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Based on policy review, medical record, and interviews, the hospital failed to provide an appropriate transfer by not providing ongoing medical reevaluations until the time of transfer and document risks of transfer for one (1) of four (4) patients transferred to other acute care hospitals. (Patient #1)

The findings include:

Based on policy and procedure review, medical record review and staff and physician interviews, hospital staff failed to provide an appropriate transfer by not providing ongoing medical reevaluations up until the time and document risks of transfer for one (1) of four (4) patient's transferred to other acute care hospitals.

~ Cross refer to §489.24(d)(4-5) Appropriate Transfer - Tag A2409

Based on policy review, medical record reviews and staff and physician interviews, the hospital failed to provide an appropriate transfer by not providing ongoing medical reevaluations up until the time of transfer and document risks of transfer for one (1) of four (4) patient's transferred to other acute care hospitals (Patient #1)

The findings include:

Medical record review revealed Patient #1 arrived to the hospital on 11/04/2022 at 1230 with elevated blood pressure. Review of an OB Flowsheet revealed vital signs at 1241 were blood pressure (BP) 174/98, temperature 98.6, pulse (P) 103, respirations 18. At 1255, Patient #1's BP was 176/99. At 1300 the fetal heart rate was a baseline of 135 with moderate variability, accelerations and no decelerations. Flowsheet review revealed Labetalol (medication to treat high BP) 20 mg IV piggyback was given at 1309, and at 1343 Patient #1 received 40 mg Labetalol IV. At 1408, flowsheet review revealed "MD @ (at) bedside ... ." Review of the History and Physical, electronically signed 11/04/2022 at 1427, revealed "CHIEF COMPLAINT: Elevated BP ....EGA (Estimated Gestational Age) 34w2d (34 weeks, 2 days) ....while in the office today pt had elevated BP's 160's/90's. She was sent to L&D (Labor and Delivery) for further evaluation. Pt denies headache, vision changes, chest pain, shortness of breath, RUQ (right upper quadrant) pain, nausea or vomiting. ..." Review of a Progress Note, signed at 1440, revealed " ...Preeclampsia with severe features vs. Gestational hypertension with severe features PLAN: HTN (hypertension) Protocol performed .... Discussed with patient requiring multiple doses of IV anti-hypertensives she meets criteria for either preeclampsia or gestational hypertension with severe features. Would recommend beginning Mag (Magnesium Sulfate) 4gm bolus followed by 2 gm/hr for seizure prophylaxis ....Discussed ....it is recommended to proceed with delivery after 34 weeks gestation. Reviewed (Hospital B) does not have the neonatal capabilities to care for a neonate and her current gestational age. I would recommend transfer to a facility with this ability. Pt desires transfer ....Will continue HTN protocol as needed with goal BP <160/110. ..." Flowsheet review revealed Magnesium Sulfate 4 grams IV bolus was given at 1439 and 2 grams per hour was started at 1503. Further review of the Progress Note revealed an addendum at 1516 that indicated "Spoke with Dr. (Name), reviewed patient and pertinent findings. Dr. (Name) agrees with plan of care and accepts transfer of pt to (Hospital Name) .... Reviewed with patient. Transfer initiated."

Medical record review revealed a Transfer Form which indicated "TO BE UTILIZED FOR ALL PATIENT TRANSFERS- EMERGENCY AND NON-EMERGENCY COMPLETE SECTIONS A AND B FOR ALL PATIENT TRANSFERS. COMPLETE SECTION D ONLY FOR EMERGENCY TRANSFERS." Transfer Form review revealed "SECTION A" included space for the accepting facility and physician along with space for the mode of transfer and nurse and physician signatures with date and time. Review of Section A revealed the name of the accepting physician along with the time the physician was contacted (1442) and the time Patient #1 was accepted for transfer (1445). Review revealed the physician (DO #3) signed and dated Section A but did not document the time of signature. Review of Section B revealed Patient #1 signed the transfer form on 11/04/2022 at 1555. Further review of the Transfer Form revealed a Section D, which indicated "ADDITIONAL PHYSICIAN DOCUMENTATION TO BE COMPLETED FOR TRANSFERS FROM THE EMERGENCY DEPARTMENT AND LABOR AND DELIVERY". A statement was hand checked which stated " ...The patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition ..." Review of Section D revealed it then included "PHYSICIAN CERTIFICATION". Review revealed a physician signature on the form, but did not reveal a date or time the form was completed. Record review revealed the last note signed by the physician was the addendum documented at 1516. Review failed to reveal any additional physician notes prior to transfer. At 2115 review of OB Flowsheets revealed " ...transport called ... went to (another outside hospital) instead of (Hospital B) ...will head to us now." The Transport Team was noted to arrive at 2225 and Patient #1 was noted as "stabilized and transferred" at 2236.

Review of the medical record did not reveal any documentation Patient #1 was seen or evaluated by a physician after 1516 prior to transfer at 2236 (7 hours later). Additionally, there was no documentation of risks verses benefits documented in the medical record.

Interview with DO #3 on 02/09/2023 at 1545 revealed the physician recalled Patient #1 and cared for her on 11/04/2022. Interview revealed DO #3 got off duty and left the facility shortly after writing the last note at 1516. Interview revealed they (the physicians) usually "switched out" at 1400 but DO #3 stayed and got the patient prepared for transport. Interview revealed DO #3 had talked with everyone and thought the Transport Team was on its way. DO #3 stated she thought the patient would be leaving in about 30 minutes, but later learned what had happened (that the team was delayed in getting to Patient #1). Interview revealed DO #3 signed off to the oncoming on-call physician and would have reported that everything was arranged and the team was on the way to transport the patient. Interview revealed DO #3 did not know if the oncoming physician saw Patient #1 prior to transfer.

Telephone interview with MD #4, the oncoming physician, on 02/09/2023 at 1545 revealed everything was arranged for Patient #1 to transfer to the outside hospital. Interview revealed things generally went well with transport so he was not sure he would have thought there was a need to see the patient before transport. Interview revealed he could have seen Patient #1 and not written a note, but did not recall.