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ADVENTHEALTH OCALA 1500 SW 1ST AVE OCALA, FL 34474 Aug. 28, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview, medical record review, transfer agreement review and transfer call log review, the facility (Hospital #2- (Munroe Regional Medical Center ) failed to ensure, that as a participating hospital that has specialized capabilities or facilities that include Neonatal Intensive Care Unit (NICU) and Labor/Delivery and has the capacity to treat the individual, that an appropriate transfer was accepted without delay from the transferring hospital (Hospital #1) for 1 of 24 patients reviewed (Patient #16). Hospital #2 initially refused the transfer of Patient #16, stating that they did not accept babies less than 32 weeks. The baby deceased while at the Free Standing Emergency Department (ED) at Hospital #1.
Refer to tag A- 2411.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, medical record reviews, transfer agreement review , policy and procedure review, bed census review, Physician Core Privileges review, on call schedules review, and transfer audio call log review, the receiving hospital (Hospital #2) failed to ensure that an appropriate transfer was accepted without delay from the transferring hospital (Hospital #1) for 1 of 5 patients reviewed (Patient #16). Hospital #2 initially refused the transfer of Patient #16, stating that they did not accept babies less than 32 weeks. The baby deceased while at the Free Standing Emergency Department (ED) at Hospital #1.


Policy and Procedure
The facility's Policy and Procedure titled "Emergency Transfers Policy" Original Effective Date: 11/1/ 2003; Revision: 9/1/2013. The policy revealed in part, "7. Receiving or Recipient Hospital Responsibilities. A Hospital that has specialized capabilities or facilities (e.g., burn unit, psychiatric unit, cardiac catheterization units shock-trauma units, neonatal intensive care units, or with respect to rural areas, regional referral centers) may not refuse to accept from a referring Hospital. An appropriate Transfer of an individual requiring such specialized capabilities or facilities, if the receiving or recipient hospital has the capacity to treat the individual."


Transfer Center Audio recordings:

A review of Direct Patient Logistics transfer center's audio communication and call log, dated 7/20/2017, between Hospital #1 and #2 for Patient #16, showed the following:
2:47 AM: Patient arrived to free standing ED at Hospital #1.
3:05 AM: A transfer request was called to Hospital #2.
3:08 AM: Unit secretary at Hospital #2 took the call for information.
3:09 AM: Attending physician for the patient was paged.
3:17 AM: Transfer center was notified patient's water broke at Hospital #1.

3:18 AM: Second call to attending physician was made with no return call.
3:20 AM: Transfer center called Hospital #2 for urgency to accept the transfer. Transfer center advised to call on-call OB/GYN at Hospital #2.
3:23 AM: The OB/GYN on-call at Hospital #2 answered the transfer center and requested to have ED to ED transfer.
(Total of 46 minutes)
3:24 AM: Transfer center called Hospital #2 to speak with ED, transfer center then sent to L&D.
3:27 AM: Transfer center called Hospital #2 back and spoke to charge nurse in the L&D (Labor and Delivery). The transfer center was advised to speak with house supervisor.
3:31 AM: Transfer center was advised that Hospital #2 does not take babies less than 32 weeks per the protocol and the NICU does not accept inbound transfers at this time.
(7 minutes)
3:41 AM: Transfer unit called Hospital #2 back again to see if Hospital #2 has a NICU.
3:45 AM: House supervisor advised the transfer center that Hospital #2 does not take patients/babies at 28 weeks.
3:47 AM: Transfer center canceled the transfer request as Patient #16 is 28 weeks pregnant and cannot go to Hospital #2.
3:52 AM to 4:10 AM: The transfer center notes show disregard.
3:58 AM: Transfer center from Hospital #1 was advised by another facility, Hospital # 3 that it is inappropriate for Hospital #2 to refuse patient, as it is an EMTALA violation.
3:59 AM: Transfer center called Hospital #2 and advised them of what Hospital #3 stated.
4:04 AM: On-call OB/GYN at Hospital #2 stated had previously stated do ED to ED Transfer.
4:06 AM: The transfer center had a conference call with attending ED physician at Hospital #1, on-call OB/GYN at Hospital #2, and House Supervisor at Hospital #2.
4:08 AM: The on-call OB/GYN physician at Hospital #2 accepted Patient #16 to L&D at Hospital #2.
4:09 AM: Transfer center stated will be ground transport with Advanced Life Support (ALS).
4:29 AM: Transfer center advised Hospital #2 that Patient #16 delivered and now may not come to Hospital #2 and advised Hospital #2 that this was a long delay.
4:31 AM: House supervisor at Hospital #2 stated please keep up to date.
4:50 AM: House supervisor at Hospital #2 asked for update on this patient. House supervisor notified by transfer center that the mother (Patient #16) will be sent to this facility. They cannot fly the baby out of Hospital #1's ED due to weather. House Supervisor at Hospital #2 is aware of above concerns. House Supervisor at Hospital #2 advised that the county Emergency Medical Services (EMS) was sending equipment to help with mother/baby until they can be transported.
5:05 AM: House Supervisor at Hospital #2 advised transfer center they need to do an ED to ED Transfer.
5:23 AM: Hospital #2 accepted transfer of Patient #16 to ED.
5:28 AM: On-call OB/GYN at Hospital #2 notified of Patient #16's condition and that placenta had not been delivered at this time.
6:30 AM: House supervisor at Hospital #2 called for correct sheet to be faxed.
6:59 AM: Transfer center stated Patient #16 reroute to Hospital #2.
7:01 AM: Patient #16 from Hospital #1 free standing ED transferred and has arrived at Hospital #2.


