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Based on interview and record review, the facility failed to ensure one of twenty sampled patients' (Patient 1) emergency medical condition (EMC - an illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm) was stabilized prior to transferring patient (Patient 1) to another facility (GACH 2), for higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates), in accordance with the facility's policy and procedure regarding Emergency Medical Treatment and Labor Act (EMTALA, a Federal law that requires anyone coming to an Emergency Department to be stabilized and treated, regardless of their insurance status or ability to pay).

This deficient practice had the potential for Patient 1 to give birth, during transport to another facility, to a premature infant (a baby born too early), with the possibility of Patient 1 suffering hemorrhage (excessive bleeding) from uterine rupture (a serious complication where the uterus tears or breaks open).

On 12/13/2023, at 8:37 a.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility ' s noncompliance with one or more requirement has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) situation in the presence of the Chief Nursing Officer (CNO) and the Director of Performance Improvement (DPI). The facility failed to ensure Patient 1's emergency medical condition (active labor [a series of continuous and progressive contractions that allows the fetus [unborn baby] to move through the birth canal]) was stabilized prior to transporting Patient 1 from GACH 1 (General Acute Care Hospital 1), to the other medical facility (GACH 2), for higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates).

Patient 1, who was G5 (Gravida- number of pregnancies), P3 (Parity or Para- number of livebirths and stillbirths [death or loss of baby before or during delivery]), Ab 2 (abortion), with a history of three previous c-sections (surgical delivery of a baby), no prenatal care (medical care received during pregnancy), and was determined to be 34 weeks gestation (amount of time of pregnancy), based on prenatal ultrasound (imaging method to create pictures of the inside of the body), was transported via 9-1-1 ambulance to GACH 2, while in active labor.

This deficient practice had the potential for Patient 1 to give birth, during transport to another facility, to a premature infant (a baby born too early), with the possibility of Patient 1 suffering hemorrhage (excessive bleeding) from uterine rupture (a serious complication where the uterus tears or breaks open).

On 12/14/2023, at 3:35 p.m., the IJ was removed in the presence of the Chief Nursing Officer (CNO) and the Director of Nursing (DON), after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The acceptable IJ Removal Plan included the following:

1. Review and revisions to policy ED-0100, Obstetrical Patient (a branch of medicine specialized in the care of pregnant women and childbirth) Presenting in the ED (Emergency Department- responsible for the provision of medical care for patients arriving in the hospital in need of immediate care), which included the process for assessing the need to transfer and to do emergency cesarean sections (c-sections) at the facility (GACH 1), if unable to transfer OB (Obstetric) patients.

2. Developed a checklist of items to assist in preparing OB (Obstetric) patient for vaginal delivery or c-section.

3. Process of preparing for c-sections at the facility.

4. Process of preparing OB patients for transfer and contacting ambulance services.

5. The duties of the ED physician and ED RN which included the responsibility for care of the newborn, until the NICU (Neonatal Intensive Care Unit- unit that specializes in providing intensive [critical] medical care to newborns) team arrives, after vaginal or c-section deliveries.

6. Surgical services - for operating room (OR) RNs to follow current practices for open lower abdominal procedures.

Findings:

During a concurrent interview and record review on 12/11/2023 at 3:39 p.m. with the Quality Review Nurse (QR), Patient 1's face sheet, dated 12/5/2023, was reviewed. The QR stated Patient 1 was admitted to the hospital (GACH 1), at 4:06 a.m., with Ruptured of Membranes (ROM - when the membranes surrounding the fetus [unborn baby] spontaneously rupture prior to 37 weeks of pregnancy resulting in leakage of amniotic fluid [fluid that surrounds the fetus during pregnancy]).

Concurrently, during record review of Patient 1's Triage (to categorize patient based on the severity of their condition and the order in which they require care and monitoring) notes, dated 12/4/2023, QR stated the following:

1. Patient 1 arrived at facility's (GACH 1) emergency department (ED- responsible for the provision of medical care for patients arriving in the hospital in need of immediate care) as a walk-in via family vehicle.

2. Patient 1 complained of having contractions (tightening and relaxing of the uterine muscles during labor to push the unborn baby out of the uterus [female reproductive organ where the baby grows]) that increased after having been discharged from another facility (general acute care hospital - GACH 2) earlier, on 12/4/2023, prior to arrival at GACH 1.

3. Patient 1 stated she (Patient 1) was discharged from GACH 2 earlier because she (Patient 1) was told she (Patient 1) was not in labor (a series of continuous and progressive contractions that allows the fetus [unborn baby] to move through the birth canal) while she was at GACH 2.

