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Based on review of Medical Record (MR), hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure:

1. An appropriate medical screening examination was performed.

2. Patient consent was obtained prior to transfer to another hospital.

3. MRs related to the EMC (Emergency Medical Condition) available at the time of transfer were sent to the receiving hospital.

4. Risk and benefits of transfer to the individual's health or the health of the unborn child were explained to the patient prior to transfer to another hospital.

Refer to A 2406 and A 2409 for findings.

Based on review of Medical Record (MR), hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure an appropriate medical screening examination was performed for one (1) of seven sampled pregnant medical records reviewed, Patient #1.

Findings include:

Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening and Treatment of Emergency Medical Conditions (EMC)
Policy Number: BBH CLN.04.01
Reviewed Date: 7/29/2024

Purpose:

To ensure individuals presenting to... Facility's emergency departments receive an appropriate Medical Screening Examination (MSE)...

Policy:

...An individual is deemed to have come to the Dedicated Emergency Department (ED) if the individual:

1. Presents at a Dedicated ED and requests examination or treatment for a medical condition...

Procedure:

A. The Facility will provide an appropriate MSE within its capability to an individual coming to the Dedicated ED, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists.

Hospital Policy: Triage, Registration, and Treatment
Policy Number: BBH CLN.04.01.PR.01
Reviewed Date: 7/29/2024

I. Procedure:

...C. Medical Screening Examination

1. An MSE will be provide by Qualified Medical Personnel to any individual who comes to the Dedicated Emergency Department...

2. The MSE will be performed by a physician or other Qualified Medical Personnel. The examination should be specific to the patient's complaint and presenting symptoms.

1. PI # 1 presented to the hospital ED on 4/20/24 at 11:25 PM with a chief complaint of labor pains.

Review of the ED physician's History of Present Illness (HPI) evaluation dated 4/20/25 at 11:39 PM revealed PI # 1 was 38 weeks pregnant with third pregnancy, denied any vaginal bleeding or discharge, and the patient's water was not broken. The physical exam documented the patient's abdomen was firm and the patient was experiencing abdominal contractions. The ultrasound revealed the baby's head was high in the uterus with a breech presentation.

Further review of the ED physicians HPI evaluation dated 4/20/25 at 11:39 PM revealed no documentation of a vaginal pelvic exam to assess cervical dilation, the fetal position, and fetal station.

Review of the MR revealed no documentation fetal heart tones were assessed.

The hospital failed to ensure a complete MSE was performed.

An interview was conducted on 5/8/25 at 1:59 PM with Employee Identifier (EI) # 3, Systems Director and Interim ED Medical Director, who stated, "I did a quick look for vaginal discharge, I did not do a vaginal pelvic exam."

Cross Refer to A2409.

Based on review of Medical Record (MR), hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure:

1. Patient consent was obtained prior to transfer to another hospital.

2. MRs related to the EMC (Emergency Medical Condition) available at the time of transfer were sent the receiving hospital.

3. Risk and benefits of transfer to the individual's health or the health of the unborn child were explained to the patient prior to transfer to another hospital.

This deficient practice did affect three of ten patients who were transferred from the hospital, including Patient Identifier (PI) # 1, PI # 3, PI # 7 and had the potential to affect all patients presenting to the hospital Emergency Department (ED) who would require a transfer to another hospital.

Findings include:
Hospital Policy: Emergency Medical Treatment Labor Act of 1986 (EMTALA)
Policy Number: BBH CLN.04.01
Reviewed Date: 7/29/24

Purpose:
To ensure individuals presenting to... Facility's emergency departments receive an ... appropriate transfer in accordance with EMTALA...

Emergency Medical Condition: A condition manifesting itself by acute symptoms of sufficient severity... such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy...

Procedure:
...B. ...the facility will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including... arrange an appropriate transfer of the individual to another medical facility...

Hospital Policy: Refusal of Treatment and Transfer
Policy Number: BBH CLN.04.01.PR.02
Reviewed Date: 7/9/2024

Procedure:

...B. Transfer of Individuals with an Emergency Medical Condition... A decision regarding transfer of a patient may be made by...physician certification.

