the sending facility's (A) L&D to the receiving facility's (B) L&D, per the two (2) EMTs involved in the transport. Physician #2 further noted that it was a judgment call made at Patient #1 ' s bedside in an emergency situation. Physician #2 noted that his/her concern was for the welfare of the Patient #1 and her baby. In addition, Physician #2 noted that another concern was that even with delivery and stabilization of Patient #1 at the sending facility (A), the baby would possibly have had to be transferred later without the mother. Physician #2 noted that ideally, the goal was to keep the mother and baby together and that he/she had considered the fact that he/she had never had a patient deliver en route to the receiving facility (B).

Review of the ultrasound report dated 07/12/17 revealed that there was a single live intrauterine pregnancy in breech position with a heart rate of 132 beats per minute. In addition, the ultrasound noted that the cervix was open with bulging membranes (bag containing amniotic fluid that surrounds the baby during pregnancy has protruded into the birth canal).

At 6:27 p.m., Nurse #7 charted a late entry for 1:55 p.m. Nurse #7 noted that he/she gave report to the L&D Charge Nurse (RNC #8 or registered nurse certified in his/her specialty, in this instance certified in L&D) and RNC #9. Nurse #7 noted that the report included the following: dilated six (6) cm, effaced 100%, 2+ station, with a bulging bag. Nurse #7 noted that Physician #2 was at Patient #1's bedside and that Physician #2 stated that he/she could not feel the cervix but that he/she did not want to check Patient #1 too aggressively.

At 6:27 p.m., RNC #8 noted that at 2:00 p.m. Physician #2 was at Patient #1's bedside and that Physician #2 stated he/she could not feel the cervix but that he/she did not want to check the patient too aggressively. RNC #8 noted that Physician #2 used an ultrasound machine to determine fetal heart tones and then requested that the ultrasound sonographer come up and perform a complete ultrasound. RNC #8 noted that at 2:15 p.m. the sonographer completed the ultrasound and that the fetal heart tones were 140. RNC #8 noted that the ambulance attendants arrived and that Physician #2 and RNC #9 signed the transfer form. RNC #8 noted that RNC #9 asked Physician #8 whom he/she had spoken with at the receiving facility. RNC #8 noted that by this time Patient#1 was on the stretcher and that Physician #8 said to transport and Patient #1 left the unit via ambulance service on 07/12/17 at 2:25 p.m.

Review of the facility's Joint Medical Staff Rules & Regulations and Departmental Rules, dated November 2016, revealed the following:
PART ONE: ADMISSION OF PATIENTS
1.4 ADMISSION INFORMATION AND ORDER
Except in an emergency, a patient will not be admitted to a Hospital until the practitioner requesting admission provides a provisional diagnosis or a valid reason and order for admission stating the unit to which the patient is to be admitted, i.e., inpatient, observation, a critical care unit, etc.
PART NINETEEN: JOINT DEPARTMENT OF OB/GYN (obstetrics/gynecology [care of the pregnant patient/care of the female reproductive system] RULES
19.3 DEPARTMENT SPECIFIC RULES
19.3.2 All patients presenting to the (name of the women's unit) shall be given an appropriate Medical Screening Examination to determine whether or not an "Emergency Medical Condition" exists as defined by the Emergency Treatment and Active Labor Act (EMTALA) or the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). For this purpose, the physicians and Hospital staff shall comply with the Hospital's policies pertaining to COBRA and EMTALA as they may change from time to time. The following individuals will be considered "Qualified Medical Personnel" as such term is used in EMTALA to provide a "Medical Screening Examination" at the (women's unit): (1) registered nurses, (2) clinical nurse specialists, and (3) nurse practitioners.


Review of the facilities policies and procedures included but was not limited to the following:

1. EMTALA - Emergency Medical Treatment and Labor Act, policy number 1102-A, effective 06/18/15, It shall be the policy of the facility to comply with federal laws and regulations, including the provisions of EMTALA.
C. Stabilization and Treatment
1. Except as set forth below, patient experiencing an Emergency Medical Condition must be stabilized prior to being discharged or transferred. A patient is considered to be stabilized when the treating physician has determined, with reasonable clinical confidence, that the patient's Emergency Medical Condition has been resolved.
2. For all patients presenting to the Emergency Department: An Emergency Department physician shall be responsible for the general care of all patients presenting to the Emergency Department until the patient's private physician, or an on-call physician, assumes that responsibility or the patient is discharged or transferred ...
3. If the DED is unable to contact the patient's requested physician, the requested physician is contacted but unavailable to come to the Hospital, or if the patient does not have a preferred physician, the physician listed on the on-call rotation schedule may be contacted to provide consultation or stabilizing treatment for the patient as deemed medically appropriate by the treating Emergency Department physician. If in the opinion of the Emergency Department physician the request for treatment by the patient ' s requested physician will result in an appropriate delay of treatment of the patient's Emergency Medical Condition, the Emergency Department physician shall contact the on-call physician.
4. The patient must consent to any proposed Stabilizing Treatment in accordance with standard Hospital protocols related to informed consent for treatment.