4. Patient 1 stated she (Patient 1) had no prenatal care (medical care received during pregnancy).

5. Patient 1 stated she (Patient 1) was told from GACH 2, that fetus (unborn baby) was 34 weeks.

6. Patient 1 complained of pain 8/10 on arrival at GACH 1.

7. Patient 1 reported she (Patient 1) had a history of three previous cesarean sections (c-section - surgical operation for delivering a child by cutting through the wall of the mother's abdomen).

Concurrently, during record review of Patient 1 ' s ED physician note, dated 12/5/2023, QR stated the following:

1. History of present illness indicated patient was pregnant for fifth time with three previous cesarean sections and one spontaneous miscarriage, and patient (Patient 1) complained of cramping pain every five minutes.

2. After initial examination, there was a concern for preterm labor (labor that starts before 37 weeks of pregnancy).

3. Obstetrician (OB - physician or surgeon qualified to provide medical care during pregnancy, labor and birth, after the birth) was consulted and recommended that patient (Patient 1) be transferred to GACH 2 for further care and evaluation in their labor and delivery unit (L&D unit- a unit that specializes in childbirth).

4. At 3:15 a.m., patient's (Patient 1) bag of waters broke, and patient (Patient 1) was re-examined and found to be dilated at 5 cm (centimeters, a unit of measurement).

5. At 3:38 a.m., an attempt was made to call GACH 2 for a neonatal intensive care unit (NICU - a specialty unit where babies get around-the-clock care from a team of experts) nurse to come to this facility (GACH 1).

6. Spoke with facility's house supervisor and chief nursing officer and informed that facility does not have any neonatal services and instructed to call 9-1-1 to transfer patient (Patient 1) to GACH 2.

7. At 3:40 a.m., OB was notified of patient's (Patient 1) progression with labor and stated he (OB) would come to the facility (GACH 1) to do a c-section for the patient (Patient 1).

8. At 3:45 a.m., patient's (Patient 1) fetus' heart rate was 136 beats-per-minute (normal fetal heart rate is 120-160).

9. At 3:47 a.m., 9-1-1 ambulance arrived.

10. At 3:50 a.m., OB arrived at facility and accompanied patient to receiving hospital (GACH 2).

11. Impression - patient was in stable condition for transfer to GACH 2.

During a concurrent interview and record review on 12/11/2023 at 4:00 p.m. with the Chief Nursing Officer (CNO) and the Director of Nursing (DON), Patient 1's ED visit record, dated 12/5/2023, was reviewed. The CNO said facility (GACH 1) had contracts with private ambulance companies, and facility (GACH 1) contacted two ambulance companies to transfer Patient 1 to GACH 2 for higher level of care. CNO stated facility (GACH 1) had been having difficulty with getting private ambulance services to come right-away. CNO stated the first ambulance company was called, shortly after Patient 1 arrived at the facility (GACH 1) and could not come until 3:30 a.m. CNO said the second ambulance company was called and could not come until 7:30 a.m. CNO stated after Patient 1's condition changed and was in active labor, after her (Patient 1) water broke, facility (GACH 1) called 9-1-1 to transport Patient 1 to GACH 2.

During an interview on 12/12/2023, at 8:29 a.m., with ED physician (MD 1), MD 1 stated the following:

1. ED triage nurse told her (MD 1) that Patient 1 came from another facility (GACH 2), had no prenatal care, was complaining of abdominal pain.

2. Patient 1 was examined.

3. MD 1 consulted with Obstetrician (MD 2) and MD 2 advised MD 1 to get Patient 1 back to GACH 2 for higher level of care.

4. Ambulance services were called to transport Patient 1 back to GACH 2.

5. Patient 1's labor progressed with the bag of waters breaking.

6. MD 1 consulted with MD 2, the second time.

7. MD 2 recommended that MD 1 call in a "crew" from GACH 2 to come to this facility (GACH 1), because there were no pediatric services (a specialty of medicine concerned with medical care of children from birth to young adulthood) and no NICU services at this facility (GACH 1).

8. CNO told MD 1 that this facility (GACH 1) cannot do c-section because there was no NICU services at this facility (GACH 1).

9. CNO instructed house supervisor to call 9-1-1 to transfer Patient 1 to GACH 2.

10. Patient 1 was stable prior to transfer to GACH 2.

11. MD 2 arrived at facility and accompanied Patient 1 to GACH 2, in the ambulance.

During an interview on 12/12/2023 at 9:00 a.m. with on-call Obstetrician (MD 2), MD 2 stated the following:

1. He (MD 2) received a call in the middle-of-the-night from MD 1 (ED physician) about Patient 1, who was in "hard labor" at 34 weeks pregnancy, was dilated at 6 cm, had a history of c-sections.