3. Transfer Process

...c. Facility must send to the receiving facility copies of all pertinent medical records available at the time of transfer...

1. PI # 1 presented to the hospital ED on 4/20/24 at 11:25 PM with a chief complaint of labor pains.

Review of the ED nurse notes dated 4/20/25 revealed the following:

At 11:40 PM, PI # 1 was experiencing contractions six minutes apart with pain a 10 on a 1-10 pain scale.

At 11:48 PM, PI # 1's contractions were two to four minutes apart until the patient was transferred to another hospital, on 4/21/25 at 12:20 AM via ambulance.

Review of the ED physician's History of Present Illness (HPI) evaluation dated 4/20/25 at 11:39 PM revealed PI # 1 was 38 weeks pregnant with third pregnancy, denied any vaginal bleeding or discharge, and the patient's water was not broken. The physical exam documented the patient's abdomen was firm and the patient was experiencing abdominal contractions. The ultrasound revealed the baby's head was high in the uterus with a breech presentation. The patient was transferred to the receiving hospital.

Further review of the ED physicians HPI evaluation dated 4/20/25 at 11:39 PM revealed no documentation of a vaginal pelvic exam to assess cervical dilation, the fetal position, and fetal station.

Review of the MR revealed no documentation fetal heart tones were assessed.

Further review of the MR revealed no documentation the risk and benefits to the unborn child were explained to the patient, the patient consented to the transfer to another hospital, and the MR was sent to the receiving hospital.

An interview was conducted on 5/8/25 at 2:55 PM with Employee Identifier (EI) # 1, Director Clinical Quality Improvement, who confirmed there was no documentation the risk and benefits to the unborn child were explained to the patient, the patient consented to the transfer to another hospital, and the MR was sent to the receiving hospital.



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2. PI # 3 presented to the ED hospital via medical flight on 3/13/2025 at 2:52 PM with a chief complaint of Aortic Dissection.

Review the ED physician's HPI dated 3/13/25 at 2:54 PM revealed PI # 3 arrived for a massive type of aortic dissection and was diagnosed with a Dissection Thoracic Aorta Unspecified Part.

Review of the Cardiothoracic Surgery consult dated 3/13/25 at 3:43 PM revealed PI # 3 had a history of Malignant Hypertension, presented with subacute dissection with acute onset spinal cord ischemia, reported a sudden onset of chest pain with bilateral lower extremity numbness, left lower extremity paralysis, and right lower extremity weakness. The computed tomography (CT) scan revealed a Type A dissection with thickened flap.

Review of the MR revealed PI # 3 was transferred to another hospital on 3/13/25 at 5:55 PM.

MR review revealed no documentation of a physician certification containing the risks and benefits of the transfer to another hospital, no documentation a consent for the transfer was obtained from the patient/family, and no documentation the medical records were sent to the receiving hospital.

An interview was conducted on 5/8/25 at 2:48 PM with EI # 1 who confirmed there was no documentation of a physician certification containing the risks and benefits of the transfer to another hospital, no documentation a consent for the transfer was obtained from the patient/family, and no documentation the medical records were sent to the receiving hospital.

3. PI # 7 arrived at the hospital ED on 4/16/2025 at 10:28 AM with a chief complaint of Abdominal and Back Pain.

Review of the ED physician's HPI dated 4/16/25 at 10:36 AM revealed PI # 7 presented with right lower quadrant pain that radiated to the rectum.

Review of the CT scan dated 4/16/25 at 3:45 PM revealed concern for ruptured ectopic pregnancy with large hemoperitoneum and probable active extravasation.

Review of the MR revealed PI # 7 was transferred to another hospital on 4/16/25 at 5:17 PM.

MR review revealed no appropriate risks, such as persistent hemorrhage, and a consent for transfer was documented.

An interview was conducted on 5/7/25 at 2:45 PM with EI # 2, ED Assistant Nurse Operations Manager, who confirmed there was no documentation a consent for transfer was obtained from the patient/family.