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Based on policy review, closed medical record review, staff and physician interviews, the hospital staff failed to provide an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition existed for 1 of 5 obstetrical patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patient #16).

The findings include:

Review of the Hospital EMTALA (per hospital Emergency Medical Treatment & Active Labor Act) policy revealed that an MSE shall be completed by a physician or Qualified Medical Personnel to determine if an emergency medical condition exists. The Hospital policy defines QMP as a physician extender and an OB RN that is "specially trained".

Medical record review of patient #16, revealed a 14 year old presenting to the Obstetrical (OB) unit on 05/08/2011 at 2026 with a chief complaint of leaking fluids. Record review revealed the patient was triaged at 2025, reporting she thought her water broke around 1930. The medical screening exam was performed by the OB nurse (nurse #1) at 2030. The exam revealed the patient had premature rupture of membranes, 1.5 centimeters dilated, 50 % effacement and -3 station. No further cervical exams were completed to determine final cervical dilation change or descent of fetus or imminent delivery. Further review revealed the patient was having irregular contractions with an intensity of "mild" and the patient was "unaware of contractions". Record review revealed documentation of the patient's prenatal record indicating the patient started prenatal care late at 22 weeks with an estimated date of delivery 6/10/2011 and presently was 35 weeks 3 days gestation. Record review revealed at 2130 the color of the amniotic fluid was documented "clear" by the RN. Record review revealed at 2200 by the nurse, that the patient was continuing to have mild irregular contractions. Record review revealed no further documentation of the status of the cervix since triage. Record review revealed the patient was discharged on 5/8/2011 at 2203, by wheelchair, to go by private vehicle to another hospital.

Telephone interview on 8/26/2011 at 1100 with Nurse #1 revealed she was the nurse assigned care of patient #16 on 5/8/201. The interview revealed when the patient came in she told her that she thought her "water broke". Interview revealed she completed testing for amniotic fluid and the results were positive. Interview revealed after completing her MSE that she notified the physician on call of the results of the MSE. The interview revealed the physician did not come in to see the patient. The interview revealed she would have been more "comfortable" if the physician had come in to see the patient. The interview revealed she was concerned enough that she talked with her supervisor regarding the physician not coming in to examine the patient.

Based on policy review, closed medical record review, staff and physician interview, the hospital failed to provide stabilizing treatment within its capability and capacity for 1 of 5 sampled obstetrical patients' who presented to the dedicated emergency department, and was discharged with an emergency medical condition (Patients #16).

The findings include:

Review of the hospital's "key point of the EMTALA law are:...7. We must take and record the patient's vital signs and address any abnormal test results prior to transfer or discharge".

Interview with administrative staff on 8/24/2011 at 1500 revealed the hospital has an obstetrical unit and Operating Rooms. The interview revealed there are 3 physician obstetrical practices that have privileges at the hospital.

Medical record review of patient #16, revealed a 14 year old presenting to the Obstetrical (OB) unit on 05/08/2011 at 2026 with a chief complaint of leaking fluids. Record review revealed the patient was triaged at 2025, reporting she thought her water broke around 1930. The medical screening exam (MSE) was performed by the OB nurse (nurse #1) at 2030. The exam revealed the patient had premature rupture of membranes, 1.5 centimeters dilated, 50 % effacement and -3 station. Further review revealed the patient was having irregular contractions with an intensity of "mild" and the patient was "unaware of contractions". Record review revealed documentation of the patient's prenatal record indicating the patient started prenatal care late at 22 weeks with an estimated date of delivery 6/10/2011 and presently was 35 weeks 3 days gestation. Record review revealed at 2130 the color of the amniotic fluid was documented "clear" by the RN. Record review revealed orders initiated by the nurse per the computer physician order entry (CPOE) at 5/8/2011 at 2104. Record review revealed documentation by the nurse at 2135 " Dr. D (on call pediatrician) called about pt. gestational age, admit and treat for unknown GBS " . Record review of nursing documentation revealed at 2200 the patient was " unaware of contractions " and " Dr. D (on call physician) spoke to Dr. E (hospitalist on call) who felt pt should be transferred to Hospital B due to late prenatal care and poss. incorrect dates. " Record review revealed a physician ' s order, CPOE on 5/8/2011 at 2149 to cancel the transfer of the patient to hospital B. Further review of the CPOE orders revealed at 2203 an order to discharge the patient. Review of nursing documentation revealed at 2220 pt and family disch to Hospital B, with prenatal chart to give to caretakers at Hospital B. Pt opted to go in private vehicle instead of an ambulance. " Further review revealed the patient was voluntarily discharged to Hospital B. Record review revealed the patient refused to be transferred by ambulance. Record review revealed the patient was discharged at 2220 to go to another hospital by private vehicle. Record review did not reveal any documentation of reassessment of the patient prior to discharge including a cervical examination.