2. He (MD 2) advised MD 1 to transfer patient (Patient 1) to GACH 2 because facility (GACH 1) had no OB services, no pediatric services, and no NICU services.

3. He (MD 2) was instructed that private ambulance services were called and were going to take several hours to transfer Patient 1 from GACH 1 to GACH 2.

4. He (MD 2) instructed MD 1 to call in a "crew" from GACH 2 to come to this facility (GACH 1).

5. He (MD 2) was told by facility's (GACH 1) nursing supervisor that this facility (GACH 1) cannot do a c-section.

6. He (MD 2) was frustrated with facility (GACH 1).

7. He (MD 2) went to GACH 1 to possibly deliver Patient 1's baby at the facility (GACH 1).

8. When he (MD 2) arrived at facility (GACH 1), he (MD 2) found out facility (GACH 1) already called 9-1-1, and the 9-1-1 ambulance was at the facility (GACH 1) to pick up Patient 1 and transport patient to GACH 2, for higher level of care.

9. Prior to Patient 1 leaving facility (GACH 1), he (MD 2) interviewed the patient (Patient 1).

10. After Patient 1 left GACH 1, he (MD 2) called GACH 2 to prepare for an emergency c-section to deliver Patient 1's baby, with a NICU team ready at the receiving facility (GACH 2).

During an interview on 12/12/2023 at 10:32 a.m. with the Chief Nursing Officer (CNO), the CNO stated the following:

1. She (CNO) received a call from the facility's house supervisor at 3:30 a.m., on 12/5/2023, that Patient 1 was in the ED and needed to get transferred to GACH 2 and the ambulance services were delayed and could not transfer Patient 1 to GACH 2, after Patient 1 arrived in ED, around midnight.

2. She (CNO) told house supervisor to call 9-1-1 to transfer Patient 1 to GACH 2 (which is the receiving facility for higher level of care).

3. Patient 1 was in preterm labor, was seen by Emergency Department Physician (MD 1), who consulted with Obstetrician (MD 2) on-call.

4. MD 2 wanted Patient 1 transferred to GACH 2.

5. Patient 1 was 5 cm dilated, had a history of previous c-sections, and no prenatal care.

6. She (CNO) was not aware of MD 2's recommendation to bring in a "crew" from GACH 2 to deliver Patient 1's infant for c-section.

7. She (CNO) was informed that Patient 1was transferred to GACH 2, after facility (GACH 1) called 9-1-1.

8. Patient 1 did not have an emergency medical condition and was stable for transfer to GACH 2, per MD 1.

9. Facility had been having difficulties getting a private ambulance service to transfer patients right away.

During an interview on 12/12/2023 at 11:22 a.m. with the house supervisor (Hse. Sup), Hse. Sup stated the following:

1. She (Hse. Sup) was working on 12/4/2023 as the night shift house supervisor for GACH 1.

2. Patient 1 was in the ED and needed to be transferred to GACH 2.

3. She (Hse. Sup) was informed of Patient 1's condition from ED charge nurse, who told her (Hse. Sup) Patient 1 needed to be transferred to GACH 2.

4. Two private ambulance companies were called and could not transfer Patient 1 until 3:30 a.m. and 7:30 a.m., respectively, on 12/5/2023.

5. ED was monitoring Patient 1, until private ambulance arrives.

6. She (Hse. Sup) was informed that Patient 1 had a change-of-condition (COC), and that Obstetrician (MD 2) was notified.

7. MD 2 wanted to do a c-section for Patient 1 at GACH 1.

8. She (Hse. Sup) spoke with ED Physician (MD 1) and MD 2, regarding Patient 1's COC - water bag broke and was in active labor.

9. She (Hse. Sup) was not aware that MD 2 wanted to do a c-section at the facility (GACH 1) for Patient 1.

10. She (Hse. Sup) stated she knew facility does not do c-sections anymore, per CNO.

11. She (Hse. Sup) stated she did not know MD 2 requested for a GACH 2 team to come to GACH 1, to do an emergency c-section for Patient 1.

12. She (Hse. Sup) called 9-1-1, after speaking with CNO and informing her of Patient 1's change of condition, with ruptured membranes, premature labor, and history of previous c-sections.

