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SAINT THOMAS RUTHERFORD HOSPITAL 1700 MEDICAL CENTER PARKWAY MURFREESBORO, TN 37129 Nov. 20, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of facility medical staff rules and regulations, facility policy review, medical record review, and interviews, the facility failed to provide a medical screening exam (MSE) by a qualified medical provider (QMP) for 1 Labor and Delivery (L&D) patient (#29) and failed to provide an appropriate transfer for 1 patient (#1) of 10 Labor and Delivery (L&D) patient's reviewed of 30 Emergency Department patients reviewed.

The findings include:

Please refer to A-2406 for failure to provide MSE by a QMP.

Please refer to A-2409 for failure to provide an Appropriate Transfer.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility medical staff rules and regulations, facility policy, medical record review, review of facility documents, and interview, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for one (1) of ten Labor & Delivery Emergency Department (ED) records reviewed, (Patient #29).

The findings include:

Review of Facility A's Medical Staff Rules and Regulations dated 9/19/19 revealed "...Section 9.1 Medical Screening Examinations ...may be provided by a Physician or by the following individuals designated as a Qualified Medical Person [Provider]...including a Registered Nurse (RN)...with each QMP acting within the scope of his/her practice as defined by State Law and in accordance with Hospital's Rules and Regulations. A RN designated as a QMP is limited to only qualified RNs practicing in Hospital's Labor and Delivery (L&D) Department and performing an MSE for a pregnant patient with such qualification established and approved by the Department of Obstetrics and Gynecology...Written training programs, written protocols, written and demonstrated competency validation criteria, and any competency validation of QMP's by non-physicians shall be approved by the Medical Executive Committee and...Department of Obstetrics and Gynecology..."

Review of Facility A's policy "Screening, Transfer, and Acceptance of Patients with a Possible Emergency Medical Condition (EMTALA)" revised 1/2018, revealed Qualified Medical Person "...means a physician or an individual deemed competent by the Department of Emergency Medicine or the Department of Obstetrics and Gynecology...The Departments may designate an individual as a Qualified Medical Person if "...2. In regards to the Obstetrical [OB] RN in the Labor & Delivery/Triage environment, a written protocol has been developed in conjunction with the Medical staff, to enable the RN to perform the MSE as the qualified medical person (QMP). The pre-established criteria for performance is validated during competency assessment and requires twelve months of recent, independent Labor & Deliver experience. 3. That individual has demonstrated sufficient competency through the successful completion of an organized written training program related to the type of medical screening examination to be performed in that department; and 4. that individual's competency has been validated using pre-established criteria for performance of medical screening examinations..."

Medical record review revealed Patient #29 (MDS) dated [DATE] at 4:32 PM with complaint of pregnancy complications. Continued review revealed Patient #29 was transferred from the ED to the OB unit for triage on 11/13/19 at 4:45 PM.

Medical record review of an OB Assessment completed by RN #1 on 11/13/19 from 4:45 PM until 5:24 PM revealed Patient #29 was 20 weeks 5 days gestation and complained of lower abdominal pain and perineum pain. Continue review revealed Patient #29's abdominal pain was described as "...constant pressure that gets worse..." and her pain level was 7 out of 10 (10 equals the worst possible pain). The perineum pain level was present with urination and was rated an 8 by the patient.
Medical record review of a discharge order dated 11/13/19 at 6:55 PM revealed the patient was discharged home with instructions to follow up with her OB physician.

Medical record review revealed no documentation Patient #29 was assessed by a physician or a QMP.

Review of a facility document "Qualified Medical Person [Providers]," undated, revealed RN #1 was not listed.

Interview with the Nurse Manager of Women's Services on 11/10/19 at 4:24 PM, in L&D nurses' station, confirmed the MSE for Patient #29 was completed by RN #1. Further interview confirmed RN #1 was not a designated QMP.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility medical staff rules and regulations, review of facility policy, medical record review, and interview, the facility failed to appropriately transfer a patient in active labor for one (1) of four (4) obstetric (OB) transferred cases reviewed, (Patient #1).