Medical Record Review Hospital #1 (Transferring Hospital):

Review of the Medical record revealed that patient #16 presented to Hospital (#1) emergency department on 7/20/2017 at 2:47 A.M., as walk-in. The patient was triaged as ESI (Emergency Severity Index) 2/Emergent. Further review of the Emergency Notes, noted revealed in part, "Patient is 28 weeks pregnant came in with what she refers to as cramping every 15 seconds since 1:15 AM. Refers that it comes and go. Patient states she had discharge for the past few days bur she thinks is just vaginal discharge normal, she has gone to her GYN (gynecological) physician did not evaluate her, they just weighed her and told her she is fine. Patient has a history of early births. "
Review revealed the following medications and nursing procedures were administered by an RN as ordered by the ED physician on 07/20/2017:
- 0315 Patient refers her water broke;
- 0319- Fluids were started 1 liter on #20G (gauge) on left A.C. (antecubital) ;
- 0320-Pt started with contractions and on average of every 30 seconds as referred by patient;
- 0341 Morphine 4 mg were administered intravenously for pain;
- 0405- Decadron 6 mg and Magnesium 1000 mg in 100 ml administered intravenously for contractions;

According to medical record review, the patient was medically screened on 07/20/2017 at 2:55 AM. The patient's Chief complaint was Pelvic and Perineal pain, and gradually worsening. Physical Examination, revealed in part, "Genitourinary bleeding, there appears to be some effacement of the cervix, with crowning beginning and 2 cm dilation ... Re-evaluation and MDM (Medical Decision Making) ...at 3:28 am still waiting for one-step (transfer center) to call back with MD ...at 3:57 Monroe states they cannot accept the patient because she is only 28 weeks and they do not accept anybody under 32 weeks. At 3:58 (Hospital #3) contacted immediately state, the patient needs to go to the closest hospital, will attempt (Hospital #4) and will contact Hospital # 2 again, the patient was finally accepted by physician at 4:10 AM at hospital # 2. The baby was delivered with an Apgar score of zero and a heart rate of 79, and a weight of roughly 800 grams (1.7637 pounds), CPR (Cardiopulmonary Resuscitation) ...CPR continued and intensivist neonatologist consultation was obtained, who advised to give dextrose 10 (dextrose medication given for neonatal [DIAGNOSES REDACTED]{low blood sugars})as IV fluids at 5cc/hr. ....(MD name) the person who attempted initially never responded. The patient still has placenta in place. The patient was accepted for transfer by hospital # 2 and ED physician was informed. A review of the EMTALA Memorandum of Transfer form dated 7/20/2017 revealed at 5:56 AM, Patient #16 Vital Signs were Temperature 98.4; Pulse: 134 (normal 60-100); Blood Pressure: 133/79 and Oxygen saturation was 98%.

Review of the ambulance report dated 7/20/2017 revealed that Patient #16 reason for transfer was the patient delivered prematurity, and need an Obstetrician. The ambulance patient care report revealed the patient left Hospital #1 at 6:03 AM and arrive at Hospital #2 at 6:41 AM.