13. She (Hse. Sup) saw MD 1 and MD 2 later, in the ED at GACH 1.

During an interview on 12/12/2023 at 1:57 p.m., with the ED Director (EDD), the EDD stated the following regarding Patient 1's ED visit from 12/4/2023 to 12/5/2023:

1. GACH 1 does not have Obstetric (OB - the branch of medicine and surgery concerned with childbirth and the care of women giving birth) services anymore.

2. OB patients that come to the ED get an initial examination by a provider who checks the labor, contractions, ruptured membranes, amniotic fluids, fetal heart tones, ultrasound, history of patient, number of pregnancies, history of deliveries.

3. The contraindications for labor included history of previous c-sections and placenta previa.

4. Women who come to the ED with above mentioned contraindications for labor must be transferred to another facility for higher level of care.

5. OB patients with a history of c-sections can be offered a trial of labor after c-sections, only at a medical center with medical services that offer 24- hour neonatal intensive care units (NICU) services, surgical services, anesthesia services, OB services, blood bank due to the potential risks to the mother and fetus.

6. During maternal patient transports to another facility, facility sends an ED nurse to accompany the patient to the receiving facility.

7. Patient 1 was a high-risk OB patient with no prenatal care and history of previous c-sections.

8. This facility (GACH 1) has no surgical services and no on-site anesthesia services.

9. After Patient 1's membranes were ruptured on 12/5/2023, at 3:15 a.m., Patient 1 was already in active labor and facility planned to transfer her to another facility (GACH 2) right away, to attend to her urgent needs.

10. Calling 9-1-1 was the only option to get Patient 1 to another facility (GACH 2) for a higher level of care.

11. Getting a team from GACH 2 to deliver Patient 1's fetus, at this facility (GACH 1) was not realistic.

12. After Patient 1's membranes were ruptured there was an emergent condition, with high risk to both mother and fetus.

13. If Patient 1 were to deliver in the transport ambulance, with her (Patient 1) history of no prenatal care and history of previous c-sections, Patient 1 would have the risk of post-partum hemorrhage (excessive bleeding after childbirth) and/or uterine rupture (a rare but life-threatening event which requires immediate treatment, when the uterine wall tears open, especially in women who try a vaginal delivery, after having had a c-section).

14. Patient 1 probably should have been re-triaged sooner, rather than later, and transferred to GACH 2, prior to her membranes rupturing at 3:15 a.m., while waiting for private ambulance companies to transport her.

A review of facility's OB Patient Presenting in the ED policy, dated 12/2023, indicated the following:

1. The following cases will be triaged as urgent, and transfer arrangements made to send patient to the OB unit at GACH 2, and OB/GYN consultant will be contacted for evaluation for conditions, including: decreased fetal movement, bleeding, leakage of amniotic fluid, high blood pressure, premature labor, active labor, lower abdominal pain with pelvic pressure/abdominal cramping.

2. ED physician will request OB consultant for any illness/problem involving a pregnant or possible pregnant woman.

3. Fetal heart tones (FHT - pulse rate of fetus) will be obtained by the ED nurse or provider and will be documented.

A review of facility's Emergency Medical and Active Labor Act (EMTALA) policy, dated 12/2023, indicated:

1. Emergency Medical Condition (EMC - a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances and/or symptoms of substance abuse), such that the absence of immediate medical attention could reasonably be expected to result in either placing the health of the individual, including a pregnant woman, the health of the woman or her unborn fetus) in serious jeopardy.

2. With respect to a pregnant woman who is having contractions, there is inadequate time to affect a safe transfer to another hospital before delivery or that the transfer may pose a threat to the health or safety of the woman or her unborn fetus.

3. Labor means the process of childbirth, beginning with the latent or early phase, and continuing through the delivery of the placenta.

4. To stabilize means, with respect to an EMC, that the individual is provided with medical treatment that is necessary to assure that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from the hospital.

5. With respect to a pregnant woman who is having contractions and who cannot be transferred before delivery without threat to the health or safety of the woman or the unborn fetus, that the woman has delivered the child and placenta.

6. Stable for discharge means the physician has determined, withing reasonable clinical confidence, that the patient has reached the point where continued medical treatment, including diagnostic work-up or treatment, could reasonably be performed as an outpatient or later as an inpatient, if the patient is given a plan for appropriate follow-up care with discharge instructions.

7. Stable for transfer between medical facilities means the physician determines within reasonable clinical confidence, that the patient will sustain no material deterioration in medical condition, because of the transfer, and that the receiving facility has the capability to manage the EMC and any reasonably foreseeable complication.

