HospitalInspections.org

Based on policy review and record review, the hospital failed to follow their "EMTALA" policy and did not provide within its capabilities the appropriate stabilizing treatment for a patient (# 2) or appropriately transfer another patient (#1) with an unstable emergency medical condition out of 38 sampled patients that presented to the emergency department seeking care from April 2011 to September 2011.

Findings included.

1. Review of the hospital Policy titled, EMTALA, revised 04/2011, stated in part on page 5 of 34, under "Stable/Stability/Stabilize": "A patient is deemed stable under Federal law, when: 1. Pregnancy - Pregnant women experiencing uterine contractions are deemed stable under the law, if:" "a. A physician, after examining the woman, certifies in the record that the woman is in "false labor"; OR b. The hospital delivers the baby and placenta." The policy continues on page 6, "2. All other cases: The patient is (or is provided appropriate care within the capabilities of the hospital to render them) in condition that no material deterioration is likely to occur from or during transfer (including discharge or referral)."

2. Review of a second hospital Policy/Procedure titled "Scope of Service- Perinatal Services" last revised 2/2011 revealed the "Purpose" of Perinatal Services is to "administer care to all ages of patients during the periods of antepartum (before birth), intrapartum (during birth), postpartum (after birth), neonate (delivery less than 36 weeks) and patients with gynecological (GYN, female reproductive organs) conditions." "Immediate care of the neonate is a rendered service including skilled response to neonate resuscitation". Under the Procedure section, the Policy stated that, "Antepartum patients experiencing complications are admitted to this unit. These patients include but are not limited to, multiple gestations (more than one baby) . . . pre term labor. . . and Cesarean birth (delivery by surgery)." The policy stated that Perinatal Services are available 24 hours a day, seven days a week and included a Level I Nursery.

3. Review of the closed medical record revealed Patient #1, a 29 week (40 weeks is full term) pregnant woman, expecting twins, arrived unscheduled on 9/5/11 at 3:20 AM complaining of contractions for an undocumented period of time. Staff I, Registered Nurse in Labor and Delivery, performed a vaginal examination which revealed Patient # 1 was in labor. At 3:50 AM Staff I contacted on-call Physician F who ordered medications to slow down Patient # 1's contractions. Physician F arrived at the hospital at 4:00AM, examined Patient #1, ordered intravenous fluid, a blood pressure medication and transfer of Patient #1 to another hospital prior to delivering the twins. The medical record did not contain evidence that Patient # 1's emergency medical condition had been stabilized within the hospital's capabilities, that the transfer was safe for the unborn babies, or that the appropriate personnel were on board the ambulance at the time of transfer. Refer to Tag A2409 for further details.

4. Review of the closed medical record revealed Patient # 2 presented to the hospital emergency department (ED) on 09/19/11 at 10:22 AM with an emergency medical condition, complaining of suicidal ideation, depression and agitation. The ED nurse practitioner and ED physician examined Patient # 2 and requested further examination by a crisis intervention counselor. Staff J (Crisis intervention counselor, social worker) determined Patient # 2 required admission to psychiatric unit. Staff J discussed Patient #2 with Physician K (on-call Psychiatrist). Staff J documented that Physician K advised it would not be therapeutic for Patient # 2 to be admitted to hospital psychiatric unit because patient's son was just released from the unit earlier in the day. Staff J documented that Physician K believed that Patient # 2 would get better therapy at another facility due to his family situation. Staff J arranged for admission and transfer to another facility. The medical record did not contain evidence that Patient # 2 was no longer at risk for harm to self, that his emergency medical had resolved at the time of transfer. The hospital's failure to admit the patient to an available bed on the adult psychiatric unit placed Patient # 2 at an unnecessary risk. Refer to Tag A2407 for further details.

Based on interview and record review the facility failed to maintain a central log for patients presenting to the emergency department for care. This system failure and routine practice has evolved and allowed the labor and delivery department to maintain a log but does not combine the logs or maintain a central log for all patients that present to the emergency department. If the presenting patient is referred to another department for triage or a Medical Screening Exam (MSE), there is no record of the patient presenting to the emergency department for tracking purposes and there is no information documented on a central log regarding the disposition of that patient. The facility sees an average of 1350 emergency cases per month.

