Down East Community 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: 46424 Based on interview and record review, the hospital failed to ensure compliance with 42 CFR 489.24, by failing to ensure its policy and procedure regarding EMTALA was followed. Findings include: Patient #1 contacted her Obstetrician on 10/14/2023 at approximately 9:30 PM, to advise that her membrane had ruptured, and she was being taken to the agreed upon hospital that had a neonatal intensive care unit. The obstetrician contacted the Labor and Delivery (L&D) nurse at Down East Community Hospital (DECH) to advise of the plan with the patient. Patient #1 was contacted by the L&D Nurse at DECH after the L&D Nurse consulted with both the obstetrician and nurse midwife regarding this case. Patient #1was reminded that she could stop at DECH if she wanted, on her way to the agreed upon hospital, to be assessed by the L&D Nurse. Patient #1 did stop at DECH to be assessed on 10/14/23 at approximately 10:11 PM. The L&D Nurse conducted an assessment and reportedly again consulted with the obstetrician who was enroute to the hospital. The obstetrician determined the patient was safe to be discharged home and continue to the agreed upon hospital. Hospital Policy, “EMTALA (Emergency Medical Treatment and Active Labor Act), (Previously Named “Transfer to Acute Care Policy”)” last reviewed 06/2023 states in part ... “C. If an Emergency Medical Condition Exists: If an Emergency Medical Condition is determined to exist as a result of the medical screening examination, a physician must either: 1. Stabilize the patient in accordance with the requirements of this Policy; 2. Admit the patient in accordance with the requirements of this Policy; or 3. Arrange for an appropriate transfer of the patient to another facility in accordance with the requirements of this Policy.” And “G. Transfers: In the event that the patient has an Emergency Medical Condition that has not been stabilized, a physician will not transfer the patient unless the transfer meets all of the following requirements: 1. Qualified Clinical Staff have provided medical treatment within the hospital’s capacity that minimizes the risks to the patient’s health and, in the case of a woman in labor, the health of the unborn child. 2. DECH clinical staff have contacted the receiving facility and ascertained and documented that the receiving facility: i. Has available space and qualified personnel for the treatment of the patient; and ii. Has agreed to accept the transfer of the patient and to provide appropriate medical treatment.” On 11/08/2023 an interview was conducted with the hospital’s obstetrician who was on-call for obstetrical coverage on the night of 10/14/2023. This physician reported DECH does not have the capacity to safely treat preterm infants. The obstetrician reported that he had initially spoken to Patient #1 at home before she left for the agreed upon hospital, and the obstetrician reported that Patient #1 did not want an ambulance to transport her to the agreed upon hospital. He reported Patient #1 stopped at DECH enroute to the agreed upon hospital and was seen by the L&D nurse. The L&D nurse conducted a sterile vaginal examination and concluded Patient #1 was not in active labor. The obstetrician also stated that the L&D nurse had contacted him after Patient #1 reported she wanted to leave the hospital and continue to the agreed upon hospital. The L&D nurse was questioning if Patient #1 needed to be discharged Against Medical Advice. The obstetrician reported that he was on his way in to physically see Patient #1 however, Patient #1 did not want to wait for the obstetrician to come in and was on her way to the agreed upon hospital as it had been determined the delivery should take place in a hospital with a NICU (Neo-Natal Intensive Care Unit). The L&D Nurse reportedly contacted the nursing supervisor at the agreed upon hospital and had given report. Transfer of the patient was never arranged, and the medical record indicated Patient #1 was “discharged home for her to follow-up in a hospital that has a NICU”. The obstetrician stated he did not call the agreed upon hospital because Patient #1 was already on her way. The obstetrician then further stated “that was not done,” regarding calling the agreed upon hospital. Additionally, the obstetrician stated, “we dropped the ball on calling [the agreed upon hospital]” and stated it was his responsibility to call the agreed upon hospital. On 11/08/2023 at approximately 10:15 AM, the attending obstetrician confirmed that he did not adhere to the provision of the policy to, contact the receiving facility, ascertain if the facility has available space and necessary staff to treat the patent, and had agreed to accept the patient.”

“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: 46424 Based on document review and interviews, it was determined that the hospital failed to complete an appropriate transfer of an obstetrical patient. Findings include: - On 10/14/2023, a 30-year-old pregnant patient was seen at Down East Community Hospital (DECH) Labor & Delivery for observation at 35 weeks 6 days for possible rupture of membranes and was assessed to have preterm premature rupture of membranes. The patient’s cervix was 1 cm dilated and she had irregular contractions. The patient’s history & physical from DECH dated 10/14/2023, states: “Patient informed of the diagnosis of preterm membrane (sic), not in active labor. Patient is stable. Patient agreed to be discharged home for her to follow-up in a hospital that has a NICU [Neonatal Intensive Care Unit]. Patient was at discharge (sic). Patient to call with any concerns.” - On 10/15/2023 at approximately 12:30 AM, this patient presented to the receiving hospital’s Emergency Department via a private vehicle. The receiving hospital’s Labor & Delivery unit charge nurse reported that she did receive a call from DECH’s Labor & Delivery department about a patient that had “left” the hospital and was told that the patient was steroid complete, grossly ruptured, and 1 cm dilated. There was not any mention that the baby was in a breech position. No other calls were made by DECH to the receiving hospital or the receiving hospital’s transfer center which assists with the transfer of patients. - The hospital policy “EMTALA (Emergency Medical Treatment and Active Labor Act (Previously Named “Transfer to Acute Care Policy”)” dated 6/2023 states in part the following requirements of a patient transfer: “DECH clinical staff have contacted the receiving facility and ascertained and documented that the receiving facility has available space and qualified personnel for the treatment of the patient; and has agreed to accept the transfer of the patient and to provide appropriate medical care.” - In an interview on 11/8/2923 at 8:30 AM, the Down East Community Hospital Compliance Officer (CO #1) confirmed that the patient’s obstetrician did not see the patient but was contacted by phone at 10:22 PM on 10/14/2023. The patient was seen by an OB nurse (RN #1), consistent with hospital policy, and was discharged at 10:35 PM. The Compliance Officer stated that she did not find any documentation of the hospital notifying the receiving hospital about the patient. - In an interview on 11/8/2023 at 9:45 AM, the patient’s obstetrician (MD #1) at DECH confirmed that he had been providing prenatal care to the patient and stated that the hospital does not have the capacity for preterm deliveries. He reported that he was on his way into the hospital on the evening of 10/14/2023 to see the patient but was informed by a nursing supervisor that the patient said she wanted to go to the receiving hospital on her own and did not want to wait to see him. The obstetrician stated that the treatment for a ruptured membrane is delivery at a hospital with a NICU. In this case, the obstetrician felt that the patient made the decision to leave the hospital. He acknowledged that there was no communication with the receiving hospital. He stated, “We dropped the ball. This was not our standard of care.” - In a telephone interview with the DECH Chief Nursing Officer Chief Nursing Officer (CNO) (RN #2) on 11/8/2023 at 10:30 AM, the CNO confirmed that there was no documentation of anyone from DECH contacting the receiving hospital about this patient and acknowledged that a patient needing a higher level of care such as this situation makes this a transfer with the requirement of communication to the receiving hospital about the transfer.”