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Based on record reviews and interviews, the hospital failed to ensure the nursing care of each patient was assigned in accordance to the patient's needs and the specialized qualifications and competence of the nursing staff assigned to the Emergency Department. This deficient practice was evidenced by no documented education/training/competency evaluation for nurses working the offsite ED, for the assessment of obstetrical patients for 7 of 7 (S9RN, S10RN, S11RN, S12RN, S13RN, S15RN, S16RN) personnel files of nursing staff assigned to the offsite ED, which were reviewed for education/training and competency in the assessment of obstetrical patients, from of a total of 27 RNs on the offsite ED roster. This offsite ED was located approximately 27 miles from the main campus where trained OB and Neonatal personnel were located.

Findings:

A review of the employee personnel files for S9RN, S10RN, S11RN, S12RN, S13RN, and S15RN, and S16RN , with the assistance of S17HR and S3RNMGR , revealed these nurses were assigned to the offsite ED. Further review revealed no documented evidence of training/education on the assessment of obstetric patients, or a competency for the assessment of an obstetric patient and her fetus(es).
In an interview 12/08/16 at 9:05 a.m. S3RNMGR verified she was the manager for both ED locations. The RN manager indicated only nurses working the offsite ED were required to have NRP certifications, because the main campus had Labor and Delivery and NICU services, so there were trained staff in-house if an infant required resuscitation. S3RNMGR reported that no training or competency evaluations of assessment of contractions were conducted for the ED staff assigned to the offsite ED, where no inpatient OB services were provided. The RN manager reported the only training she had in the assessment of the presence and/or pattern of uterine contractions was in nursing school. S3RNMGR reported no policy or procedure could be provided for assessment of the OB patient in the Emergency Department. The Education Director also verified the annual training and skills competency for nurses working in the offsite ED did not include assessment for the frequency, duration, or strength of contractions.

In a phone interview 12/8/16 at 12:00 p.m. S10RN indicated she was a charge nurse at the Offsite ED. S10RN indicated, regarding OB patients were assessed for rupture of membranes with nitrazine (litmus) paper, SVE/pelvic exam done by the MD, and FHT's listened to, using a Doppler. She reported they (the nurses working at the offsite ED) couldn't really tell if the patient was having contractions because they have no fetal monitor at that ED. She said all they can do is try to time them (contractions) when a patient tells them she is having one. She reported other than what she received in nursing school, she had not received training in assessment of OB patients.

In an interview 12/8/16 at 12:15 p.m. S11RN verified that she had not had training or her competency evaluated for assessment of an obstetric patient, specifically contractions.

EMTALA Complaint Survey #LA00044391
Abbreviations

ACLS Advanced Cardiac Life Support
CC Clinical Coordinator
cm centimeters
CNO Chief Nursing Officer
CPAP Continuous Positive Airway Pressure
DirEd Director of Education
DON Director of Nursing
ED Emergency Department
EMTALA Emergency Medical Treatment and Active Labor Act
FHTs Fetal Heart Tones
H & H Hemoglobin and Hematocrit
HR Human Resources
LAC Louisiana Administrative Code
MVC Motor Vehicle Crash
NICU Neonatal Intensive Care Unit
NP Nurse Practitioner
NRP Neonatal Resuscitation Program
OB Obstetrics
OB/GYN Obstetrics and Gynecology
OMC-BR Ochsner Medical Center in Baton Rouge
PALS Pediatric Advanced Life Support
PI Performance Improvement
QA Quality Assurance
RN Registered Nurse
RNMGR Registered Nurse Manager
SROM Spontaneous Rupture of Membranes
SVE Sterile Vaginal Exam


Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

1) Failure to ensure stabilizing treatment and/or an appropriate transfer was provided to a patient (Patient #4) who presented to the hospital's emergency department with an "angulated displaced fracture of the left distal radius with involvement of the growth plate". The hospital failed to provide Patient #4 with an appropriate transfer to a receiving hospital for stabilization of an emergent medical condition when the transferring hospital did not have the capabilities to provide the stabilizing treatment. (See findings in A-2407); and