Findings included:

1. During an interview on 09/12/11 at 5:10 PM Staff E, Nursing Director of Perinatal Department, stated that patients presenting to the Emergency Department (ED) who are greater than 20 weeks pregnant with an obstetric related complaint are transported (Labor and Delivery Nurse comes to ED) to the labor and delivery department for a medical screening examination (MSE). Patients are not logged in as presenting to the emergency department. Staff E stated that patients are logged into the labor and delivery log book.

2. During an interview on 09/13/11at 8:30 AM Staff C, Chief Nursing Officer, stated that patients presenting to the emergency department that are greater than 20 weeks pregnant with an obstetric complaint are not entered into the emergency department log system. Staff C stated the patients are logged into the labor and delivery log book.

3. During an interview on 09/20/11at 10:30 AM Patient #1 stated that she arrived at the facility emergency department on 09/5/11 around 3:30 AM. She stated that the emergency department entrance was the only one open at that time of night. She stated that she was asked a few questions and taken directly to the labor and delivery department.

4. Review of the ED Log dated 09/4/11and 09/5/11 did not show documentation indicating Patient # 1 had presented to the emergency department seeking care.

5. Review of the facility policy titled EMTALA, page 18, #4, reviewed 04/2011, revealed that: Patients with 20 weeks or greater estimated gestation who presented to the emergency department will be evaluated in the obstetrical department following initial log entry in the emergency department. The patient shall be transported to the obstetrical department by wheelchair or gurney by an emergency department nurse. An emergency department record will be created on the patient with at least the name, date of birth, time of presentation, estimated gestation, and presenting complaint noted. The record shall state the patient was transferred to the obstetrical department by wheelchair or gurney, the name of the nurse accompanying the patient, the time of the transfer and the time of arrival in the obstetrical department together with any medically relevant observations, vital signs and interventions.
The hospital staff failed to follow this policy and did not document in the ER log as required.

Based on policy review, record review and interview, the hospital failed to provide within its capabilities and capacity, the appropriate stabilizing treatment to a patient (# 2) prior to transfer, out of 38 patients selected for review from April 2011 to September 2011.

Findings included:

1. Review of policy titled, "EMTALA" dated 04/11 showed, in part, "Patients presenting with symptoms of psychiatric disturbances and expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others are considered to have an emergency medical condition under federal law."

2. Review of policy number 02.001 "Admission Criteria" effective 3/19/10 revealed at secton D. "Examples of appropriate ... reasons/situations for admission:" included "1. Appropriate, Suicide attempt or suicidal risk, risk of violence or dangerous assaultive behavior or other acutely uncontrolled behavior ..."

2. Review of the closed medical record revealed Patient # 2 presented to the hospital emergency department (ED) on 09/19/11 at 10:22 AM expressing suicidal thoughts and complaints of depression and agitation. The ED nurse documented that Patient # 2 appeared "anxious, nervous, tearful, depressed", and "to have ineffective coping." Further documentation revealed Patient # 2 was withdrawn or isolated, had few resources/support counseling, and verbalized statement of suicidal intent. Patient # 2 was evaluated by a nurse practitioner, an ED physician and a crisis intervention counselor. Staff J (Crisis intervention counselor, social worker) determined Patient # 2 required admission to a psychiatric unit. Staff J discussed Patient #2 with Physician K (on call Psychiatrist). Staff J documented that Physician K advised it would not be therapeutic for this patient to be admitted to the hospital's psychiatric unit because the patient's son was just released from the unit earlier today. Staff J documented that Physician K believed the patient would get better therapy at another facility due to his family situation. Staff J arranged for admission and transfer to another hospital with psychiatric capabilities. Documentation on the hospital's "EMTALA TRANSFER AND AUTHORIZATION FORM" specified Patient # 2 required ambulance transport and departed the hospital at 4:12 PM. The medical record did not contain evidence that Patient # 2 was no longer suicidal, that his emergency medical condition was stabilized within the hospital's capabilities at the time of transfer.

3. Review of hospital records revealed Staff K is privileged to practice Psychiatry as a Courtesy Staff member from 01/26/11- 01/25/13.

4. Record review of the Adult Psychiatric Unit census on 09/19/11 showed nine current patients with a unit capacity of 10. Geriatric Unit census was five current patients with a capacity of 10.