Telephone interview on 8/26/2011 at 1100 with Nurse #1 revealed she was the nurse assigned care of patient #16 on 5/8/201. The interview revealed when the patient came in she told her that she thought her "water broke". Interview revealed she completed testing for the presence of amniotic fluid and the results were positive. The interview revealed she called the on call obstetrical physician, Dr. F and reported her findings from the MSE. The interview revealed patient #16 was not Dr. F ' s patient, she had late prenatal care and Dr. F wanted the patient to be transferred to Hospital B by ambulance. The interview revealed Dr. F did not come in to evaluate the patient and did not talk with the family about the transfer. The interview revealed she was so concerned about Dr. F not coming to see the patient that she reported her concerns to the supervisor.

Interview with Dr. F (on call OB physician for 5/8/2011) on 8/26/2011 at 1215 revealed she did come in the night of 5/8/2011 and talked with patient #16's family. The interview revealed she consulted with Dr. D, the pediatrician on call to see what his preference was. The interview revealed Dr. D preferred for the patient to be transferred to hospital B since the patient started late with prenatal care and questionable gestational age with probability of delivery of premature infant. The interview revealed hospital A did not have the capability to provide care for a premature infant at gestational age 34 weeks or below. The interview revealed Dr. D had reviewed the medical record for patient #16 and her documentation was not in the record. The interview revealed that Dr. D. did not examine patient #16 when she came in.
Telephone interview with nurse A (assigned supervisor/case manager on duty at hospital A on 5/8/2011) on 9/13/2011 at 0911 revealed she did not have knowledge of a 14 year old OB patient presenting to the OB unit on 5/8/2011 with complaint of premature rupture of membranes. The interview revealed no nursing staff came to her with concerns of the OB on call physician not coming in to see patient #16. The interview revealed had she been called she would have had the patient sign an Against Medical Advice form if she refused to go by ambulance. The interview revealed she is called on all transfers prior to the transfer but understood this patient was discharged.

Telephone interview with Physician D (on call pediatrician) on 9/13/2011 at 1539 revealed he was on call on 5/8/2011 as the on call pediatrician. The interview revealed the on call OB physician (Dr. F) called and asked him what was his preference regarding a 14 year old with questionable gestational age. The interview revealed he told physician F that due to her age, unsure of gestational age with possibility of delivery of premature infant and age of patient he preferred she be transferred to Hospital B. The interview revealed he was not aware that the patient had premature rupture of membranes.

Based on policy review, closed medical record review and staff interviews the hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer for 1 of 3 sampled obstetrical patients that was transferred or discharged with an emergency medical condition (EMC) by failing to ensure: the receiving hospital had available space; that there was qualified personnel at the receiving hospital for treatment of the patient; and that they had agreed to accept the transfer of the patient. Additionally, there was a lack of physician documentation that indicated the medical benefits and risks of the transfer to a woman in labor . (Patient #16).

The Findings include:

Review of hospital policy "transfers to another facility" revised 4/8/2010 revealed "...It is the physician's responsibility to ensure there is an accepting physician when transfer must occur for medical necessity...Patient transfer form must be completed and signed by all of the following: a. transferring physician b. nurse calling report c. patient or legal representative...A report must be given to the receiving hospital and documented".

Medical record review of patient #16 revealed a 14 year old presenting to the Obstetrical (OB) unit on 05/08/2011 at 2026 with a chief complaint of leaking fluids. Record review revealed the patient was triaged at 2025. The medical screening exam was performed by the OB nurse (nurse #1) at 2030. The exam revealed the patient had premature rupture of membranes, 1.5 centimeters dilated, 50 % effacement and -3 station. Record review revealed documentation of the patient ' s prenatal record indicating the patient started prenatal care late at 22 weeks and was 35 weeks 3 days gestation. Record review revealed initiated orders by the nurse per the computer physician order entry (CPOE) at 5/8/2011 at 2104. Record review revealed documentation by the nurse at 2135 " Dr. D (on call pediatrician) called about pt. gestational age, admit and treat for unknown GBS " . Record review of nursing documentation revealed at 2200 the patient was " unaware of contractions " and " Dr. D (on call physician) spoke to Dr. E (hospitalist on call) who felt pt should be transferred to Hospital B due to late prenatal care and poss. Incorrect dates. " Record review revealed a physician ' s order, CPOE on 5/8/2011 at 2149 to cancel the transfer of the patient to hospital B. Further review of the CPOE orders revealed at 2203 an order to discharge the patient. Review of nursing documentation revealed at 2220 " pt and family disch to Hospital B, with prenatal chart to give to caretakers at Hospital B. Pt opted to go in private vehicle instead of an ambulance. " Further review revealed the patient was voluntarily discharged to Hospital B. Record review revealed the patient refused to be transferred to a tertiary care hospital by ambulance. Record review revealed the patient was discharged at 2220 to go to a tertiary care hospital by private vehicle. Record review did not reveal any documentation of reassessment of the patient prior to discharge