8. Transfer means the movement, including discharge, of a patient outside the hospital ' s facilities, at the direction of any person employed or associated, directly or indirectly, with the hospital.

9. Within the capability of the hospital means those services which the hospital is required to have a condition of its license, as well as hospital ancillary services routinely available to the emergency department (ED).

10. A medical screening examination (MSE) will be provided by a qualified medical person to any individual who comes to the hospital and seeks an examination of medical treatment to determine if the individual has an EMC, whether eligible for insurance benefits and regardless of ability to pay.

11. If it is determined that the individual has an EMC, medical examination and treatment will be provided, as required to stabilize the EMC, within the capability of the hospital, or to arrange for transfer of the individual to another medical facility, in accordance with the procedures set forth.

12. The provision of MSE, stabilizing treatment, or appropriate transfer will not be delayed to inquire about the individual ' s method of payment or insurance status.

13. The hospital will provide emergency services and care without regard to an individual's preexisting medical condition, insurance status or ability to pay for medical services.

14. Policy applies to all individuals in any ambulance subject to the policies and procedures of the local EMS authority that is on the hospital property, even if instructed not to come to the hospital.

15. Within the capability of the ED, the MSE shall determine within reasonable medical probability, whether an EMC exists. The MSE shall be performed by a physician or by a qualified medical person and must be documented.

16. After an initial MSE, the physician determines that the individual requires the services of an on-call physician, the on-call physician shall be contacted.

17. The hospital may transfer an individual with no EMC to another facility for non-medical reason. Before transferring the individual, the hospital shall the individual for a preferred contact person to be notified of the transfer and contact the individual and alert the individual about the proposed transfer.

18. When it is determined that the individual has an EMC, the hospital shall, within the capability of the staff and facilities available, stabilize the individual to the point where the individual is either stable for discharge or stable for transfer.

19. The facility shall provide for an appropriate transfer of the unstabilized individual to another medical facility.

20. The facility shall provide an appropriate transfer of the unstabilized individual to another medical facility, only pursuant to patient request, or when a physician in consultation with a physician, certifies that the expected benefits to the patient from the transfer outweigh the risks of transfer.

21. The transfer from this facility to a receiving medical facility of an individual with an unstabilized EMC shall be carried out, within the facility's capabilities, provide medical treatment, which minimizes the risks to the individual's health, and the in the case of a woman who is having contractions, the health of the woman and the unborn fetus.

Based on interview and record review, the facility failed to ensure one of twenty sampled patients' (Patient 1) emergency medical condition (EMC - an illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm) was stabilized prior to transferring patient (Patient 1) to another facility (GACH 2), for higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates).

This deficient practice had the potential for Patient 1 to give birth, during transport to another facility, to a premature infant (a baby born too early), with the possibility of Patient 1 suffering hemorrhage (excessive bleeding) from uterine rupture (a serious complication where the uterus tears or breaks open).


Findings:

During a concurrent interview and record review on 12/11/2023 at 3:39 p.m. with the Quality Review Nurse (QR), Patient 1's face sheet, dated 12/5/2023, was reviewed. The QR stated Patient 1 was admitted to the hospital (GACH 1), at 4:06 a.m., with Ruptured of Membranes (ROM - when the membranes surrounding the fetus [unborn baby] spontaneously rupture prior to 37 weeks of pregnancy resulting in leakage of amniotic fluid [fluid that surrounds the fetus during pregnancy]).

Concurrently, during record review of Patient 1's Triage (to categorize patient based on the severity of their condition and the order in which they require care and monitoring) notes, dated 12/4/2023, QR stated the following:

1. Patient 1 arrived at facility's (GACH 1) emergency department (ED- responsible for the provision of medical care for patients arriving in the hospital in need of immediate care) as a walk-in via family vehicle.

2. Patient 1 complained of having contractions (tightening and relaxing of the uterine muscles during labor to push the unborn baby out of the uterus [female reproductive organ where the baby grows]) that increased after having been discharged from another facility (general acute care hospital - GACH 2) earlier, on 12/4/2023, prior to arrival at GACH 1.

3. Patient 1 stated she (Patient 1) was discharged from GACH 2 earlier because she (Patient 1) was told she (Patient 1) was not in labor (a series of continuous and progressive contractions that allows the fetus [unborn baby] to move through the birth canal) while she was at GACH 2.

4. Patient 1 stated she (Patient 1) had no prenatal care (medical care received during pregnancy).

5. Patient 1 stated she (Patient 1) was told from GACH 2, that fetus (unborn baby) was 34 weeks.

6. Patient 1 complained of pain 8/10 on arrival at GACH 1.

7. Patient 1 reported she (Patient 1) had a history of three previous cesarean sections (c-section - surgical operation for delivering a child by cutting through the wall of the mother's abdomen).