5. During a phone interview on 09/23/11 at 3:00 PM Staff J, Social Worker, stated that he/she was advised that Patient #2's son had just been discharged from the hospital's Adult Psychiatric Unit. Staff J was further advised by Physician K (Psychiatrist) that the patient's son discussed a lot of family dynamics during group sessions and implicated his father, Patient #2, as the source of many of his problems. Staff J stated that Physician K was concerned about confidentiality and the safety of Patient #2 if he/she was admitted to this unit.

6. During a phone interview on 10/11/11 at 2:30 PM Staff A, Quality Officer, stated that the hospital did have a bed available on the Adult inpatient psychiatric unit at the time Patient #2 was being evaluated in the ED but the psychiatrist did not want to admit due to potential confidentiality and safety issues.

9. During a phone interview on 10/13/11 at 5:10 PM Staff L, ED Physician, stated that he hand wrote a note on the transfer form for Patient #2 to indicate that there was no appropriate available bed at the facility. Staff L did this because he was aware there was a bed available on the adult psychiatric unit but he was advised it would not be appropriate for this patient because the patient's son had just been discharged from this unit. Staff L stated that he could not override the psychiatrist's decision.

Based on policy review, record review and interview, the facility failed to appropriately transfer a woman (patient # 1) in active labor with twins out of 38 patients sampled from April 2011 to September 2011.

Findings included:

1). Review of the hospital's Policy/Procedure titled "Scope of Service- Perinatal Services" last revised 2/2011 revealed the hospital had the capabilities to provide stabilizing care to Patient #1 and her unborn babies. According to the policy, the " Purpose " of the Perinatal Services is to "administer care to all ages of patients during the periods of antepartum (before birth), intrapartum (during birth), postpartum (after birth), neonate (delivery less than 36 weeks) and patients with gynecological (GYN, female reproductive organs) conditions." The Policy further stated that "Services include antepartum care, intrapartum care, postpartum care, pediatrics and GYN surgery. Immediate care of the neonate is a rendered service including skilled response to neonate resuscitation." Under the Procedure section, the Policy stated that, "Antepartum patients experiencing complications are admitted to this unit. These patients include but are not limited to, multiple gestations (more than one baby), diabetes (high blood sugar), preeclampsia (high blood pressure/swelling during pregnancy), eclampsia (high blood pressure/seizures/swelling during pregnancy), hyperemesis (continuous vomiting), pre term labor, threatened abortions (possible miscarriage), placenta previa (placenta is the temporary organ which joins the mother and the fetus, in placenta previa it forms on the lower part of the uterus, normally it forms in the upper part), placenta abruptus (lining of the placenta separates from the uterus), PROM (premature rupture of membrane -"water breaking" too soon), incomplete abortion (miscarriage), and Cesarean birth (delivery by surgery)." The policy stated that Perinatal Services are available 24 hours a day, seven days a week and included a Level I Nursery.

2). Review of the closed medical record revealed Patient #1, a 29 week (40 weeks is full term) pregnant woman expecting twins, arrived at the facility unscheduled on 9/5/11 at 3:20 AM complaining of contractions for an undocumented period of time. Staff I, Registered Nurse in Labor and Delivery, applied an external fetal monitor (EFM) to evaluate the baby's heart rate. At 3:30 AM Staff documented the baby's baseline heart rate was 155 beats per minute with variability and accelerations present (both are measures of fetal health). Staff I, documented contractions every one and a half minutes lasting 40 to 70 seconds with strong intensity. Staff I performed Fetal Fibronectin Test (FFN test is an indicator of pre term labor) and sent specimen swab to lab for evaluation. Staff I performed a vaginal examination on Patient #1 which revealed cervix was dilated to 5 centimeters (during childbirth cervix dilates from 0 to 10 centimeters to allow for fetal movement), effaced (thickness of cervical wall measures in per cent) 90% and station (position of babies head in relation to the mothers pelvis) of -2 (rated from -5 to +5, +5 is baby head crowning) with closest baby in vertex position (head first). At 3:50 AM Staff I contacted Physician F. Staff I administered Terbutaline (medication to slow contractions) 0.25 milligrams subcutaneously to Patient #1 as ordered by Physician F. Physician F arrived at facility at 4:00 AM, examined Patient #1, which revealed fetal heart rate of 120 beats per minute with variability and accelerations, contractions every one and a half minutes with undocumented duration- strong intensity, cervix dilated to 6 centimeters, 90% effaced, -2 station and vertex presentation. Physician F ordered intravenous fluid, a blood pressure medication and transfer of Patient #1 to another facility. Documentation indicated that paramedics arrived to labor and delivery department at 4:30 AM and departed at 4:35 AM. Additional documentation noted that Physician F was asked twice if an RN should accompany paramedics on transfer and responded that it was not necessary. The medical record did not contain evidence that Patient # 1's emergency medical condition was stabilized, that there was sufficient time to effect a safe transfer to the intended receiving hospital or that the transferring physician ensured that the appropriate medical personnel accompanied the patient during transfer.