The findings include:

Review of Facility A's Medical Staff Rules and Regulations dated 9/19/19 revealed a "...Section 13.1 Criteria for transfers revealed "...(a) no patient that has not been stabilized or who is in active labor may be transferred unless: 1. The patient (or legal representative) requests a transfer; 2. A physician or qualified medical personnel signs a certification stating that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the patient's medical condition caused by such a transfer. (b) Additionally, such patient may be transferred to another medical facility only when...1. It is determined that the receiving facility has available space and qualified personnel for the treatment of the patient. 2. The receiving facility has agreed to accept the transfer and provide appropriate medical treatment; and 3. The patient's stabilized condition..."

Review of Facility A's policy "Screening, Transfer, and Acceptance of Patients with a Possible Emergency Medical Condition (EMTALA)" revised 1/2018, revealed Qualified Medical Person "...means a physician or an individual deemed competent by the Department of Emergency Medicine or the Department of Obstetrics and Gynecology...The Departments may designate an individual as a Qualified Medical Person if "...2. In regards to the Obstetrical [OB] RN in the Labor & Delivery/Triage environment, a written protocol has been developed in conjunction with the Medical staff, to enable the RN to perform the MSE as the qualified medical person (QMP). The pre-established criteria for performance is validated during competency assessment and requires twelve months of recent, independent Labor & Deliver experience. 3. That individual has demonstrated sufficient competency through the successful completion of an organized written training program related to the type of medical screening examination to be performed in that department; and 4. that individual's competency has been validated using pre-established criteria for performance of medical screening examinations..."

Medical record review revealed Patient #1 was admitted to Facility A's OB triage unit on 10/26/18 at 8:30 AM with complaint of abdominal pain and vaginal bleeding. Further review revealed the patient was 20 weeks and 6 days gestation.

Medical record review of an OB assessment dated [DATE] from 8:58 AM until 11:30 AM revealed Patient #1's membranes (fluid filled sac surrounding the baby) were intact and no vaginal bleeding was noted. Continued review revealed Patient #1 had occasional uterine irritability (not true labor contractions) with no contractions noted on the fetal monitor (TOCO monitor used to detect fetal heart rate and uterine contractions) or by palpation (method of feeling with the fingers or hands during a physical examination) from 8:58 AM-11:30 AM.

Medical record review of an abdominal ultrasound radiology report dated 10/26/18 at 11:15 AM revealed Patient #1's cervix (lower portion of uterus which opens during labor) appeared completely funneled (a sign of cervical incompetence) with no discernible cervical length (increasing the risk of preterm labor and premature birth). Continued review revealed Physician #1 (on call OB physician) was notified of the ultrasound results on 10/26/18 at 12:00 PM.

Medical record review of a Nurse's note dated 10/26/18 at 11:50 AM revealed Patient #1 had blood tinged urine with a small pooling of blood on the bottom of the toilet.

Medical record review of a Physician's assessments dated 10/26/18 at 12:12 PM revealed Physician #2 performed a vaginal exam (exam to determine cervical dilation) and Patient #1's cervix was dilated (open) 5-6 centimeters (cm) (complete dilation is 10 cm) and the membranes were intact (not ruptured) and bulging (amniotic sac protruding through dilated cervix).

Medical record review of a Nurse's assessment dated [DATE] at 12:30 PM revealed Patient #1 had contractions every 1-3 minutes with duration of 40-70 seconds. Further review revealed "...MD [medical doctor] at bedside discussing plan of care with pt [patient], pt agrees to be transferred to [Hospital B]..." Further review revealed no documentation the Physician at Hospital A spoke to a physician at Hospital B regarding the transfer.

Medical record review of a medication administration record dated 10/26/18 at 12:43 PM revealed Patient #1 received Indocin (medication sometimes used to slow contractions). Further review at 12:49 PM revealed the patient received Ampicillin (antibiotic) and Zithromax (antibiotic).

Medical record review of a Nurse's assessment dated [DATE] at 1:00 PM revealed Patient #1 was having contractions every 3-5 minutes with duration of 60-90 seconds. Further review revealed Patient #1 was placed in Trendelenburg position (head down, feet up).

Medical record review of a Nurse's note dated 10/26/18 at 1:00 PM revealed "...EMS [emergency medical services] has arrived and place pt on stretcher for transport to [Hospital B]..." Further review revealed no documentation Patient #1 was examined prior to transfer to Hospital B to determine if the patient's cervix dilation had increased.

