HospitalInspections.org

Based on interview, record review, review of the Bing Maps website, hospital video, and review of the facility's policies, it was determined the facility failed to ensure all individuals that presented to the Emergency Department (ED) with an emergent condition were stabilized, and if the facility could not provide needed treatment, the patient was given an appropriate transfer to another facility who could provide needed treatment, for one (1) of twenty (20) sampled patients, Patient #1.

The findings include:

Fac1 1 failed to conduct repeated cervical exams, monitor vital signs, obtain IV access for potential administration of medications, and document the specific labor risks verses benefits prior to transferring P1 to Fac2.

Cross Refer to 2409.

Based on interview, record review, review of the Bing Maps website, hospital video, and review of the facility's policies, it was determined the facility failed to ensure all individuals that presented to the Emergency Department (ED) with an emergent condition were stabilized, and if the facility could not provide needed treatment, the patient was given an appropriate transfer to another facility who could provide needed treatment, for one (1) of twenty (20) sampled patients, Patient #1.

The findings include:

Review of Facility #1's policy titled, "EMTALA: Medical Screening, Treatment and Transfer of Patients to Another Facility", revised October 2020, revealed the a physician in the Emergency Department (ED) would medically screen patients who presented to the ED requesting examination and/or treatment. Further review revealed medical screening was an ongoing process that required physician evaluation according to the patient's condition.

Review of the website Bing Maps, https://www.bing.com/maps/directions, revealed FAC2 was 24.7 miles and approximately 28 minutes by car from FAC1.

Review of P1's medical record from FAC1 revealed, on 02/20/2025, P1 arrived to FAC1 via ambulance at 6:32 AM. No physician orders or physician attestation could be found.

Review of FAC1's security video, from 02/20/2025, revealed:
6:31:01 P1 ambulance pulled into ambulance bay and brought P1 in the door at 6:32 AM to room 3
6:33 AM Registered Nurse (RN) 1 arrived to P1's room and received report from EMS at 6:34 AM
6:34:56 AM Physician 1 to room
6:35:13 AM Physician 1 departed room
6:40:24 AM RN1 departed room
6:41:43 AM EMS departed room
6:40:58 AM RN1 returned and departed room
6:48:49 AM RN1 returned room
6:52:43 AM RN1 departed room to get Physician 1
6:53:07 AM RN1 and Physician 1 returned to room
6:54:09 AM RN1 departed room
6:54:27 AM RN1 returned to room with a rolling stool
6:56:02 AM Physician 1 departed room
6:57:30 AM RN1 departed room
6:57:44 AM RN1 returned to room
6:58:20 AM RN1 departed room
7:10:00 AM Physician 2 entered room along with RN5
7:11:44 AM Physician 2 and RN5 departed room
7:14:33 AM EMS entered from ambulance bay to nurse's station
7:15:40 AM House supervisor entered the room
7:16:30 AM House supervisor left the room
7:17:57 AM RN5 entered the room and appeared to have paperwork
7:18:10 AM RN5 departed the room
7:20:30 AM EMS entered the room with the stretcher and stopped in the doorway
7:21:00 AM Second EMS entered room with the stretcher into the room
7:23:23 AM EMS departed with P1
7:23:42 AM EMS to ambulance bay
7:23:45 AM EMS loaded P1 onto the ambulance
7:24:08 AM EMS shut ambulance doors
7:26:26 AM Ambulance departed bay

During an interview, on 03/24/2025 at 3:03 PM, FAC2's Market Director of Corporate Responsibility (MDCR)stated P1 came to FAC2 in labor and the head of the baby was delivered in the elevator on the way to the OB unit by the EMS staff. The MDCR further stated once the EMS staff arrived on the unit, nurses delivered "the rest of the baby". She continued to state P1 told her Physician 1 had held up two fingers spread apart which in OB terms meant she was four centimeters dilated. MDCR stated P1 arrived at FAC2 at 7:52 AM and her baby was delivered at 7:54 AM.

During an interview, on 03/24/2025 at 3:03 PM, FAC2's Interim Market Chief Medical Officer (CMO) stated FAC2 had received records from FAC1 which stated P1 lived close to FAC1. She further stated P1's water broke at home and P1 did not seek medical attention at that time, but P1 later called 911 for transport and was triaged at FAC1 with contractions three to three and one-half minutes apart. She continued to state FAC1 called EMS for transport to FAC2.

MDCR and CMO both expressed concerns P1 was multipherous with her fifth child and had comorbidities including substance abuse history and had no IV access.

During interview, on 03/26/2025 at 8:36 AM, FAC1 night House supervisor stated she came in to help RN1 when two ambulances came in at the same time on 02/20/2025, as the other nurse with RN1 had left at 3AM, and RN1 was the only nursing working the ED at that time. She further stated she took care of the other patient that came into the ED that morning and only went in to help P1 take off her track pants. She continued to state when she takes care of an OB patient in labor, she assesses the patient visually, then gets vital signs, then asks questions about how far along in the pregnancy the patient was, if they were to term, and if they had prenatal care. Additionally, she stated she does a head to toe assessment, puts the patient on a monitor, gets the fetal heart tones, and "sets up the bed" for the doctor so he doesn't have to come in and out of room, which included putting a chux under the patient and removing the patient's clothing from the waist down. The House Supervisor stated she would also start IV in case it was needed later. She further stated every patient was different about how far along they were and how expedient the labor progressed. She continued to state the doctor would check the patient for ruptured membranes and dilation, and FAC1 did not have an OB department but did have equipment to deliver a baby in the ED if needed. Additionally, she stated P1 had always planned to deliver at Fac2 so the ED doctor called a receiving Physician at Fac2 and gave report.