2) failure to provide documented evidence to indicate an appropriate transfer was provided for 4 (#1, #6, #8, #10) of 11 (#s 1-11) patients, of a sample of 30, who presented to the hospital's off-site ED with an emergency medical condition. This failed practice was evidenced by :
1) Patient #1 & #6 transferred to another facility when services were provided by the transferring hospital,
2) Patient #10 transferred to another facility in a personal vehicle without documentation that the patient's guardian chose to transport the patient in their own vehicle and had the specific risks of that mode of transportation explained to them; and
3) Patient #8 in labor with her 6th baby at 33 1/2 weeks and fully dilated being transported by ambulance service without personnel qualified to provide care to a Pre-term infant. (See findings in A-2409)

Based on record review and interview, the hospital failed to ensure stabilizing treatment and/or an appropriate transfer was provided to a patient (Patient #4) who presented to the hospital's emergency department with an "angulated displaced fracture of the left distal radius with involvement of the growth plate". The hospital failed to provide Patient #4 with an appropriate transfer to a receiving hospital for stabilization of an emergent medical condition when the transferring hospital did not have the capabilities to provide the stabilizing treatment.
Findings:Patient #4
Review of the medical record for Patient #4, an 8 year old, revealed she presented to the offsite ED with her mother 10/01/16 with a complaint of left wrist pain after a fall. Further review revealed the patient was seen by S23NP who documented the symptoms were reported as aggravated by movement, use and palpation. After a review of X-rays, the patient was diagnosed with an angulated displaced fracture of the left distal radius with involvement of the growth plate. Notes in the medical record documented a sugar tong splint was applied by S23NP. S23NP documented: Re-evaluation & notification of the need to transfer: I informed patient's mother that pediatric and orthopedic surgical services are not available at this facility or at Ochsner Medical Center-Baton Rouge (main campus). I explained to the patient's mother that upon review of the radiographs provided... of the patient's left wrist, S21MD and myself determined that the patient had an angulated displaced fracture of the left distal radius with involvement of the growth plate and required care at a hospital which has specialized capabilities such as pediatric or trauma services. The mother requested that the patient be transferred to (Hospital A). Further review of provider notes revealed Hospital A was consulted for transfer. The ED physician at Hospital A did not accept the transfer, and then recommended transferring the patient to another hospital, which was located in New Orleans (approximately 94 miles away). At 5:55 p.m. S21MD consulted with the Ochsner Medical Center-Baton Rouge on-call orthopedist and discussed the case. The on-call orthopedist recommended attempting a closed reduction and stated they [Ochsner's Orthopedic physicians] do no treat patient's under 16 years of age. A sugar tong splint was applied and the patient was discharged to home, in the care of her mother. An entry in the medical record by S23NP was noted as follows, "The patient has remained hemodynamically stable throughout the entire ED visit and her condition was initially stabilized for discharge or transfer with an unresolved emergency medical condition that will require further treatment following the initial stabilization provided..." Further review of the medical record revealed no documentation of any attempt to contact another facility providing the same services the patient had been determined to need, when a transfer was sought at Hospital A. No documentation was found of the mother's signed refusal of a transfer to another hospital.

In an interview 12/06/16 at 1:07 p.m. S23NP reported that it was felt the patient should be seen by a pediatric orthopedist since her injury involved the growth place. He reported the parents of Patient #4 did not want to go to New Orleans or somewhere else. The NP indicated that after the patient's mother said she didn't want to have her daughter transferred to New Orleans, no further attempts were made to find a receiving hospital for transfer. The NP confirmed that the ED staff did not have the patient's mother sign any document attesting to her not wanting to go to another facility. He said they don't have patients sign anything acknowledging they don't want to go to a specific facility.

In an interview 12/06/16 at 11:30 a.m. S21MD reviewed the medical record of Patient #4. S21MD confirmed the patient's medical record did not document discussions with the patient's mother regarding transfer to another facility (after Hospital A refused to accept the transfer) or her refusal of a transfer to a pediatric hospital in New Orleans, or any other hospital. He confirmed the patient was discharged to home with instructions to follow up with her primary physician and a pediatric orthopedist.