Concurrently, during record review of Patient 1 ' s ED physician note, dated 12/5/2023, QR stated the following:

1. History of present illness indicated patient was pregnant for fifth time with three previous cesarean sections and one spontaneous miscarriage, and patient (Patient 1) complained of cramping pain every five minutes.

2. After initial examination, there was a concern for preterm labor (labor that starts before 37 weeks of pregnancy).

3. Obstetrician (OB - physician or surgeon qualified to provide medical care during pregnancy, labor and birth, after the birth) was consulted and recommended that patient (Patient 1) be transferred to GACH 2 for further care and evaluation in their labor and delivery unit (L&D unit- a unit that specializes in childbirth).

4. At 3:15 a.m., patient's (Patient 1) bag of waters broke, and patient (Patient 1) was re-examined and found to be dilated at 5 cm (centimeters, a unit of measurement).

5. At 3:38 a.m., an attempt was made to call GACH 2 for a neonatal intensive care unit (NICU - a specialty unit where babies get around-the-clock care from a team of experts) nurse to come to this facility (GACH 1).

6. Spoke with facility's house supervisor and chief nursing officer and informed that facility does not have any neonatal services and instructed to call 9-1-1 to transfer patient (Patient 1) to GACH 2.

7. At 3:40 a.m., OB was notified of patient's (Patient 1) progression with labor and stated he (OB) would come to the facility (GACH 1) to do a c-section for the patient (Patient 1).

8. At 3:45 a.m., patient's (Patient 1) fetus' heart rate was 136 beats-per-minute (normal fetal heart rate is 120-160).

9. At 3:47 a.m., 9-1-1 ambulance arrived.

10. At 3:50 a.m., OB arrived at facility and accompanied patient to receiving hospital (GACH 2).

11. Impression - patient was in stable condition for transfer to GACH 2.

During a concurrent interview and record review on 12/11/2023 at 4:00 p.m. with the Chief Nursing Officer (CNO) and the Director of Nursing (DON), Patient 1's ED visit record, dated 12/5/2023, was reviewed. The CNO said facility (GACH 1) had contracts with private ambulance companies, and facility (GACH 1) contacted two ambulance companies to transfer Patient 1 to GACH 2 for higher level of care. CNO stated facility (GACH 1) had been having difficulty with getting private ambulance services to come right-away. CNO stated the first ambulance company was called, shortly after Patient 1 arrived at the facility (GACH 1) and could not come until 3:30 a.m. CNO said the second ambulance company was called and could not come until 7:30 a.m. CNO stated after Patient 1's condition changed and was in active labor, after her (Patient 1) water broke, facility (GACH 1) called 9-1-1 to transport Patient 1 to GACH 2.

During an interview on 12/12/2023, at 8:29 a.m., with ED physician (MD 1), MD 1 stated the following:

1. ED triage nurse told her (MD 1) that Patient 1 came from another facility (GACH 2), had no prenatal care, was complaining of abdominal pain.

2. Patient 1 was examined.

3. MD 1 consulted with Obstetrician (MD 2) and MD 2 advised MD 1 to get Patient 1 back to GACH 2 for higher level of care.

4. Ambulance services were called to transport Patient 1 back to GACH 2.

5. Patient 1's labor progressed with the bag of waters breaking.

6. MD 1 consulted with MD 2, the second time.

7. MD 2 recommended that MD 1 call in a "crew" from GACH 2 to come to this facility (GACH 1), because there were no pediatric services (a specialty of medicine concerned with medical care of children from birth to young adulthood) and no NICU services at this facility (GACH 1).

8. CNO told MD 1 that this facility (GACH 1) cannot do c-section because there was no NICU services at this facility (GACH 1).

9. CNO instructed house supervisor to call 9-1-1 to transfer Patient 1 to GACH 2.

10. Patient 1 was stable prior to transfer to GACH 2.

11. MD 2 arrived at facility and accompanied Patient 1 to GACH 2, in the ambulance.

During an interview on 12/12/2023 at 9:00 a.m. with on-call Obstetrician (MD 2), MD 2 stated the following:

1. He (MD 2) received a call in the middle-of-the-night from MD 1 (ED physician) about Patient 1, who was in "hard labor" at 34 weeks pregnancy, was dilated at 6 cm, had a history of c-sections.

2. He (MD 2) advised MD 1 to transfer patient (Patient 1) to GACH 2 because facility (GACH 1) had no OB services, no pediatric services, and no NICU services.

