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MASSAC MEMORIAL HOSPITAL 28 CHICK STREET, PO BOX 850 METROPOLIS, IL 62960 July 23, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on document review and staff interview it was determined in 1 of 7 (Pt #1) ED patients being transferred that the CAH failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The CAH failed to provide the patient with an appropriate transfer. (C2409).
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview it was determined in 1 of 7 (Pt #1) ED patients requiring transfer the CAH failed to ensure an appropriate transfer.

Findings include:

1. The medical record of Pt #1 was reviewed on 7/22/15 and 7/23/15. On 7/12/15 at 6:42 PM, Pt #1 walked into the ED with chief complaint of pregnancy in active labor. Onset of symptoms (pain in back, butt, vomiting, and noticed bleeding after using the bathroom) began at 5:00 PM. Pt #1 was triaged and a received a MSE at 6:43 PM. Pt #1 was assessed by the RN and was visually inspected for crowning of the baby's head. There was no crowning or opening of vagina noted. At 6:45 PM, the amniotic fluid ruptured while in the ED bed. Contractions were documented as being 2 minutes apart, lasting 30 seconds, regular pattern with strong/firm intensity. At 6:50 PM, the ED physician examined Pt #1 and documented that Pt #1 was 2 cm. dilated, station 2 and 10% effaced with presence of clear amniotic fluid. The RN documented that physician reported "she is 2 cm dilated and 20% effaced". Documentation indicated the RN was making telephone calls to the receiving hospital to arrange for transfer during the triage process.

2. The ambulance report in the medical record was reviewed on 7/22/15 and 7/23/15. The ambulance is owned by the CAH. Documentation indicated Pt #1 departed the ED at 7:10 PM and was having contractions 2 minutes apart lasting approximately 30 seconds. Vitals signs remained stable and having regular contractions throughout transport. Pt #1 was checked for crowning throughout transport. At approximately 7:19 PM, the baby was delivered in the back of the ambulance. The ambulance report indicated mother and baby were stable when arriving at receiving hospital at 7:28 PM.

3. On 7/22/15 at 1:50 PM, an interview was conducted with ED RN (E#4). E#4 recalled Pt #1 and assessing her for crowning. "She was screaming the whole time. It was hard to get her to focus". E#4 recalled that Pt #1's father and other people were with her. E#4 stated, "everyone was working trying to get her ready for transfer". E#4 stated, "I can't remember the last time we had a delivery in the ED, it has been several years".

4. On 7/22/15 at 2:30 PM, an interview was conducted with ED physician (E#5). E#5 recalled Pt #1 as being about [AGE] years old and her labor pains started about an hour before she came in to the ED. E#5 recalled Pt #1's water breaking shortly after her arrival. Pt #1's family was at bedside the whole time. E#5 stated " I examined her and she was 2 cm, 10-15 % effaced and a stage 0, no crowning". E#5 stated, " I explained to the patient and family about the risks and benefits of transferring". E#5 stated, "The hospital is about 10-15 minutes from here, after assessing, no pregnancy complications and first baby, I thought she would have plenty of time to get to the other hospital."

5. Documentation on "PATIENT TRANSFER FORM" under "SECTION 1 Patient Consent to Transfer (nurse Complete)" indicated risks and benefits were explained to the patient and family. Under "SECTION 2 Transfer Requirements (Nurse Complete)" under Accepting Physician: No physician name was filled in. Under "SECTION 4 Patient Condition and Risk (Physician Complete)" it was marked Patient has been stabilized so, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from transfer. however, under same section there was nothing marked under Condition at time of transfer: Stable/Unstable. There was inconsistencies between the physician ' s pelvic exam results versus assessment and behavior of the patient (i.e. " screaming the whole time " and contractions 2 minutes apart ... " )


6. On 7/22/15 at 2:00 PM, an interview was conducted with the Chief Nursing Officer (E#1). E#1 reported that "After we learned of the incident, we had a performance improvement meeting on 7/14/15 to review the processes and events to see what we could have done differently to have prevented this from happening. We did see some inconsistencies with the documentation and know there is room for improvement."