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ACOMA-CANONCITO-LAGUNA IHS HOSPITAL EXIT #102 OFF I-40 1/2 MILE SOUTH SAN FIDEL, NM 87049 Aug. 18, 2011
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the facility failed to provide an appropriate transfer of pregnant women in labor that presented to the Emergency Department of the hospital. There were 5 (Patients #3, #5, #7, #15, #25) out of 7 pregnant women in labor that were transferred to other hospitals via the patients' private vehicles. The hospital staff failed to utilize appropriate transportation with appropriate equipment and personnel to ensure the safety of the pregnant women in labor and the unborn children.
It is determined that this deficient practice creates an Immediate Jeopardy situation and places the health of the pregnant women and the health their unborn children in immediate jeopardy
Findings:
1. Patient #3, was a [AGE] year old female with two prior C-sections and in early latent labor. She presented on ,d+[DATE], 2010 at 0840 with contractions every 5 minutes without bleeding. She stated that her contractions started at 0300 on 12/10/2011 and had a planned C-section on 12/14/2010 at a hospital in Albuquerque, NM. A physician at the Albuquerque hospital was contacted at 0930. At that time the physician agreed to accept the patient for transfer.
From 0830 to 1200, the patient was provided pain management and rest. Review of the medical records showed that the patient was instructed to walk from 1345 until 1600 when the patient was transferred via a private vehicle.
2. Patient #5, was a [AGE] years old, presented to the Emergency Department (ED)complaining of labor pain on 12/14/2010 at 01:30 AM. Her gestational age was 39 weeks. She has an obstetric history of three living children and also spontaneous abortions. She was placed on the fetal monitor and the fetal heart tones (FHT) were 130 ' s with regular contractions. Her cervical examination was 4 cm/70% effacement/-3 station and observed a small amount of bloody show. Contractions were moderate at palpation.
At 1:50 PM, the patient was advised to travel by POV (privately owned vehicle) to where she was scheduled to deliver. She then exited the ED with her spouse. Husband was instructed not to speed. The ED staff instructed the patient to go directly to the labor and delivery unit of the other hospital which was approximately 45 minutes away.
However, the patient never made the approximately 45 minutes trip to the other hospital. The nurses from the ED contacted the intended hospital an hour later and were informed that the patient never made it there. At 5:15 am, the ED staff called a closer hospital which was approximately 30 minutes away and they were informed that the patient arrived at their facility at 2:40 am. There was no transfer arrangements made with the closer hospital.
3. Patient #7, a pregnant woman who (MDS) dated [DATE] at 5:06 with complaints of contractions since the morning of 12/22/2010. She informed the ED staff on arrival that her contractions were every five minutes. The ED staff wrote on the medical record "contraction noted, palpates moderate, FHR (fetal heart rate) 130s."
A vaginal exam revealed her cervix at "2/-3/70%. FHR reassuring with good acels and average variability." The medical record showed that "at 5:40, monitors discontinued. Pt. dressed. Pt's mother and pt's boyfriend are with pt." The patient's mother told the ED staff that she knows where the other hospital approximately 45 minutes away was located. The ED staff instructed the patient's mother and the patient's boyfriend to take the patient to the other hospital. The patient was transported by privately owned vehicle to the hospital approximately 45 minutes away.
4. Patient #15, a [AGE] year old pregnant woman who (MDS) dated [DATE] at 11:33 AM with complaints of "contractions that started last night." Her gestational age was 38 weeks. She is gravida 8, para 3. She informed the ED staff that "she never has gone to term with her pregnancy." Medical record showed "active fetus, heart tones 146-178, right after contraction FHT's are around 146 increase after settles down ut no decels noted on monitor." The patient was transported to a hospital approximately 45 minutes away by her husband on their privately owned vehicle.
5. Patient #25, a [AGE] years old pregnant woman who (MDS) dated [DATE] with complaints of labor pain. Her gestational age was 33 weeks. She has an obstetric history of two spontaneous abortions and one living child. She is a previous cesarean section in 2003. Her last ultrasound was done on March 14, 2011 and revealed placenta previa. She was diagnosed to have genital HSVI (Herpes) on April 15, 2011 and was treated with antibiotics. During the ED visit she was placed on fetal monitor, the Fetal Heart Rate (FHR) were 140-150, not able to track contraction due to artifact and maternal movements. She was medicated with Morphine for pain control. She was also hydrated with intravenous LR and laboratory test were drawn. The doctor did not do a vaginal examination to assess for dilatation due to " placenta previa " . However nothing was mentioned during this visit concerning the potential for vaginal delivery after recently been diagnosed with vaginal herpes. After she was monitored for approximately an hour, the fetal monitor strip showed contractions to be 3 - 4 minutes part. The pregnant woman was transferred in POV.