2. Scope of Care for Women's and Children's Services, policy number 670.306, effective 12/30/16, revealed the purpose of the policy was to adequately plan and provide nursing care for the obstetric patient in the critical care setting. The policy defined Level II Newborn Care as sick newborns who do not require intensive care but require 6-12 hours of nursing time each day. This policy indicated that the women's unit included:
--The Birthplace consist of fourteen (14) labor/delivery/recovery rooms, three (3) antepartum rooms, twenty-five (25) mother-baby rooms, two (2) operating suites, a three (3) bed post-anesthesia care unit, a four (4) bed antepartum testing and triage area, an observation nursery.
2. Neonatal Intensive/Special Care Nursery consists of an eighteen (18) level II nursery that contains 6 private rooms and 12 open beds.
The policy noted that the unit provided normal newborn care and Level II neonatal intensive care.


3. Laboring and Non-Laboring Obstetrical Patient Triage Assessment and Disposition: Presenting to the Emergency Department or OB Triage, policy number 670.301, effective 12/30/16 revealed it was the policy of the women's unit that the Obstetrical Patient, laboring and non-laboring presenting to the Emergency Department (ED) or to Obstetrical (OB) Triage will be assessed and guided to the appropriate service based on their immediate medical needs.
C. Patient Presentation to Obstetrical Triage: Obstetrical patients 20 weeks or greater gestation by date and/or history presenting to OB Triage with pregnancy related complaints will be seen and treated in OB Triage.
The procedure was to perform and record patient triage/Quick assessment including: (RN)
1. Chief Complaint;
2. Possible complications of pregnancy
3. Gestational age of fetus
4. Fetal Heart tones (FHT) when applicable/possible
5. Additional assessment as needed.


4. Admission Guidelines for the Neonatal Intensive Care Unit, policy number N1.3, effective 01/01/2016, revealed the Criteria for Transfer to an Outside Facility included but was not limited to the following:
--Infant's with the need for procedures and/or special care which are not routinely provided in the NICU are eligible for transfer at the discretion of the physician. Any infant delivered before 30 completed weeks' gestation.


Interviews

During an interview on 07/21/17 at 9:00 a.m. in the ED Command Center, the Director of Women and Children Services (#6) stated, we don't transfer many pregnant women to other facilities because facility B (the Director gave the name of the facility) is nearby and high risk patients go to that facility. The Director explained that the facility's L&D delivers women who are at least 32 weeks pregnant. The Director stated the facility's (A) Certificate of Need (CON) was for a level II birthing center. The Director explained that Georgia has not designated maternal levels of care. The Director went on to explain that Georgia and the American Academy of Pediatrics define newborn care as the following:
--level I hospitals provide basic newborn nursery care for babies that are low risk;
--level II hospitals provide care for stable to moderately ill newborn infants born at 32 weeks' gestation or who weigh at least 1500 grams (3.3 pounds) who are expected to need short term nutritional and/or ventilation support;
--level III hospitals provide care for infants who are less than 32 weeks' gestation or who weigh less than 1500 gm that may require long term sustained life support; and
--level IV hospitals provide care for all gestational ages, when the infant might require urgent access to pediatric subspecialists such as pediatric surgery and pediatric anesthesia for congenital or acquired medical conditions.

The Director #6 stated the facility routinely delivers women whose gestational (length of pregnancy) is 32 weeks or more. He/she explained that women who are less than 32 weeks' gestation and are in preterm labor can be admitted and placed on Magnesium Sulfate (medication used to stop uterine contractions) in an attempt to prevent a premature birth. The Director went on to say that the intent was to try and maintain the pregnancy for if possible. The Director added that the physician (#2) had transferred patient (#1) and that the intent had been to keep the mother and baby together. The Director stated that staff in the Women and Children Services Department had received receive EMTALA training in orientation and that the Department had received EMTALA training in December of 2015. In addition, the Director explained that staff had been assigned an EMTALA computer based learning and that it had to be completed by 08/20/17. The Director clarified that pregnant patients presenting with signs and/or symptoms of labor were triaged by a Registered Nurse that had received specific training in evaluating cervical dilation, cervical effacement, station of the baby, and monitoring contractions and fetal heart tones. The Director explained that a patient would then be admitted to observation until the Clinical Coordinator determined whether the patient met inpatient admission criteria. The Director confirmed that the patient (#1) had been admitted to observation and was not an inpatient at the time of the transfer.