3. He (MD 2) was instructed that private ambulance services were called and were going to take several hours to transfer Patient 1 from GACH 1 to GACH 2.

4. He (MD 2) instructed MD 1 to call in a "crew" from GACH 2 to come to this facility (GACH 1).

5. He (MD 2) was told by facility's (GACH 1) nursing supervisor that this facility (GACH 1) cannot do a c-section.

6. He (MD 2) was frustrated with facility (GACH 1).

7. He (MD 2) went to GACH 1 to possibly deliver Patient 1's baby at the facility (GACH 1).

8. When he (MD 2) arrived at facility (GACH 1), he (MD 2) found out facility (GACH 1) already called 9-1-1, and the 9-1-1 ambulance was at the facility (GACH 1) to pick up Patient 1 and transport patient to GACH 2, for higher level of care.

9. Prior to Patient 1 leaving facility (GACH 1), he (MD 2) interviewed the patient (Patient 1).

10. After Patient 1 left GACH 1, he (MD 2) called GACH 2 to prepare for an emergency c-section to deliver Patient 1's baby, with a NICU team ready at the receiving facility (GACH 2).

During an interview on 12/12/2023 at 10:32 a.m. with the Chief Nursing Officer (CNO), the CNO stated the following:

1. She (CNO) received a call from the facility's house supervisor at 3:30 a.m., on 12/5/2023, that Patient 1 was in the ED and needed to get transferred to GACH 2 and the ambulance services were delayed and could not transfer Patient 1 to GACH 2, after Patient 1 arrived in ED, around midnight.

2. She (CNO) told house supervisor to call 9-1-1 to transfer Patient 1 to GACH 2 (which is the receiving facility for higher level of care).

3. Patient 1 was in preterm labor, was seen by Emergency Department Physician (MD 1), who consulted with Obstetrician (MD 2) on-call.

4. MD 2 wanted Patient 1 transferred to GACH 2.

5. Patient 1 was 5 cm dilated, had a history of previous c-sections, and no prenatal care.

6. She (CNO) was not aware of MD 2's recommendation to bring in a "crew" from GACH 2 to deliver Patient 1's infant for c-section.

7. She (CNO) was informed that Patient 1was transferred to GACH 2, after facility (GACH 1) called 9-1-1.

8. Patient 1 did not have an emergency medical condition and was stable for transfer to GACH 2, per MD 1.

9. Facility had been having difficulties getting a private ambulance service to transfer patients right away.

During an interview on 12/12/2023 at 11:22 a.m. with the house supervisor (Hse. Sup), Hse. Sup stated the following:

1. She (Hse. Sup) was working on 12/4/2023 as the night shift house supervisor for GACH 1.

2. Patient 1 was in the ED and needed to be transferred to GACH 2.

3. She (Hse. Sup) was informed of Patient 1's condition from ED charge nurse, who told her (Hse. Sup) Patient 1 needed to be transferred to GACH 2.

4. Two private ambulance companies were called and could not transfer Patient 1 until 3:30 a.m. and 7:30 a.m., respectively, on 12/5/2023.

5. ED was monitoring Patient 1, until private ambulance arrives.

6. She (Hse. Sup) was informed that Patient 1 had a change-of-condition (COC), and that Obstetrician (MD 2) was notified.

7. MD 2 wanted to do a c-section for Patient 1 at GACH 1.

8. She (Hse. Sup) spoke with ED Physician (MD 1) and MD 2, regarding Patient 1's COC - water bag broke and was in active labor.

9. She (Hse. Sup) was not aware that MD 2 wanted to do a c-section at the facility (GACH 1) for Patient 1.

10. She (Hse. Sup) stated she knew facility does not do c-sections anymore, per CNO.

11. She (Hse. Sup) stated she did not know MD 2 requested for a GACH 2 team to come to GACH 1, to do an emergency c-section for Patient 1.

12. She (Hse. Sup) called 9-1-1, after speaking with CNO and informing her of Patient 1's change of condition, with ruptured membranes, premature labor, and history of previous c-sections.

13. She (Hse. Sup) saw MD 1 and MD 2 later, in the ED at GACH 1.

During an interview on 12/12/2023 at 1:57 p.m., with the ED Director (EDD), the EDD stated the following regarding Patient 1's ED visit from 12/4/2023 to 12/5/2023:

1. GACH 1 does not have Obstetric (OB - the branch of medicine and surgery concerned with childbirth and the care of women giving birth) services anymore.

