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MOUNT SINAI BETH ISRAEL FIRST AVENUE AT 16TH STREET NEW YORK, NY 10003 June 22, 2017
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical review, document review and staff interview, the facility failed to effect a safe transfer to a receiving facility in proximity to the transferring hospital to minimize the risk to the health of the patient and her unborn child.

This failure placed the patient and her unborn child at risk for harm.

Findings include:

Review of medical record for Patient #1 identified a [AGE]-year-old female at eight months' gestation who was triaged in the Emergency Department (ED) on 12/13/16 at 1:06 AM with a chief complaint of vaginal bleeding. The patient reported, "Bleeding started prior to arrival in the ED, the color bright red with clots." The patient also complained of abdominal pain which she rated as seven (7) on a Pain Scale Index of one (1) to 10.
Triage vital signs were as follows Temperature (T) 97.6, Pulse (P) 102, Respirations (R) 19, and Blood pressure (BP) 120/85.

On 12/13/16 at 1:48 AM, Staff B (ED physician) documented, "A [AGE]-year-old female Gravida (Pregnant woman)1, pregnancy 0, abortion 0; 8 months pregnant female with past medical history of asthma presents to the ED complaining of heavy vaginal bleeding and lower abdominal cramps since 12:00 AM. The patient reports that she didn't feel well yesterday and had nausea and vomiting and thought it was food poisoning. The patient has had regular follows ups with her gynecologist in another hospital and has had regular ultra sounds. Otherwise, she reports no other acute complaints. The patient's last normal monthly period was 4/23/16."

Review of system noted positive lower abdominal cramping and positive vaginal bleeding. Examination of the patient noted "positive gravida, abdomen soft non-tender, No guarding or rebound."

At 2:32 AM, physician noted Doppler heart beat as 120 (normal: 120 - 160) and patient will be transferred to another facility.

At 2:41 AM, ED nurse documented "fetus heart rate 104 measured by portable Doppler, ED physician was present while Doppler was in use. Patient is awaiting transportation to L&D (Labor and delivery)."

At 2.51 AM, Staff B ordered the transport for patient #1 to Facility B that was approximately one hour away. The physician noted the reason for transfer is Specialty Care unavailable at Mount Sinai Brooklyn site. Level of care required during transportation is Paramedic Condition guarded.

Reassessment of the patient's vital signs at 2.57 AM noted: T-97.8, P-112 (Normal 60 -100 beats per minute), R-18, BP-99/65, Oxygen saturation -100 percent.

There was no evidence of a reassessment of the patient's vital signs and the heart rate of the fetus prior to the transfer of the patient to Facility B on 12/13/16 at 3:30 AM.

Review of medical record for Patient #1 at Facility B, revealed the patient arrived at the facility on 12/13/16 at 4:20 AM, approximately one (1) hour after departure from the transferring facility. The initial sonogram after her arrival at the facility on 12/13/16 at 4:20 AM revealed an absence of fetal heart rate and a diagnosis of Placenta Abruption (Placenta separating from the wall of the uterus.).

Review of facility's policy titled 'Inter - Hospital Transfer "last revised January 2016 notes the purpose is "To establish protocols for centralization of patient transfers throughout the Health Systems. The Patient Transfer Coordinator will be responsible for transferring patients from a hospital or urgent care center to one of the hospitals within the health system and will be the central liaison to work with the respective Finance Departments, Bed Management and the Referring and Accepting physicians, The Patient Transfer Center Coordinator will be responsible for communicating with all parties involved maintaining a seamless transition between institutions for all patients transfer(s)."

There was no documentation in the medical record that the facility attempted to secure transfer to a facility near the hospital to minimize the risks to the patient's health and her unborn child.

At interview with Staff A, Director of Emergency Department on 06/22/17 at approximately 11:15 AM, she stated that the facility did not have an obstetrics and gynecological (OB/GYN) service and that transfer was required for Patient #1. Staff A stated that it was the ED physician's decision to transfer the patient to a facility within the Health System. Staff A stated she is unable to provide the justification for staff B decision regarding the patient's transfer.