During an interview on 07/21/17 at 11:10 a.m. in the ED Command Center, Physician #2 stated that he/she had been practicing as an obstetrician since 1974. Physician #2 confirmed that Patient #1 was his/her office patient and that the patient's first prenatal visit had occurred later in the pregnancy. Physician #2 stated he/she was in the office when he/she was contacted by phone on 07/12/17 and informed that Patient #1 had presented to the Labor and Delivery (L&D) unit complaining of pain. Physician #2 said that he/she asked Nurse #7 to check Patient #1. Physician #2 said that he/she was initially told that Patient #1 was 22 weeks pregnant but after reviewing Patient #1's office chart realized that the patient was 27 weeks pregnant. Physician #2 stated that Nurse#7 reported that Patient #1 was dilated to six (6) centimeters. Physician #2 said that he/she had a lot of confidence in the L&D nurses' training and competencies. Physician #2 stated that he/she told Nurse#7 that Patient #1 had to be transferred and that he/she (the physician) would be right over. Physician #2 further explained that his/her office was located three (3) to four (4) minutes away from the hospital. Physician #2 said that he/she arrived and explained to the Patient #1 that she needed to be transferred to facility B because facility B had a Neonatal Intensive Care Unit (NICU) and that Candler Hospital only provided care for patients that were at least 32 weeks pregnant. Physician #2 also stated that he/she told the Patient #1 that he/she could deliver the baby but that the goal was to keep the mother and baby together in the same hospital and that Patient #1 had agreed to the transfer. The hospital failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that on 7/12/2017 patient #1 who was experiencing an obstetrical emergency medical condition, eminent delivery of her unborn child, was stabilized prior to transferring the patient to Hospital B.



During an interview on 07/21/17 at 2:30 p.m. in the ED Command Center, the L&D Registered Nurse (RN #7) stated that he/she had worked L&D since 2002. RN #7 explained that he/she had received training which had included shadowing another nurse. RN #7 explained further that annual competency testing included monitoring contraction, monitoring fetal heart tones, and evaluating the cervix. RN #7 explained that the facility utilized a cervical board (tool used to evaluate dilation and effacement of the cervix). RN #7 confirmed that he/she remembered Patient #1. RN #7 stated that Patient#1 had been dilated to six (6) cm with a bulging membrane. RN #7 confirmed that he/she notified Physician #2 and was instructed to place the patient in an L&D room and to start Lactated Ringers and Magnesium Sulfate. RN #7 explained that he/she had notified the Charge Nurse (#8) and the Physician #2 that Patient#1 was 22 weeks pregnant per the dates the patient had initially reported. RN #7 said that after the Physician #2 checked his/her office chart the Patient#1 was determined to be 27 weeks pregnant. RN #7 stated that the Physician #2 had informed him/her that they would have to transfer Patient#1. He/she confirmed having had EMTALA training but stated he/she was unsure of the date.

During an interview on 07/21/17 at 3:20 p.m. in the ED Command Center, RNC #9 (Registered Nurse Certified in Obstetrics) stated he/she had worked L&D for 21 years. RNC #9 explained that his/her annual competency testing included monitoring for contractions, fetal heart tones monitoring, and performing vaginal examinations for cervical dilation, cervical effacement, and the baby's station. RNC #9 stated that the facility used a cervical dilation tool to evaluate staff competencies for evaluating cervical dilation and effacement. The RNC said that he/she remembered Patient #1 and that on 07/12/17 RN #7 was taking the patient to a room and the Charge Nurse (#8) told the unit secretary to call the EMS.


During an interview with the L&D Charge Nurse (RN #8) on 07/22/17 at 12:45 p.m. in the ED Command Center, RN #8 explained that he/she had worked at Candler Hospital for over 34 years. RN #8 stated that he/she has worked L&D for 25 years and was the L&D Charge Nurse on 07/12/17. RN #8 clarified that he/she is an RNC (nationally certified RN in obstetrics). RN #8 further explained that he/she is also a member of AWON (Association of Women's Health Obstetric and Neonatal Nurses). RN #8 stated he/she remembered Patient #1. RN #8 explained that Patient #1 arrived by ambulance to the L&D triage where it was reported that Patient #1 was at 22 weeks of gestation, but that it was later determined that the patient was actually 27.3 weeks' gestation. RN #8 stated Patient #1 was assessed by the triage nurse (RN#7) and that he/she got a call that the patient needed to be admitted. RN #8 said that since the patient was at 27.3 weeks' gestation, Physician #2 wanted an intravenous line started for Magnesium Sulfate (used to slow down labor) to try and prolong the pregnancy. RN #8 stated that the patient was admitted to room 356 and orders initiated. RN #8 said that the triage nurse (RN #7) came back to the patient's room and reported that Physician #2 thinks the patient should be transferred.

The RN #8 stated the Physician #2 arrived and examined Patient #1. RN #8 stated that the patient was large and that fetal heart tones were difficult to obtain. RN #8 said that Physician #2 did the ultrasound at the patient's bedside without much success, so Physician #2 ordered for the sonographer to come and obtain the ultrasound. RN #8 stated that the baby's heart tones were recorded and that the position of baby was breech.