During a interview, on 03/26/2025 at 9:24 AM, RN1 stated P1 called EMS and EMS brought to P1 to Fac1. She further stated EMS had called from pickup and said P1's contractions were one minute apart, and P1 was asking to be transported to Fac2 but Physician 1 stated to bring her to Fac1 if her contractions were that close. She continued to state when P1 arrived, she got her in a room and timed her contractions to be about three min 15-20 seconds apart, did an assessment, and helped P1 get undressed from the waist down, did a visual assessment for imminent signs of the child birth. Additionally, she stated P1's clothes were dry with no leaking fluids and the baby was not crowning. She stated she obtained fetal heart tones in 150's which was good, then she alerted Physician 1, put her assessment in the computer, and accompanied the doctor for a vaginal exam. She further stated Physician 1 stated P1's membranes were intact, but did not say anything about dilation to her. Additionally, she stated P1's vital signs were good, she was still having contractions, but she never timed the contractions less than 3 minutes. She stated Physician 1 asked the clerk to get the OB physician at Fac2 on the phone, then Physician 1 gave report to the Fac2 Physician (Physician 3). She further stated she copied paperwork and called report to the Fac2 nurse. Additionally, she stated Fac2 nurse did not indicate whether she was expecting the call with report. She stated with transfers, it was the doctor's call where to transfer or if the patient had a preference. She further stated the decision to place an IV (intravenous access) before transfer depended on the patient's stability and stage of labor and she did not believe P1 needed an IV in this case.

During an interview, on 03/26/2025 at 10:15 AM, Physician 1 (Fac1 ED doctor) stated P1 came in by EMS in labor and was getting OB care in the town where FAC2 was located. He further stated P1 had requested EMS take her to Fac2. He continued to state he performed an examination and, during a digital check, felt fullness, with P1's membranes being intact, and P1 had contractions four to five minutes apart. Additionally, he stated he spoke to the physician on call for Fac2 (Physician 3) and he accepted P1. Physician 1 stated he thought P1 could make the 20 minute ride to Fac2 prior to delivery. He further stated he did not recall being alerted to P1's arrival prior to EMS bringing her in, and he had two patients arrive by EMS at the same time. He continued to state he did a quick assessment on P1 and called the pediatrician in case the baby's delivery was imminent. Additionally, he stated his assessment was P1 needed to be transferred to FAC2 and told the clerk to get the on call OB physician for FAC2 on the phone, then that physician accepted P1 and he assumed that the physician notified FAC2 P1 was coming. He stated FAC2's call center "sucks" and it could take one to one and a half hours to get a doctor, and he preferred calling the physician directly. He further stated the decision to transfer or not depended on the patient and, in this case, he thought P1 could make the 20 minute ambulance ride because her membranes were intact, and his judgement was she could get to FAC2 prior to delivery. He continued to state IV access was not always started prior to transfer.

During an interview, on 03/26/2025 at 2:34 PM, FAC2's labor and delivery nurse (RN2) stated she received report on 02/20/2025 from FAC1 and was not notified of a cervical exam being done. She further stated it was reported by FAC1 P1 was "overdue", which was not true. She continued to state she was not aware of receiving P1 prior to getting report, and called the Nursing Manager after she got off the phone and she was not aware either. Additionally, she stated if the infant had been delivered in the back of the ambulance, EMS had no ability to resuscitate the baby or keep it warm. She stated when P1 arrived EMS yelled "the baby is coming" as they got off the elevator onto the OB floor and four or five nurses responded. She further stated when she pulled back the sheet covering P1, she saw the baby's purple head already delivered and the entire baby was delivered without difficulty within two minutes. Additionally, she stated if the baby had shoulder dystocia or other complications, they would have about seven minutes to deliver the baby once the head was birthed, otherwise there was a risk of major complications, such as possible cord prolapse, cerebral palsy, other neurological issues, or even death. She stated this was P1's 5th child, which usually meant delivery progressed quickly. She further stated EMS arrived on the unit at 7:52 AM and the baby was delivered 7:54 AM.

During an interview, on 03/27/2025, Physician 2 stated she was called about 6:00 AM regarding a patient coming into the ED with 1 minute contractions, in case she was needed. She further stated when she arrived, Physician 1 said P1's contractions were four minutes apart and she was dilated three centimeters and Physician 2 would not be needed. She continued to state she knew P1 and spoke with her but did not assess her.

During an interview, on 03/27/2025 at 11:49 AM, Physician 3 stated he received a call from Physician 1 about a patient in early labor and requested a transfer. He further stated, in hindsight, it would probably have been better to deliver the baby in FAC1 ED and transfer mom and baby, but he was told P1 was in early stages of labor and it was safe to transfer her.

The State Survey Agency (SSA) Surveyor was unable to reach P1 for an interview after attempts on 03/24/2025 at 4:30 PM and 03/25/2025 at 9:10 AM.

In summary, Fac1 1 failed to conduct repeated cervical exams, monitor vital signs, obtain IV access for potential administration of medications, and document the specific labor risks verses benefits prior to transferring P1.