In an interview 12/06/16 at 1:40 p.m. S24MD, Medical Director of ED reported that they did not have patient's or their representatives sign an AMA or other documentation when they refused a transfer or transportation via ambulance or with trained personnel. After a review of the medical record for patient #4, S23MD reported that he did not see the patient's wrist, but reviewed what was documented in the record, and spoke with the providers and he did not see a breech in the standard of care.In an interview 12/07/16 at 8:53 a.m. S15RN, after review of the medical record of Patient #4 reported she was present when S23NP explained the discharge instructions to the patient's mother. S15RN indicated she was the nurse who called Hospital A for a transfer, but she did not try to call any other hospital after that. S15RN confirmed there was no acknowledgment of a refusal, by Patient #4's mother, to transfer the patient to another facility. S15RN reported when a patient or parent guardian refuse a specific transfer it's situational as to whether or not they get the patient to sign AMA, or make other arrangements. The RN indicated the ED staff do not get any document signed for a refusal of transfer such as to another location, if the patient or parent seems competent enough to understand and make an informed decision.

Based on record review and interview, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 4 (#1, #6, #8, #10) of 11 (#s 1-11) patients, of a sample of 30, who presented to the hospital's off-site ED with an emergency medical condition. This failed practice was evidenced by :
1) Patient #1 & #6 transferred to another facility when services were provided by the transferring hospital,
2) Patient #10 transferred to another facility in a personal vehicle without documentation that the patient's guardian chose to transport in their own vehicle and had the specific risks of that mode of transportation explained to them; and
3) Patient #8 in labor with her 6th baby at 33 1/2 weeks and fully dilated being transported by ambulance service without personnel qualified to provide care to a Pre-term infant.Findings:1) Patients transferred to another facility when the same services were provided by the transferring hospital:Review of a Plan for the Provision of Care, provided by the DON , with a MED and Board of Trustees Approval date of 11/17/16, revealed in part, under scope of services, that Ochsner Medical Center-Baton Rouge is a 151 bed community hospital that provides Level II Emergency Department (Baton Rouge and Iberville locations), Critical Care, Cardiopulmonary Services, Laboratory services, Cardiac Catherization Lab, Telemetry services, Observation, Acute Medical/Surgical Services, Radiology services, and Surgical services- Inpatient and Outpatient.Patient #1:Review of the medical record for Patient #1, a 63 year old, revealed she presented to the ED 10/06/16 at 2:57 a.m. via ambulance with respiratory distress. She was medically evaluated by the physician S19MD on arrival, at which time he intubated the patient and she was placed on a ventilator. Review of the patient history revealed the patient was discharged from Hospital A recently for heart failure. Diagnoses for this ED visit included Respiratory Distress and Congestive Heart Failure (CHF). Notes in the medical record revealed results of labs and pending labs were discussed with the family, and questions were answered. Further review revealed provider noted contact with Hospital A, who accepted the patient for transfer. The provider's disposition noted the patient was transferred with her condition documented as serious. The patient was transferred to Hospital A via ambulance service, on CPAP. Review of a scanned Transfer consent timed at 4:15 a.m. revealed it documented the reason for transfer was higher level of care/continuation of care. The risks of transfer were documented as MVC. The benefits of transfer were documented to be higher level of care. In the space for the patient's signature, handwritten documentation noted, "unable to sign", and was witness/signed, by hand, by 2 RNs. Further review of the medical record revealed no signed documentation by any family member or patient representative attesting to the request for transfer to Hospital A.Review of the On-call physician's schedules for October 5 & 6, 2016 revealed S25MD was the Pulmonologist on call for Pulmonology services. Further review of the on-call schedule revealed availability of physicians for Cardiology, Cardio-Intervention, and Hospitalist services. Patient #6
Review of the medical record for Patient #6 revealed she was a 62 year old who presented to the offsite ED 9/26/16 at 11:18 p.m. with abdominal pain and nausea. After examination, lab tests, and X-rays, she was diagnosed with abdominal pain, unspecified, Anemia, and Gastrointestinal hemorrhage, unspecified. The patient was assessed to be awake, alert,and appropriate. An Occult Blood Stool test was positive for occult blood. Hospital A was contacted and agreed to accept the patient for transfer. The patient was transferred to Hospital A at 3:35 a.m. (9/27/16) in stable condition via ambulance service. Further review revealed a scanned Consent to Transfer form with the reason for transfer documented as "admission", and medically necessary. Risk documented on the transfer consent was "worsening of condition", with benefits listed as "higher level of care-inpatient services and GI". The consent form was signed by Patient #6 and S19MD signed the attestation. Further review of the medical record revealed no documentation of a patient request for transfer, or anything signed by Patient #6 acknowledging she was aware that Ochsner Medical Center-Baton Rouge had inpatient services and Gastroenterology services and could admit her for medical care.