During an interview with the Neonatologist (Physician #14) on 07/23/17 at 11:45 p.m. in the ED Command Center, Physician #14 stated he/she had been in-house on 07/12/17. Physician #14 stated the facility had a Level II Nursery and that they provided care for babies 32 weeks or greater or at least 1250 gm (2 pounds 12 ounces). Physician #14 confirmed that in an emergency the facility had the experienced staff and equipment to provide stabilizing treatment for a baby born at 27 weeks. Physician #14 said that the Neonatologists had all worked at Level IV hospitals. In addition, Physician #14 aid that in that instance the receiving facility (B) would send their neonatal transport team to transport the baby. Physician #14 said that ultimately the best thing was to try and transfer the mother before the baby was born so that the mother and baby would not be separated. Physician #14 confirmed that he/she had just completed EMTALA training during July 2017.

On 07/23/17, the Director of Women and Children Services (#6) performed a query from 07/01/16 to 07/23/16 for babies delivered at less than 32 weeks' gestation. There was one (1) baby born on 09/09/16 at 27 weeks that was delivered and transferred to the receiving facility B. In addition, the Director confirmed that the facility had neonatologist and anesthesiologist in-house 24 hours a day seven (7) days a week.

Based on review of facility A's medical records, Transfer Center recordings, the facility's Joint Medical Staff Rules & Regulations and Departmental Rules, policies and procedures, staff interviews, Paramedic interview, EMT interview, query of births less than 32 weeks' gestation, it was determined that the facility failed to provide medical treatment within its capacity that minimized the risk in this case to a women in labor, the health of the unborn child the individual's health an appropriate transfer for one (#1) of twenty (20) sampled patients, and her unborn infant child (#22). The facility also failed to effect an appropriate transfer through qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures during the transfer of patient #1.


Findings were:

Review of the facility ' s Joint Medical Staff Rules & Regulations and Departmental Rules, dated November 2016, revealed the following:
PART FOUR: TRANSFER OF PATIENTS
4.1 ALL TRANSFERS
To ensure continuity of care among settings, organizations and providers, appropriate patient information must be communicated whenever patients are transferred. In addition to any information required by hospital policy, the following information must be shared with other providers assuming responsibility for the patient ' s care:
4.1.1 the reason for the transfer,
4.1.2 the patient ' s physical and psychosocial status,
4.1.3 a summary of care provided and progress toward goals, and
4.1.4 community resources or referrals provided to the patient.
4.3 TRANSFER TO ANOTHER FACILITY
4.3.1 GENERAL REQUIREMENTS
A patient shall be transferred to another medical care facility only upon the order of the Attending Staff member, only after arrangements have been made for admission with the other facility, including its consent to receiving the patient, and only after the patient is considered sufficiently stabilized for transport. All pertinent medical information necessary to insure continuity of care must accompany the patient. All Hospital policies relating to transfer for patients must be followed.

Review of the facilities policies and procedures included in part but was not limited to the following:
1. EMTALA - Emergency Medical Treatment and Labor Act, policy number 1102-A, effective 06/18/15, It shall be the policy of the facility to comply with federal laws and regulations, including the provisions of EMTALA.
D. PATIENT TRANSFERS TO A MEDICAL FACILITY
1. A patient in an Emergency Medical Condition may be Transferred to another medical facility before Stabilization if:
b. Based on the information available at the time of transfer, the physician determines that the medical benefits to be received at another medical facility outweigh the risk to the patient of being Transferred (including, in the case of a woman in labor, the risks to the unborn child) and a certification to this effect is signed by the physician ("physician-initiated transfer "). The physician shall complete the applicable transfer form (See Patient Care Policy #6045-PC Admissions, Transfer and Discharge in the Acute Care Setting).
2. Appropriate steps shall be taken and treatment provided to minimize the risks associated with the Transfer.
3. In all cases of patient Transfer, consent of the receiving hospital must be obtained and documented in the patient ' s medical record before the Transfer. This consent is to include that the receiving hospital has available space and qualified personnel to provide treatment to the patient. The patient ' s condition must also be documented in the medical record prior to the Transfer.
4. Copies of the patient ' s medical record, including, but not limited to, symptoms, preliminary diagnosis, treatment provided, test results, and informed written consent or transfer certification.
5. The Transfer of a patient shall be carried out by qualified personnel using transportation equipment appropriate for the patient ' s medical condition.
1. Ensure compliance with EMTALA Policy: Treatment and Transfer of Individuals Seeking Emergency Treatment.
2. Obtain order from physician including status and level of care.
3. Note name of receiving physician.
4. Notify the admitting office of the healthcare facility that is to receive the patient and request a bed in the area specified by the physician.
5. Notify patient and family.
6. Complete " Patient Transfer to another Hospital Facility " paper form.
7. Have physician document risks/benefits and sign in appropriate space.
a. Address each area of information requested.
b. Call the receiving nurse and give patient report. Note nurse ' s name, title, phone number, and additional information requested in appropriate area. Document on the Handoff Communication assessment.
c. Have patient (or person signing on patient ' s behalf) read and sign appropriately signature must be witnessed.
d. The nurse shall sign appropriately.
E. Detach copy of form and the send to receiving facility with patient.
f. Original copy of form becomes part of the medical record and should be scanned into the EMR.
8. Complete and have patient sign "Authorization for Release of Information".
9. Print documents/test results as requested by the physician or receiving facility to be sent with the patient.
10. After confirmation that the room is ready, contact Clinical Care Coordination to arrange transportation.
a. If indicated, nurse or respiratory therapist must accompany patient according to physician order or unit policy.
b. Once a ready bed is given, the patient must be transferred as soon as possible, but no later than 2 hours.
11. Discharge patient according to the steps listed under "Discharging Patient".