Telephone interview on 8/26/2011 at 1100 with Nurse #1 revealed the nurse was assigned the care of Patient #16 on 5/8/2011. The interview revealed the patient presented directly to the OB unit with complaint of " thought water had broken " . The interview revealed testing was positive for amniotic fluid. The interview revealed she called the on call physician Dr. F and reported her findings from the MSE. The interview revealed patient #16 was not Dr.F's patient, she had late prenatal care and Dr. F wanted the patient to be transferred to Hospital B by ambulance. The interview revealed Nurse #1 talked with the patient and the family about the ambulance transportation. The interview revealed patient #16 's parents, Father of Baby (FOB), and FOB 's mother were the family that she spoke to. The interview revealed the patient did not want to be transported by ambulance. The interview revealed she talked with Dr. F and told her the patient refused to go by ambulance. The interview revealed Dr. F did not come in to evaluate the patient and did not talk with the family about. The interview revealed Dr. F. ordered the patient to be discharged to go to Hospital B by private vehicle. The interview revealed the FOB and FOB's mother transported patient #16 by private vehicle. The interview revealed she did not call Hospital B to give report on patient 16's diagnosis or that she was coming by private vehicle. The interview revealed she did not check to see if patient made it to Hospital B. The interview revealed nurse #1 was not aware of any discussion with the on call pediatrician about patient #16. The interview revealed she was so concerned about Dr. F not coming to see the patient that she reported to the supervisor her concerns that night.

Interview with Dr. F (on call OB physician for 5/8/2011) on 8/26/2011 at 1215 revealed the physician did come in the night of 5/8/2011 and talked with patient #16's family. The interview revealed she consulted with Dr. D the pediatrician on call to see what his preference was. The interview revealed Dr. D preferred for the patient to be transferred to hospital B since the patient started late with prenatal care and questionable gestational age with probability of delivery of premature infant. The interview revealed hospital A did not have the capability to provide care for a premature infant at gestational age 34 weeks or below. The interview of patient #16 was discussed with Dr. E the on call hospitalist also. The interview revealed she had reviewed the medical record for patient #16 and her documentation was not in the record. The interview revealed she had documented the calls with the two physicians and the final decision to transfer patient #16 and her calls to hospital B's physician staff accepting the patient. The interview revealed patient #16 refused to go by ambulance. The interview revealed she was told by nursing staff that the patient could not be transferred by private vehicle (POV), so the patient would have to be discharged to go by POV. The interview revealed she was not aware that the patient could be transferred by POV. The interview revealed she did not examine patient #16 when she came in. The interview revealed she remembered there was a couple identified as family and she talked with them about the option of patient going to hospital B by ambulance. The interview revealed delivery was not imminent. The interview revealed the intent was for the patient to go to hospital B to receive care due to her late prenatal care and questionable gestational age. The interview revealed the risks of sending the patient to hospital B was continued premature labor and umbilical cord prolaspe. The interview revealed she knew the patient made it to hospital B because the nurse told her but she did not remember which nurse.

Telephone interview with nurse A (assigned supervisor/case manager on duty at hospital A on 5/8/2011) on 9/13/2011 at 0911 revealed she did not have knowledge of a 14 year old OB patient presenting to the OB unit on 5/8/2011 with complaint of premature rupture of membranes. The interview revealed no nursing staff came to her with concerns of the OB on call physician not coming in to see patient #16. The interview revealed had she been called she would have had the patient sign an Against Medical Advice form if she refused to go by ambulance. The interview revealed she is called on all transfers prior to the transfer but understood this patient was discharged.

Telephone interview with Physician D (on call pediatrician) on 9/13/2011 at 1539 revealed he was on call on 5/8/2011 as the on call pediatrician. The interview revealed the on call OB physician (Dr. F) called and asked him what was in preference regarding a 14 year old with questionable gestational age. The interview revealed he told physician F that due to her age, unsure of gestational age with possibility of delivery of premature infant and age of patient he preferred she be transferred to Hospital B. The interview revealed he was not aware that the patient had premature rupture of membranes.

Review of the medical record for patient #16 at Hospital B (receiving hospital) revealed the patient arrived at the hospital on 5/8/2011 at 2250. (30 minutes after discharge from hospital A). Record review revealed documentation: " Referring hospital: Hospital A ...Point of Origin: Transfer from Hospital ...Mode of arrival: private vehicle. " Review of documentation by the physician revealed " Hospital course- Pt is a fourteen year old G1 now P1001 S/P SVD at 35 wks 3 days gestation. She presented to the outside hospital with PROM and was transferred to Hospital B. Cervical exam was 1 centimeter and upon arrival to Hospital B she was 4/80/-2 (4 centimeters dilated, 80 effacement and minus 2 station). Record review revealed the patient delivered on 5/9/2011 at 0406.

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