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Based on review of hospital policies and procedures, medical records, and interviews with hospital staff, the hospital failed to enforce its policies and procedures to comply with the requirements of 42 CFR 489.24 by not providing an appropriate medical screening examination for one (Patient #1) of five pregnant patients thought to be in active labor. And for transfer of two (Patients #1 and #5) of six patients who had an emergency medical condition (EMC) requiring transfer to another acute care hospital, and whose medical records were reviewed.

Findings:

1. The hospital's policy, "Guidelines for Emergency Department Services", revised 10/05/09, on page 2 appropriately defines stability for women in labor. The policy documents "...This standard also states that a pregnant woman is not legally stable until the baby and placenta have been delivered." On bottom of page 3 and top of page 4, the policy defines, "Emergency medical conditions include:...Pregnancy with contractions (defined as unstable)...". This policy also requires, "...The receiving hospital must give acceptance in advance. The acceptance must be documented in the medical record; Patient gives written consent for transfer; The patient must be transferred by an appropriate medical transfer vehicle. A patient may not be transferred in a private passenger vehicle unless the patient refuses to be transported by ambulance. The patient's refusal must be in writing. The physician will order appropriate medical personnel to attend the patient, maintain and/or initiate treatment or medications and manage known potential adverse affects...Copies of the medical record, x-rays and laboratory tests will accompany the patient when transferred...".

2. The hospital's policy, "Treatment & Transfer", revised 09/28/09, documents, "...If the patient has an emergency medical condition the patient will be provided necessary medical treatment to stabilize the emergency medical condition, such that, within reasonable medical probability, no material deterioration of the condition is likely to result from or occur during a transfer to another facility or with respect to the pregnant woman in labor, the woman has delivered, including the placenta, or the physician, physician's assistant or nurse practitioner has determined the woman to be in false labor, or that the woman can be appropriately transferred..." The policy also requires for unstable transfer, "...The patient/responsible party must be made aware of the risks and benefits of transfer. The patient/responsible party must consent in writing by signing the Authorization for transfer form. The reason for the request to transfer shall be documented on the Authorization for Transfer Form...The physician documents on the Authorization for Transfer Form the benefits and risks of transfer and certifies in writing the benefits of transfer outweigh the risks...The receiving facility must have available space and qualified personnel to treat the patient. The patient's physician or designee must obtain acceptance...The patient's physician will determine the most appropriate mode of transportation based upon an individual assessment of the patient's needs. Copied (sic) of currently available medical records must be sent with the patient...Other pertinent records not available at the time of the patient's transfer shall be sent to the receiving facility as soon as practicable after transfer."

3. For Patient #1, an appropriate medical screening examination was not conducted; for Patients #1 and #5, the hospital did not follow these policies and did not effect an appropriate transfer according to these policies and the regulations.

Based on review of hospital policies and procedures, medical records, and interviews with hospital staff, the hospital failed to provide an appropriate medical screening examination for one (Patient #1) of five patients whose records were reviewed of patients who had an emergency medical condition (EMC) and were pregnant and thought to be in active labor.

Findings:

Patient #1- The patient presented to the emergency room (ER) on 02/19/13 at 1614 with complaints of full term pregnancy and experiencing "tightening of stomach". The patient reported she was scheduled for a cesarean section later in the week at another hospital (Hospital A - hospital name omitted). The nurse, Staff C, recorded as a late entry for 1630 that the patient reported she had called the Hospital A to report possible contractions and was told to go to the ER to have them "determine active labor." The (PA) physician assistant, Staff D, examined the patient at 1640 and performed a pelvic examination. Staff D documented this was the patient's fifth pregnancy, with two of the births by cesarean sections. Moderate regular contractions every five minutes were recorded. The PA documented being unable to visualize the cervix due to amniotic fluid and vaginal cord infringement. Because of this, the PA could not determine the dilation of the cervix and should have performed a sterile digital exam. This was not performed.

Staff D documented at 1655, "Advised pt (patient) to proceed to Hospital A (name of hospital omitted) d/t (due to) amniotic fluid in vaginal canal coupled with reg (regular) contractions of moderate intensity. Pt verbalizes understanding."

The surveyors reviewed Patient #1's medical record during the interview with Staff D at 1410 of 04/12/13.

Based on review of hospital policies and procedures, medical records, and interviews with hospital staff, the hospital failed to provide an appropriate transfer for two (Patient #1 and 5) of six patients whose records were reviewed of patients who had an emergency medical condition (EMC) and were transferred to another acute care hospital.

Findings:

1. Patient #1- The patient presented to the emergency room (ER) on 02/19/13 at 1614 with complaints of full term pregnancy and experiencing "tightening of stomach". The patient reported she was scheduled for a cesarean section later in the week at another hospital (Hospital A - hospital name omitted). The nurse, Staff C, recorded as a late entry for 1630 that the patient reported she had called the Hospital A to report possible contractions and was told to go to the ER to have them "determine active labor." The (PA) physician assistant, Staff D, examined the patient at 1640 and performed a pelvic examination. Staff D documented this was the patient's fifth pregnancy, with two of the births by cesarean sections. Moderate regular contractions every five minutes were recorded. Staff D documented at 1655, "Advised pt (patient) to proceed to Hospital A (name of hospital omitted) d/t (due to) amniotic fluid in vaginal canal coupled with reg (regular) contractions of moderate intensity. Pt verbalizes understanding." The Patient Discharge Instructions documented, "Proceed to Hospital A (hospital name omitted) to Labor and Delivery. Active labor contractions 5 min (minutes) apart." The patient left ambulatory at 1658, accompanied by a friend. The medical record did not contain evidence Hospital A was contacted and a request for transfer executed and accepted.

Interviews with Staff C and D on the afternoon (Staff C at 1340 and Staff D at 1410) of 04/12/13 revealed:
a. Transfer paperwork and physician certification was not initiated;
b. Hospital A was not contacted to verify they could accept transfer of Patient #1; and
c. A copy of Patient #1's medical record, with the exception of the Discharge Instructions, was not sent to Hospital A.


2. Patient #5 - The patient presented to the ER on 12/15/12 at 1400 with complaints of pains, pressure and being 26 weeks pregnant. The nurse recorded the patient reported having strong regular contractions every 45 minutes for the last three and a half hours. The nurse calculated the patient was 29 weeks into her third pregnancy. The record documented the patient saw an obstetrician at another hospital (Hospital Z - hospital name omitted). The PA, Staff D, examined the patient at 1425 and documented only a speculum pelvic exam was performed as "very tender to speculum exam." Staff D recorded a consult at 1530 with the patient's obstetrician and wrote that the obstetrician "Prefers pt goes to (Hospital Z - hospital name omitted) ER for OB (obstetric) workup today. Pt reports she can get a ride..." Staff D wrote the Clinical Impression was premature contractions." The Patient Discharge Instructions document, "Proceed to (Hospital Z - hospital name omitted) ER per Dr. (name of patient's obstetrician). The patient left at 1600. The medical record did contain telephone numbers for the patient's obstetrician and Hospital Z written on the back of the PA's portion of the record, but did not contain documentation whether Hospital Z was contacted and a request for transfer executed and accepted. The patient was not transferred by appropriate transportation. The patient left by private transportation rather than by ambulance. The record did not contain evidence the patient had refuse to be transferred by ambulance.

During the interview with Staff D on the 04/12/13 at 1410, she stated she could not remember if she contacted the hospital, but did not execute transfer paperwork or send a copy of the medical record with the patient.