Medical Record Review of Candler Hospital - Transfer Form

Review of the Candler Hospital Patient Transfer to Another Facility form for Patient #1 revealed the following:
1. Patient Condition - the box checked informed the patient that she "may be at risk for deterioration from or during transport."
2. Reason for transport - the box checked indicated the transport was necessary to receive equipment or services not available at this facility.
3. Risks of transfer - was noted to be delivery during transfer. In addition, a box was checked indicating that all transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement and limited medical capacity of transport units that my limit available care in the event of a crisis.
4. Benefit of transfer - included Perinatology (branch of medicine (obstetrics and pediatrics) dealing with the fetus and infant during the perinatal period/time of birth) and Neonatology (subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn infant). On 7/12/2017. Candler Hospital had the capabilities of physical space, labor and delivery rooms, equipment and specialized services of obstetrical and Neonatology ; and the facility had the on -call services Obstetrician (#2) for patient#1 to provide stabilizing services for the patient and her unborn child (#22).


Transfer Center Recordings
Review of the receiving facility's (B) Transfer Center's recordings dated 07/12/17 revealed the following:
1. Recording #1 at 2:15 p.m.
The Transfer Center Operator #12 states give me your name doctor.
Sending facility's Physician #2 gives his/her name and spells his/her first name.
The Transfer Center Operator #12 thanks physician #2 and asks what facility the physician is calling from.
Physician #2 replies by giving the name of the sending facility (A) and states he/she is calling from the L&D department.
The Transfer Center Operator #12 asks for physician #2's call back number.
Physician #2 provides his/her phone number and the phone number to the L&D department. Physician #2 informs the Transfer Center Operator #12 that Patient #1 is in premature labor and that the patient is 27.3 weeks pregnant. Physician #2 states, we don't have a whole lot of time by the way and we're going to get her over there.
The Transfer Center Operator #12 replies, let me see who's on-call.
2. Recordings #2 and #3 are copies of the first recording and have no additional information.
3. Recording #4 at 2:22 p.m.
The Transfer Center Operator #12 answers and gives his/her name.
The receiving facility's on-call physician #13 responds and gives his/her name.
The Transfer Center Operator #12 informs the on-call physician #13 that physician #2 is calling from the sending facility (A) and that physician #2 has a 27.3 weeks' pregnant patient that physician #2 says is completely dilated. Per (gives a nurse's name) L&D and Neonatal are good.
The on-call physician #13 asks, she's completely dilated?
The Transfer Center Operator #12 states, yeah that's what he/she (physician #2) told me to tell you.
The on-call physician #13 states that's kind of unsafe.
The Transfer Center Operator #12 responds yeah, he/she (the sending physician #2) said because we don't have much time.
The on-call physician #13 says right, ok.
4. Recording #5 at 2:23 p.m.
The sending physician #2 answers the phone and says hello.
The Transfer Center Operator #12 informs physician #2 that the on-call physician #13 at the receiving facility is on the line. The Transfer Center Operator #12 says go ahead doctors.
Facility' B's on-call physician #13 says hello.
Facility A's physician #2 greets physician #13. Physician #2 stated, I've got a patient that is dilated six (6) cm and she is 27.3 days pregnant. Physician #2 continues to speak but is unclear. The physician does state that he/she doesn't know if the patient is hour glass (lack of progression despite contractions) or what.
Facility B's on-call physician #13 asks if the Patient #1 is vertex (head first) or breech (buttocks or feet first)?
Facility A's physician #2 states, I don't know let me check. Physician #2 confirms that Patient #1 is breech.
Facility B's on-call physician #13 repeats, she's breech on the ultrasound?
Facility A's physician #2 states yeah.
Facility B's on-call physician #13 states I'm not sure, can you tell if it's hour glassing with the ultrasound?
Facility A's physician #2 states I don't know, while I was in here talking to you the transfer people might have gone, we have EMS, she's (Patient #1) is in route now.
Facility B's on-call physician #13 asks, she's (Patient #1) is in route where?
Facility A's physician #2 states she's (Patient #1) in route to (gives the name of facility B) your place.
Facility B's on-call physician #13 asks, she's already in route here?
Facility A's physician #2 states yeah, I may have moved her a little bit early.