Review of the Ochsner On-call schedules for 9/26/16 and 9/27/16 revealed S26MD was on call from 6:00 a.m. to 6:00 p.m. both days.

In an interview on 12/06/16 at 3:30 p.m. S19MD, after review of the medical records of Patient #1 and Patient #6, reported the following :
With regards to Patient #1, S19MD reported the patient presented to the offsite ED and was transferred to Hospital A, where she had been admitted a few days prior to presenting to the offsite ED again. She was discharged from Hospital A and presented to the offsite ED on 10/06/16, a day or two later, with respiratory failure. She was intubated as soon as she arrived and placed on a vent. She was transferred to Hospital A, and was able to be extubated before she left the ED, and was transferred on CPAP. He reported the family came to the ED, and they wanted the patient transferred back to Hospital A (where she had been admitted a few days prior to coming to the ED). S19MD reported he always asks if they (the patient) would rather go to Hospital A. He said they (Ochsner-BR staff) would like to keep them (patients) at Ochsner, but many times the patients would prefer to go to Hospital A. S19MD verified he did not document that the family asked to have the patient transferred to Hospital A. S19MD verified that Ochsner had medical staff on-call that could provide the medical services Patient #1 needed.
With regards to Patient #6, S19MD reported the patient was diagnosed to have a GI Bleed as a result of a positive occult stool test, even though her H &H was normal. He reported OMC-BR did not offer GI, then. When asked to clarify, he reported they did offer GI services and had on-call GI physicians. He reported he asked the patient where she wanted to go, and she told him she wanted to go to Hospital A. S19MD verified that no documentation was made of a discussion with the patient or her desire to be transferred to Hospital A. S19MD said he probably could have documented better.

12/07/16 at 12:05 a.m. S3RNMGR, with S2DON, S4Quality, S5Quality, and S6EDCC present during the interview, verified the transfers for Patient #1 and Patient #6 were made when the main campus of the hospital offered those services, and had physicians on call for the services Patient #1 and Patient #6 needed on the dates the patients were transferred.2) Patient transferred to another facility in a personal vehicle without documentation that the patient's guardian chose to transport in their own vehicle:

Patient #10
Review of the medical record for Patient #10 revealed she was a 15 year old who presented to the off-site ED on 11/28/16 with a complaint of a cut on her wrist obtained when a post she was washing slipped and broke. The clinical impression was documented as a Flexor tendon laceration of the right wrist with open wound, 2) Laceration of the right wrist, and 3) Type I or II open nondisplaced fracture of styloid process of right ulna. The parents requested a transfer to Hospital A, which provided both pediatrics and orthopedics, and a transfer was accepted by Hospital A. Review of a nursing note at 7:38 p.m. revealed "S20MD states OK for patient to travel to (Hospital A) via private vehicle if family feels comfortable to do so..." The nurse's note indicated the parents preferred to travel to Hospital A via private vehicle.

Further review revealed no transfer consent form, and no documentation signed by patient's guardian acknowledging the risks of transporting Patient #10 via private vehicle, or refusing transfer transportation with trained personnel.

In an interview on 12/06/16 at 1:40 p.m. S24MD, Medical Director of ED reported no forms, AMA or other, were used to provide information regarding discussions with patients about transfers to other facilities and their refusal of those transfers. S24MD indicated patients (or their family/representative) were not required or asked to sign any documentation that they refused a transfer or transportation. In an interview on 12/07/16 at 12:05 a.m., after review of the medical record for Patient #10, S3RNMGR and S2DON confirmed there was no documentation of Patient #10's parents refusing transfer by ambulance or of having risks of using private vehicle discussed.