3). Review of hospital September 2011 on call schedule revealed that an Obstetrician and Pediatrician were on call on 9/5/11.

4). Review of Physician F's (on-call obstetrician) Medical Credentialing file revealed the physician has been an active staff member since 2000 and had privileges for performing cesarean sections and the resuscitation of infants. He/she has been Chairperson of the Obstetrics/Perinatology Department for 2 years.

5). Review of the Ambulance Service report revealed that upon arrival, the patient appeared in severe distress, was having contractions every 6-7 minutes and that staff at the intended receiving hospital "asked if an OB nurse could ride with the EMS crew and the doctor on duty [Physician K] stated that no nurse was available." The ambulance service report revealed they departed the facility at 4:50 AM to transport Patient #1 to receiving hospital. At an undocumented time (between 4:50 AM and 5:29 AM), the patient's water broke (a sign of imminent fetal delivery), the paramedic reported this event to the intended receiving hospital and was advised to divert to Hospital B (the closest facility) and that an air ambulance would arrive shortly. Ambulance Service report indicated arrival to Hospital B at 5:29 AM.

6). Review of Hospital B's medical record revealed shortly after arrival, Patient #1 underwent an emergency cesarean section due to fetal compromise. Medical record revealed the infants were transferred quickly to Hospital C for a higher level of care.

7). During an interview on 9/13/11 at 11:40 AM, Physician F stated that he/she has utmost confidence in the facility labor and delivery nursing staff. Physician F stated that we try not to intentionally deliver premature, high risk babies here because of our resources and their (the babies' ) needs. If there is a lack of imminent delivery or a lack of danger to the mother we will transfer high risk deliveries. Physician F tells patients that the mother is the best incubator money can buy and it's best for the baby to stay in the womb as long as possible. He/she stated that we strive to keep the mother and baby together, if delivery occurs at this facility it is likely that the babies will be transferred to a higher level of care and the mother may stay here or go to a different facility than the baby. If high risk pregnancies are not transferred, the facility would be tying up expert resources (MD and RN's) in a county that has limited resources. He/she stated that it is not a problem to assemble an operating room team. He/she stated that the physician is responsible for deciding whether a nurse should accompany the patient during transport and that it does not happen often. "I guess my feeling is that if an RN needs to go, the patient should probably be staying here."

8). During an interview on 09/14/11 at 2:15 PM Staff E, Registered Nurse Director, stated that the labor and delivery department nurses were very capable of handling delivery of pre term twins. The department has delivered pre term twins via cesarean section at 29 weeks gestation and recently a pre term baby at 26 weeks gestation. The babies were transferred to a higher level of care after delivery.

9). During an interview on 09/14/11 at 3:30 PM Staff I, Registered Nurse, stated Patient #1 arrived to department as documented on 09/5/11, was quickly evaluated and he/she called report to Physician F. Staff I stated that he/she was trained and capable of managing pre term twins via cesarean section or vaginal delivery. Staff I stated that Physician F arrived at facility quickly after being notified and decided to transfer Patient #1. Because of the gestational age of the twins and the dilation of Patient #1 ' s cervix Staff I asked Physician F several times if a nurse should accompany patient and paramedics on the transport and was advised that was not necessary.

10). During an interview on 09/20/11 at 10:30 am Patient #1 stated she arrived at the hospital in the early morning, spoke to someone at the ED desk, told them about her condition and was then taken to labor and delivery. Patient # 1 stated that her water broke within two to three minutes after departing the facility.