Facility B's on-call physician #13 states, I'm not sure that's safe, with a breech baby with a complete bag. I mean if she ruptures (bag of fluid burst) and prolapses a cord (umbilical cord comes out of the uterus, this can cause compression on the cord and decrease blood flow to the baby).
Facility A's physician #2 states, well, yeah, I guess we can turn her around. But, by the time we turn her around, but she may be closer here than to gives name of facility B. If you think we should turn her around.
Facility B's on-call physician #13 states, I don't think that sounds safe to me. To send a breech person with membranes bulging.
Facility A's physician #2 states, I agree, but, I agree, I agree with you. I have no problem with that but they were already going down the hall with the patient.
Facility B's on-call physician #13 states, I think she probably needs to stay there.
Facility A's physician #2 states, ok let me talk to them.
Both doctors agree and they disconnect. The Transfer Center Operator #12 then thanks the on-call physician #13 and they hang up.
5. Recording #6 at 3:05 p.m.
Facility B's Transfer Center Operator #12 asks the on-call physician #13 if he/she needs a copy of the transfer.
The on-call physician #13 asks, do you know what happened?
The Transfer Center Operator #12 states what, did the patient (#1) show up here?
The on-call physician #13 replies yes.
The Transfer Center Operator #12 gasp.
The on-call physician #13 states, I hung up the phone with you and I had to get on the phone with somebody else.
The Transfer Center Operator #12 states he/she told his/her supervisor about the call as soon as we hung up.
The on-call physician #13 states, then my cell phone rang and it was (gives name of physician #2 from facility A) and he/she said that patient is already in route and I said what. On-call physician #13 continues by saying that facility A's physician #2 told me the patient was already on the way down the hall. The on-call physician #13 states that he/she told (facility A's physician #2) I did not accept that transfer and he/she (physician #2) said well I'll see what I can do, wait, she's (Patient #1) has already gone. The on-call physician #13 states, I hung up the phone and called the nurse up in L&D and told the nurse that I had declined a transfer and the patient might show up. I think they (facility A) had tried to turn the transport vehicle around.
The Transfer Center Operator #12 states, I put it as a cancellation because he/she (facility A's physician #2) said I agree with you I'll try and catch her (Patient #1).
The on-call physician #13 states yeah, I did not accept her (Patient #1).
The Transfer Center Operator #12 states I know you did not accept her. That I know for sure and I told my supervisor once we hung up. I'll have them pull the transfer.
The on-call physician #13 states he/she (facility A's physician #2) called me back on my cell phone and said he/she couldn't stop the patient and that the patient was already here (facility B). And I was like, she's already here?
The Transfer Center Operator #12 states and she (Patient #1) wasn't even accepted.
The on-call physician #13 states so then the patient rolls up to L&D and meanwhile he/she (facility A's physician #2) is on the phone with me and I'm pointing out that it was not correct what happened. And, she (Patient #1) rolled up to L&D and broke her water and prolapsed the cord and abrupted (separation of the placenta from the uterine wall. They did a vaginal delivery they didn't have time to do a caesarean section. And I said see this is what happens.
The Transfer Center Operator #12 states he/she will have the recording pulled and the two (2) hang up.

Review of the Candler Hospital Patient Transfer to Another Facility form for Patient #1 revealed the following:
5. Mode of transport - was listed as Basic Life Support Ambulance.
6. B. Documentation revealed the patient had signed the form signifying that she understood the risks and benefits associated with the transfer.
7. A. The transfer destination was noted as the receiving facility (facility B).
B. There was no indication that the patient had been accepted by the receiving facility (facility B).
C. There was no accepting physician indicated on the form
8. Indicated the patient gave consent for copies of the medical record to be sent to the receiving facility (facility B).
9. Indicated the patient's belongings were sent with the patient.
10. Indicated the patient's temperature, pulse, respirations, and blood pressure were essentially within normal limits.
11. Failed to indicate which portions of the medical record were sent to the receiving facility.
This form was signed by Physician #2, RNC #8, RNC #9, and Patient #1. In addition, Emergency Medical Technician (EMT #11) signed the form at 2:38 p.m.