Review of Policy # OMCBR.DEPT.ED.13, titled "Arrival, Discharge, Transfer, and Admission Guidelines for the Emergency Department" provided by S1CNO as current documented, in part: "... C. 1. The transferring physician will document the reason for transfer...". Review of the policy revealed no procedure relative to a patient's and/or patient representative's refusal of a transfer in the form of an AMA to include a signed attestation by the patient or their legal representative. Further review revealed no procedure relative to the need to document the refusal of complying with medical advice/recommendations during the provision of medical care of emergent medical condtions. In addition, there was no procedure relative to the need to clearly explain and document risks associated with their refusal of medical advice/recommendations during the provision of medical care of emergent medical condtions. 3) Patient in labor with her 6th baby at 33 1/2 weeks and fully dilated being transported by ambulance service without personnel qualified to provide care to a Pre-term infant.
Review of Policy # OHS.ED.001, titled "Admission, Discharge and Transfer Guidelines for the Emergency Dept" (date of issue February 2013), provided by S4Quality as current, revealed, in part:
" ...5. The final disposition that a patient receives and will be documented in the medical record may include the following: ...c. discharge, d; Left against medical advice (AMA), e. transfer to another facility ...C. Transfer: 1. Patients requesting or in need of transfer to another facility will be deemed stable by the ED physician before a transfer can be approved. * In situations where the patient is not stable, the benefits of the transfer must outweigh the risks. 2. The transferring physician will document the reason for transfer, accepting physician, method of transfer and care required during transfer.Patient # 8
Review of the medical record of Patient #8, a 40 year old, revealed she presented to the offsite ED 11/3/16 at 6:20 p.m., with the complaint of spontaneous rupture of membranes 1 to 2 hours prior to her arrival in the ED. Patient #8 reported this was her 6th pregnancy, and 6th delivery. The patient was assessed to have limited prenatal care in Baton Rouge. Further review revealed on physician exam, the patient was found to have a cervix dilated to 10 cm. with active fluid leaking, with no active contractions. S22MD documented the patient requested to be transferred to Hospital C in Baton Rouge (approximately 26 miles from the free standing offsite ED in Plaquemine, LA). S22MD spoke to a physician at Hospital C, where Patient #8 was accepted for transfer. S22MD documented he "informed patient and family that OB/GYN service(s) is/are not available at the facility and patient requests to be transferred to (Hospital C). Notified of test results and need of transfer to another facility with available service(s). They understand and agree with the plan as discussed..." Patient #8's diagnosis was documented as "Labor abnormal", and she was transferred with her condition documented as "stable" in the provider's notes. Further review revealed a scanned Transfer Consent which listed the reason for transfer as "higher level of care" and medically necessary. Patient #8's transfer assessment, on the Transfer consent, was "Fair". The transfer consent documented the patient was screened and an emergency medical condition was identified, and a box was checked next to the statement, "stabilization is established- The patient's emergency medical condition has been treated such that, within reasonable medical probability, no material deterioration of the condition is likely to result from or occur during the transfer of the individual, or with respect to a pregnant woman who is having contractions, the woman has delivered Including the placenta)." The risks of transfer were listed as motor vehicle crash and worsening of condition, with the benefits of transfer being a higher level of care. The transfer consent was signed by the patient and S22MD. Further review revealed Patient #8 was transferred, undelivered, to Hospital C via ambulance. No documentation of an explanation or discussion with Patient #8 identifying the specific risks of delivery and delivery of a preterm infant during transfer without qualified personnel trained in delivery and care of a preterm infant was noted.In an interview 12/7/16 at 3:15 p.m. S22MD, after a review of the medical record for patient #8, verified he was the ED physician who provided care to the patient on 11/03/16. S22MD reported the patient was a 41 year old G6P5 (Gravida 6 Para 5) at about 33 and 1/2 weeks gestation, with a complaint of spontaneous rupture of membranes about 1-2 hours prior to arriving at the freestanding offsite ED. She reported limited prenatal care at Hospital C and denied any contractions or pain on her arrival to the ED. S22MD verified his exam of the patient documented that she was 10 cm dilated (complete), with active (amniotic) fluid leaking, FHT's were positive at 150's to 160's, and she had no active contractions. S22MD reported he spoke with a physician at Hospital C who agreed to accept the patient for transfer. S22MD reported he informed the patient and family that no OB/GYN services were available at this facility (site), and the patient requested to be transferred to Hospital C, in Baton Rouge, via ambulance, with ambulance attendants only. He verified that no staff trained in the delivery of, or care of a newborn preterm rode with her. He indicated that he was the only physician in the Iberville ED, and would not be able to leave. When asked if he considered a G6P5 at 33 1/2 weeks, with ruptured membranes, and completely dilated to be stable for transfer with only ambulance attendants, he asked, "Should I have not transferred her?"