Jeff Davis Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47718 Based on medical record review, policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination and stabilization within its capability and capacity for one (P#1) of 20 sampled patients when P#1 presented to the Emergency Department (ED) on April 3, 2024 with a complaint of 38 weeks pregnant with “vaginal leaking all night with contractions starting 4am.” Specifically, the facility failed to ensure that P#1 had a pelvic exam conducted to determine cervical dilation, effacement, station, and fetal presentation. Additionally, the facility failed to ensure that P#1 and her unborn child were stabilized prior to transfer, including but not limited to how advance in labor P#1 was and the presentation of the unborn child, to ensure the risk of delivering en route were minimized. Findings included: Cross-refer to C-2406 as it relates to the facility’s failure to provide an appropriate medical screening exam within its capability and capacity to determine if an emergency medical condition existed. Cross-refer to C-2409 as it relates to the facility’s failure to ensure stabilizing treatment prior to transfer, including but not limited to how advance in labor P#1 was and the presentation of the unborn child, to ensure the risk of delivering en route were minimized.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47718 Based on review of medical records, policy and procedures, and staff interviews it was determined that the facility failed to ensure that one (P#1) one of 20 sampled patients received an appropriate medical screening exam within the facility’s capability and capacity to determine if a medical emergency condition existed. On April 3, 2024, P#1 presented to the facility’s emergency department (ED) with complaints of 38 weeks pregnant with “vaginal leaking all night with contractions starting 4am.” The facility failed to ensure that P#1 had a pelvic exam to determine cervical dilation, effacement, station, and fetal presentation. Findings included: A review of Patient (P) #1’s medical record revealed that P#1 was admitted to the Emergency Department (ED) on 4/3/24 at 8:33 a.m. with the chief complaint of 38 weeks pregnant with “vaginal leaking all night with contractions starting 4am.” A review of the hospital document titled “ED Note Physician” dated 4/3/24 at 8:38 a.m., written by Nurse Practitioner (NP) BB, revealed that P#1 was 38 weeks pregnant and stated her last two children were delivered one week earlier than their due dates. NP BB documented “...pt [patient] presents ... via ems [Emergency Medical Services] in active labor.” On arrival to the ED, P#1’s contractions were every four minutes, lasting 45 seconds to one minute. P#1 stated she had vaginal leaking all night, and contractions had started at 4:00 a.m. The physical exam revealed that P#1’s abdomen was “soft, diffuse abdominal pain, labor pains, contractions every 5 minutes lasting 355[sic]-45 seconds [35 to 45]...” There was no documentation that an exam to determine cervical dilation, effacement, station, and fetal presentation was completed. P#1 was transferred via an ambulance to a receiving facility (Hospital B) on 4/3/24 at 9:39 a.m. A review of Hospital B’s History and Physical (H&P) Note dated 4/3/24 at 11:12 a.m. revealed that P#1 presented with complete dilation of the cervix (last stage of labor before birth), 100% effacement, fetal station +1, with fetal presentation documented as breech (confirmed by bedside ultrasound at Hospital B). An interview was conducted on 4/9/24 at 11:10 a.m. with Registered Nurse (RN) EE in the facility’s staff training room. RN EE stated P#1 had been hurting since 4:00 a.m. (at home). RN EE said that NP BB came in to see P#1 and went straight to call the receiving facility. RN EE stated that NP BB said he did not check how far P#1 was dilated because he (NP BB) did not want to rupture the membranes and further complicate issues. RN EE also stated that there was no wetness on P#1’s bed, but when she (RN EE) did an external vaginal examination, there was a little bit of wetness, which she tested, and the result of the test was safe (nitrozine test negative for fluid collected outside of P#1’s vagina). A telephone interview was conducted on 4/9/24 at 11:30 a.m. with Registered Nurse (RN) FF in the facility’s staff training room. RN FF stated that P#1 came directly to Trauma 1, and she (P#1) stated that contractions started earlier. RN FF explained that the facility’s policy was that nursing staff did not check the cervix. A telephone interview was conducted on 4/9/24 at 11:45 a.m. with Nurse Practitioner (NP) BB in the facility’s staff training room. NP BB stated that P#1 presented with contractions every three to five minutes. NP BB said that he only did a visual examination of P#1’s vagina based on his (NP BB) experience not to insert anything into the vagina if there was no imminent delivery to prevent further complications. A review of the hospital’s policy titled “Triage in the Emergency Department,” last revised February 2024, revealed that Emergency Medical Treatment and Labor Act (EMTALA) law stated, “If you had an emergency or are in labor, you had the right to receive, within the capabilities of this hospital’s staff and facilities: ‘An appropriate Medical Screening Examination Necessary Stabilization Treatment (including treatment for an unborn child) and, if necessary, an appropriate transfer to another facility...” Cross Refer to C2409.