Patient #1 Medical Record from Hospital B

Review of the receiving facility B's medical record (Medical Record #21) for Patient #1 who was transferred from Candler Hospital on 07/12/17 revealed the following:

Physician notes revealed that the patient presented to facility B's L&D on 07/12/17 at 2:33 p.m. The physician noted that the sending facility (A) transferred the patient who was in premature labor, was dilated to six (6) cm, with an intact membrane. The physician noted that the transfer had not been accepted because it was believed that the transfer was unsafe because the patient was in premature labor with contractions and a breech baby. The physician further noted that the EMTs reported that the patient was dilated 10 cm and that the patient's membranes had ruptured. Physician notes indicated the patient was moved to the operating room at 2:36 p.m. in preparation for an emergency cesarean section. The physician noted that the patient was examined and the baby's feet were felt in the vagina. The physician noted that he/she explained to the patient that since the baby had descended into the vagina, a vaginal delivery was the safest option. At 2:40 p.m., the physician noted that with the first push, the baby's feet and thighs were delivered and with the second push the baby's shoulders were delivered. The physician noted that although the mother continued to push, the baby's head would not deliver and that the physician had to push on the mother's abdomen to help deliver the baby's head. The physician noted that the baby's head was entrapped for 15 seconds. The physician noted that the baby was completely delivered at 2:41 p.m., and that the baby was dried and turned over to the Neonatal Intensive Care Unit (NICU) staff for resuscitation (assisted breathing). Documentation revealed that the patient had no complications during the delivery and was up walking on 07/14/17. Documentation revealed that the patient was discharged on 07/16/17.

Review of the receiving facility B's medical record (Patient #22) for the infant revealed the following:
Documentation revealed that the baby was born on 07/12/17 at 2:41 p.m. and that the baby weighed 1130 gm or 2 pounds and 7 ounces. Documentation revealed the baby's APGAR score (used to evaluate a newborn on a scale of 0-2 for each of the following: appearance [color], pulse rate, grimace [reflex irritability], activity [muscle tone], and respirations. A score of 0-3 requires resuscitation) at one (1) minute was one (1), at five (5) minutes the APGAR score was three (3), and at ten (10) minutes the APGAR score was eight (8). Documentation revealed the baby was intubated (tube placed into the airway to provide mechanical ventilation) and that the patient was placed on positive pressure ventilation. The physician noted that at the time of birth the baby had a high potential for serious morbidity (disease) or death. Documentation revealed the baby was admitted to the NICU where the baby continued to receive mechanical ventilation and nutritional supplements. Physician notes indicated the baby had severe bruising, no noted deformities, and that the baby received Curosurf (medication used to treat lung disease in premature infants). Documentation revealed that the baby stabilized and that discharge plans were for the baby to be discharged on 07/26/17.


Interviews

During an interview on 07/21/2017 at 11:10 a.m., in the ED Command Center, Physician #2 stated that he/she called facility B's transfer center and gave the Transfer Center Operator (#12) the patient's (#1) information. Physician #2 said that in the meantime the ambulance attendants arrived and that the situation was hectic. Physician #2 said that the Charge Nurse (RN#8) was helping to move Patient #1 to the stretcher and down the hall toward the elevator. Physician #2 stated that he/she told them that Patient #1 had not yet been accepted but that out of compassion for the patient Physician #2 told them to go ahead and transfer the patient. Physician #2 explained he/she was on the phone with the receiving facility's on-call Physician, (#13) and Physician #13 told Physician #2 that he/she thought Patient #1 ought to be kept at the sending facility because he/she did not think the transfer would be safe. Physician #2 said, he told Physician #13 that the transfer was already in progress but that Physician #2 would try to turn them around. Physician #2 further stated that he/she had the nurses call the EMTs to try and get them to return but they made it to the receiving facility (B) in three (3) minutes, and they couldn't bring the Patient #1 back. Physician #2 said that he/she had never transferred a patient without an accepting hospital and accepting doctor before but that he/she had a working relationship with the receiving facility (B) and that he/she thought Patient #1 would be accepted. Physician #2 said he/she had not had EMTALA training but knew EMTALA existed. He/she explained that the facility's (A) neonatologist could stabilize a premature baby but then the baby would have to be transferred separated from the mother. Physician #2 said his/her concern had been to keep the mother and baby together. Physician #2 explained that he/she did the same thing in his/her private practice and that if he/she thought another physician could provide a higher level of care he/she referred the patient. The physician added that he/she had never had a patient deliver en route to another facility.

During an interview on 07/21/17 at 1:15 p.m. in the ED Command Center, the Medical Chair (Physician #3) of the Obstetric/Gynecology/Oncology Departments stated he/she had received EMTALA training. Physician #3 explained that after Patient (#1) had been transferred he/she had discussed EMTALA with the Department' s Medical Staff. He/she stated that in Physician #2 ' s medical judgment and past history with the receiving facility B), the Physician #2 proceeded to transfer Patient #1 before obtaining an accepting physician.

During an interview on 7/21/2017 at 2:30 p.m., RN #7 provided the patient's medical information for the EMS. RNC #9 explained that the transfer forms were prepared and that he/she witnessed the transfer form and then left the room to care for another patient. RNC #9 said that he/she was not present when Patient #1 was transported by the EMS. RNC #9 said that he/she was not sure whether he/she had received EMTALA training. RN #7 explained that Physician #2 examined Patient#1. RN #7 stated that he/she gave report to the Charge Nurse (#8) and another nurse (#9) and that he/she went back to triage because there was another patient coming.