Medical record review of a Hospital to Hospital Transfer Form dated 10/26/18 at 1:00 PM revealed Patient #1 was transferred to Hospital B (4.5 hours after arrival) for a possible cerclage (a procedure to suture the opening of the cervix closed to prevent premature delivery). Further review revealed a box was checked indicating "...there is no reasonable likelihood of deterioration of condition from or during transport (stable)..." Continued review revealed a box was checked indicating "...risk of transfer....deterioration of condition enroute..." Continued review revealed the transferring physician certification was not complete indicating the Physician at Hospital A had "...reviewed the patient's vital signs and current status with [a physician] ..." with the accepting Physician at Hospital B.

Medical record review of an admission history and physical from Hospital B dated 10/26/19 at 3:09 PM revealed Patient #1's membranes were bulging and the cervix was dilated to 4-5 cm. Continued review revealed the TOCO monitor showed Patient #1 had contractions every 2-5 minutes. Further review revealed the patient was not a candidate for a rescue cerclage because "...she was contracting and in preterm labor...explained tocolytics [medication to slow contractions] are not indicated (unlikely to be helpful) given her active labor, painful contractions, and advanced dilation..."

Medical record review of a Nurse's assessment at Hospital B dated 10/26/19 at 3:45 PM revealed Patient #1's cervix was dilated to 3-4 and was 4-5 cm at 4:00 PM. Further medical record review revealed the patient cervix was dilated to 9 cm and 100% effaced (cervix paper thin) at 6:30 PM. Continued medical record review revealed Patient #1 delivered on 10/27/19 at 3:20 AM (12 hours and 11 minutes after arrival to Hospital B).

Medical record review of a Physician's progress note dated 10/27/18 at 3:30 PM revealed the baby was deceased (10 minutes after delivery).

Interview with Registered Nurse #1 at Hospital A on 11/19/19 at 9:15 AM, in the L&D breakroom, confirmed Physician #2 checked Patient #1's cervix and the patient's cervix was dilated to 5-6 cm.

Telephone interview with Physician #3 (Interventional Radiologist) at Hospital A on 11/19/19 at 2:10 PM revealed Patient #1's ultrasound "...looks bad in general...there was no cervical length..." Continued interview confirmed the ultrasound showed the patient's cervix was completely funneled with no discernible cervical length remaining.

Telephone interview with Patient #1 on 11/19/19 at 7:13 PM revealed the patient went to her OB Physician's office the morning of 10/26/18 because she was having abdominal pain and vaginal bleeding. Further interview confirmed Patient #1 was sent to the OB triage unit at Hospital A by her physician for an abdominal ultrasound. Continued interview revealed Physician #2 checked Patient #1's cervix but did not tell her how much she had dilated. Further interview revealed Physician #2 told the patient she would receive medicine to stop her labor and a cerclage at Hospital B and she agreed to the transfer. Continued interview revealed Patient #1 was transferred to Hospital B by EMS on 10/26/18 at 2:00 PM, where she was told by a physician at Hospital B she was in labor and would not be getting a cerclage or medication to stop the labor. Further interview revealed Patient #1's baby was born with a heartbeat, but died 10 minutes later.

Telephone interview with Physician #4 (High Risk OB Physician) at Hospital B on 11/20/19 at 1:15 PM revealed Patient #1 was not a candidate for a cerclage because the patient's cervical dilation was 5 cm. Further interview revealed Physician #4 did not remember talking with Physician #2 about Patient #1.

Telephone interview with Physician #2 at Hospital A on 11/20/19 at 2:55 PM revealed Patient #1 (MDS) dated [DATE] with complaints of abdominal pain and vaginal bleeding. Further interview confirmed Patient #1 was 20 weeks and 6 days pregnant and her cervix was funneling. Continued interview revealed Physician #2 consulted Physician #4 at Hospital B for a possible cerclage for Patient #1 and Physician #4 told Physician #2 there was no guarantee he would be able to perform a cerclage on Patient #1 due to the small amount of cervix remaining. Further interview confirmed Patient #1's cervix was dilated to 5 cm on exam.