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 47718 Based on review of medical records, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that one (P#1) of 20 patients received stabilizing treatment prior to transfer, including but not limited to how advance in labor P#1 was and the presentation of the unborn child, to ensure the risk of delivering en route were minimized. Findings included: A review of Patient (P) #1’s medical record revealed that P#1 was admitted to the Emergency Department (ED) on 4/3/24 at 8:33 a.m. with the chief complaint of 38 weeks pregnant with “vaginal leaking all night with contractions starting 4am.” A review of a hospital document titled “ED Note Physician” dated 4/3/24 at 8:38 a.m., written by Nurse Practitioner (NP) BB, revealed that P#1 was 38 weeks pregnant and she stated that her last two children were delivered one week earlier than their due dates. On arrival to the ED, P#1’s contractions were every four minutes, lasting 45 seconds to one minute. There was no documentation that an exam to determine cervical dilation, effacement, station, and fetal presentation was completed. On 4/3/24 at 9:31 a.m., P#1 was transferred from Hospital A to Hospital B. A review of the “Hospital Transfer Authorization” document revealed that the reason for the transfer was “labor (services not available).” A review of the form failed to reveal that a selection for P#1’s condition was made. The options to select included: “1. Individual was stabilized within reasonable medical probability, no material deterioration of the individual condition or the condition of the mother and unborn child(ren) was likely to result from transfer. 2. The individual’s condition had not been stabilized; however, the individual would benefit from a higher level of care which outweighed the risk associated with the transfer. 3. The individual was in active labor. However, the expected benefits of transfer outweighed the potential risk to the mother and/or unborn child(ren).” An interview was conducted on 4/9/24 at 11:10 a.m. with Registered Nurse (RN) EE in the facility’s staff training room. She said P#1 stated she had been hurting since 4:00 a.m. (at home). RN EE said that NP BB came in to see P#1 and went straight to call the receiving facility. RN EE stated that NP BB said he did not check how far P#1 was dilated because he (NP BB) did not want to rupture the membranes and further complicate issues. A telephone interview was conducted on 4/9/24 at 11:30 a.m. with Registered Nurse (RN) FF in the facility’s staff training room. RN FF stated that P#1 came directly to Trauma 1, and she (P#1) stated that contractions started earlier. RN FF stated that P#1 requested to be taken to the other (receiving) facility. RN FF explained that the facility’s policy was that nursing staff did not check the cervix. A telephone interview was conducted on 4/9/24 at 11:45 a.m. with Nurse Practitioner (NP) BB in the facility’s staff training room. NP BB stated that P#1 presented with contractions every three to five minutes. NP BB said that he only did a visual examination of P#1’s vagina based on his (NP BB) experience not to insert anything into the vagina if there was no imminent delivery to prevent further complications. A review of the hospital’s policy titled “Transfer of Patients: from (Hospital A) to Other Facilities ...” effective July 2023, revealed “To ensure (Hospital A) complies with Emergency Medical Treatment and Active Labor Law (EMTALA), provides continuity of care between hospitals, assures proper medical screening and assure patients medical condition is stabilized prior to transport, assures patient safety in transport ...IV. Procedures for Transfers of Patients from (Hospital A) to other facilities ...The physician or physician extender completes and signs the certification of transfer (Patient Agreement for Transfer Form) to include summary of the medical risks and medical benefits of transfer ...The patient cannot be transferred unless Form is completed. Reason for unstable transfer must be documented in the risks and benefits section ...” A review of the receiving facility’s (Hospital B) History and Physical (H&P) Note dated 4/3/24 at 11:12 a.m. revealed that P#1 presented with complete dilation of the cervix (last stage of labor before birth), 100% effacement, fetal station +1, with fetal presentation documented as breech (confirmed by bedside ultrasound at Hospital B). A continued review revealed that the unborn baby was in a breech presentation (buttocks or lower extremity delivering first), and a need for a stat (now) cesarean delivery secondary to breech presentation was discussed with P#1. Documentation revealed that upon immediate transfer to the operating room (OR), grossly ruptured membranes had occurred with thick meconium fluid. Documentation revealed that upon arrival to the OR, a breech vaginal delivery had to be performed due to P#1’s advanced nature. Cross Refer to C2406.”