During an interview on 7/21/1017 at 3:20 p.m. RNC #9, he/she stated that RN #7 provided the patient's medical information for EMS. RNC #9 explained that the transfer forms were prepared and that he/she witnessed the transfer form and then left the room to care for another patient. RNC #9 said that he/she was not present when Patient #1 was transported by the EMS. RN #9 said that he/she had received EMTALA training.

During an interview on 07/21/17 at 4:30 p.m. in the ED Command Center, the Paramedic (#10) and EMT (#11) confirmed that they were the two (2) EMS staff that transported Patient #1 to the receiving facility (B) on 07/12/17. Both reported that they had dropped a patient in the facility's ED when they were notified by their Dispatcher that there was a patient on L&D that was ready to be transferred to the receiving facility (B). Paramedic#10 explained that they got up to L&D and a nurse coming out of the patient's room said the patient was ready to go and that he/she (Paramedic) said not until we get report. Paramedic #10 and EMT #11 stated that the nurse reported that the patient was 27 weeks pregnant, had been dilated six (6) cm for over an hour, and that the baby was in a breech presentation. Paramedic #10 and EMT #11 said that the nurse informed them that the physician had examined the patient and that the patient had a bulging membrane with contractions that were seven (7) minutes apart and that the patient was receiving Magnesium Sulfate. Both also stated that the nurse reported that the patient could not deliver vaginally and needed to be transported to the receiving facility (B). Paramedic #10 said that while they were waiting Physician #2 asked if the nurses had called report and that neither of the two (2) nurses knew the number to the receiving facility. Paramedic #10 said that Physician #2 said that he/she would call.

Paramedic #10 said that while moving the patient to the stretcher the patient had a contraction. The EMT said that he/she timed the contraction and that the next contraction occurred three (3) minutes later. Both interviewees agreed that the nurse informed them that the patient was stable for transfer. The EMT said that by the time they got to the ambulance the patient had another contraction. The Paramedic said that the patient reported feeling pressure and patted near her behind. The Paramedic stated, I looked and there was no baby present, there was another contraction, the patient reported more pressure, and there was still no baby present. The Paramedic explained that the patient continued to have contractions and when they arrived at the L&D Unit (of receiving facility B) no one knew they were coming. The Paramedic stated that they gave report and upon moving the patient from the stretcher to the bed they noticed fluids on the stretcher. The L&D staff (receiving facility B) rushed the patient to the operating room and within two (2) to three (3) minutes a nurse came out and said the baby had been born. The Paramedic said that the nurse reported that the baby had been born vaginally because there was no time for a caesarean section and that there was lots of blood and fluid in the infants' airway. The Paramedic explained that he/she had a picture on his/her phone of the transport times. After reviewing his/her phone the Paramedic said they were en route from hospital (A) at 2:24 p.m. and arrived at the other hospital (B) at 2:27 p.m. Both interviewees stated they had reported the incident to their supervisor because they were not equipped to deliver a premature baby and that they felt the mother, baby, and themselves had been placed at risk. They both agreed that they had not been given an adequate report. The facility failed to effect an appropriate transfer of Patient #1 on 7/12/2017 and her unborn premature neonate as evidenced by failing to transport the patient, who was in active labor, in an Advanced Life Support EMS unit.

An interview was conducted with the L&D Charge Nurse (RN#8) on 07/22/2017 at 12:45 p.m. RN #8 explained that Physician #2 wanted to transfer Patient #1. RN #8 stated that the transfer forms were obtained and that Physician #2 went to call the transfer center. RN #8 said that the patient was readied for transfer and that the ambulance attendants arrived quickly. RN #8 stated that that when they got the patient in the hall RN #8 asked Physician #2 if the patient was good to transfer or would the physician like to examine her again. Physician #2 replied, no. RN #8 stated that he/she asked Physician #2 if Patient #1 could go and that the Physician #2 first hesitated and then said yes, she can go. RN #8 said that he/she then asked Physician #2 again it the patient was ready to go and that the physician replied yes, send her. RN #8 confirmed that he/she had not examined Patient #1. RN #8 said that Patient #1 was having some contractions at least from what could be seen on the monitor. RN #8 explained that Patient #1 was a larger woman and that it is more difficult to pick-up fetal heart tones and contractions in larger women. RN #8 said that the patient was transferred at the orders of Physician #2 who had checked the patient.

The facility inappropriately transferred patient #1 on 7/12/2017 as evidenced by failing to provide medical treatment that was within its capacity that minimized the risks of patient #1's health and her unborn born child (#22). As this resulted in an inappropriate transfer of the patient and her unborn child.