Baby #16 Medical Record review:

Review of medical record from Hospital #1, dated 7/20/2017, documentation by the ED physician showed that Patient #16's baby delivered at 4:10 AM: Apgar (measures of physical condition of a newborn infant) 0, fasting sugar (fs) 61, heart rate 79, but then went down to 33, Cardiopulmonary Resuscitation (CPR) started immediately. Vascular access obtained epinephrine given total of 3 times, neonatologist consultation obtained, recommends dextrose 10 at 5 cc/hr., airway attempted but endotracheal tubes were too large to fit her trachea, bagging with oxygen (O2) continuously done and baby remained pink throughout the resuscitation. The neonatologist then advised to stop the resuscitation, parents informed and ultrasound of the heart revealed cardiac stand still. Further review of the medical record revealed a physical examination was performed baby #16 was unresponsive. The primary care physician (neonatologist intensivist) declared the baby expired at 5:48 AM. Documentation by the MD revealed in part, Clinical Impression: Cardiopulmonary Arrest; Second Impression: Prematurity of fetus."

Hospital #2 On-Call Schedule

Review of the hospital's call schedule (7/17/2017 -7/23 2017) was reviewed and verified that on 7/20/2/107 Hospital #2 had an Obstetrician on call, when Hospital #1 called requesting to transfer patient #16. Review of the on-call physician's Obstetrics and Gynecology Clinical privileges dated 5/30/2017 were reviewed. The Obstetrics Core Privileges revealed in part, "Yes (was checked) Admit, evaluation, diagnose, treat and provide consultation to female patient of all ages, and/or provide medical and surgical care of the female reproductive system and associated disorders, including major medical diseases that are complicating factors in pregnancy. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the techniques and skills ... Obstetrics: ... Management of high risk pregnancy inclusive of such conditions as pre-eclampsia, Third trimester pregnancy ...Manual removal of Placenta ..." On 7/20/2017 Hospital #2 had the capabilities and facilities to treat Patient #16.


Bed Census Reports

The bed Census report dated 7/20/2017 for the time 7:00 PM to 0300 am was reviewed. The labor and delivery unit total bed capacity is 12, as 3 beds were available. The Neonatal Intensive Care Unit total bed Capacity is 12, as 2 beds were available. On 7/20/2017 Hospital #2 had the bed capacity to treat patient #16.

Transfer Agreement:

A review at Hospital #1's ED transfer log showed that 4 patients were transferred to the Labor/Delivery (L&D) Unit at Hospital #2. A review of the transfer agreement between these two facilities (Hospital #1 and #2) showed that if Obstetrics and Labor/Delivery are needed, that a transfer is then conducted. The purpose of the agreement is that the transferring facility (Hospital #1) will accept patients meeting its admission criteria. The receiving facility (Hospital #2) will accept patients from Hospital #1 who are in need of acute obstetric care offered by Hospital #2 and not available at Hospital #1. This also includes NICU (Neonatal Intensive Care Unit) transfer.

Interviews

During an interview on 8/25/2017 at 9:15 AM, the Director of Risk Management for Hospital #2 stated Hospital #2 initially accepted the transfer of Patient #16 per the on-call physician for OB/GYN/Labor Delivery at Hospital #2. This happened on 7/20/2017. Patient #16 was 28 weeks pregnant and her water broke while at Hospital #1. Hospital #1 called stating that Patient #16 and her baby were coming to Hospital #2 and then later stated only Patient #16 was coming, not the baby. Patient #16 was transferred to Hospital #2 for the delivery of the placenta.


During an interview on 8/25/2017 at 10:00 AM, the Director of Maternal Child Health for Hospital #2 stated that the on-call OB/GYN accepted the transfer of the patient to Hospital #2's Emergency Department (ED). Patient #16 presented to Hospital #2's ED and then transferred to Labor/Delivery at Hospital #2. Patient #16 stayed in Hospital #2 for 48 hours and discharged home. Director of Maternal Child Health for Hospital #2 stated if a baby had been sent with Patient #16, the neonatologist would have made the determination if the baby needed level 3 NICU.

Hospital #1 facility initially refused to accept from a transferring Hospital #1 (did not have obstetrical services, or neonatal ICU services) Patient #16 on 7/20/2017; as facility #1 had specialized capabilities (Obstetrics) and/or facilities and the capacity initially to accept patient #16 on 7/20/2017. As this initial refusal resulted in a significant delay in the care and treatment of her emergency medical condition.