2. OB patients that come to the ED get an initial examination by a provider who checks the labor, contractions, ruptured membranes, amniotic fluids, fetal heart tones, ultrasound, history of patient, number of pregnancies, history of deliveries.

3. The contraindications for labor included history of previous c-sections and placenta previa.

4. Women who come to the ED with above mentioned contraindications for labor must be transferred to another facility for higher level of care.

5. OB patients with a history of c-sections can be offered a trial of labor after c-sections, only at a medical center with medical services that offer 24- hour neonatal intensive care units (NICU) services, surgical services, anesthesia services, OB services, blood bank due to the potential risks to the mother and fetus.

6. During maternal patient transports to another facility, facility sends an ED nurse to accompany the patient to the receiving facility.

7. Patient 1 was a high-risk OB patient with no prenatal care and history of previous c-sections.

8. This facility (GACH 1) has no surgical services and no on-site anesthesia services.

9. After Patient 1's membranes were ruptured on 12/5/2023, at 3:15 a.m., Patient 1 was already in active labor and facility planned to transfer her to another facility (GACH 2) right away, to attend to her urgent needs.

10. Calling 9-1-1 was the only option to get Patient 1 to another facility (GACH 2) for a higher level of care.

11. Getting a team from GACH 2 to deliver Patient 1's fetus, at this facility (GACH 1) was not realistic.

12. After Patient 1's membranes were ruptured there was an emergent condition, with high risk to both mother and fetus.

13. If Patient 1 were to deliver in the transport ambulance, with her (Patient 1) history of no prenatal care and history of previous c-sections, Patient 1 would have the risk of post-partum hemorrhage (excessive bleeding after childbirth) and/or uterine rupture (a rare but life-threatening event which requires immediate treatment, when the uterine wall tears open, especially in women who try a vaginal delivery, after having had a c-section).

14. Patient 1 probably should have been re-triaged sooner, rather than later, and transferred to GACH 2, prior to her membranes rupturing at 3:15 a.m., while waiting for private ambulance companies to transport her.

A review of facility's OB Patient Presenting in the ED policy, dated 12/2023, indicated the following:

1. The following cases will be triaged as urgent, and transfer arrangements made to send patient to the OB unit at GACH 2, and OB/GYN consultant will be contacted for evaluation for conditions, including: decreased fetal movement, bleeding, leakage of amniotic fluid, high blood pressure, premature labor, active labor, lower abdominal pain with pelvic pressure/abdominal cramping.

2. ED physician will request OB consultant for any illness/problem involving a pregnant or possible pregnant woman.

3. Fetal heart tones (FHT - pulse rate of fetus) will be obtained by the ED nurse or provider and will be documented.

A review of facility's Emergency Medical and Active Labor Act (EMTALA) policy, dated 12/2023, indicated:

1. Emergency Medical Condition (EMC - a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances and/or symptoms of substance abuse), such that the absence of immediate medical attention could reasonably be expected to result in either placing the health of the individual, including a pregnant woman, the health of the woman or her unborn fetus) in serious jeopardy.

2. With respect to a pregnant woman who is having contractions, there is inadequate time to affect a safe transfer to another hospital before delivery or that the transfer may pose a threat to the health or safety of the woman or her unborn fetus.

3. Labor means the process of childbirth, beginning with the latent or early phase, and continuing through the delivery of the placenta.

4. To stabilize means, with respect to an EMC, that the individual is provided with medical treatment that is necessary to assure that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from the hospital.

5. With respect to a pregnant woman who is having contractions and who cannot be transferred before delivery without threat to the health or safety of the woman or the unborn fetus, that the woman has delivered the child and placenta.

6. Stable for discharge means the physician has determined, withing reasonable clinical confidence, that the patient has reached the point where continued medical treatment, including diagnostic work-up or treatment, could reasonably be performed as an outpatient or later as an inpatient, if the patient is given a plan for appropriate follow-up care with discharge instructions.

7. Stable for transfer between medical facilities means the physician determines within reasonable clinical confidence, that the patient will sustain no material deterioration in medical condition, because of the transfer, and that the receiving facility has the capability to manage the EMC and any reasonably foreseeable complication.

8. Transfer means the movement, including discharge, of a patient outside the hospital ' s facilities, at the direction of any person employed or associated, directly or indirectly, with the hospital.

9. Within the capability of the hospital means those services which the hospital is required to have a condition of its license, as well as hospital ancillary services routinely available to the emergency department (ED).

10. A medical screening examination (MSE) will be provided by a qualified medical person to any individual who comes to the hospital and seeks an examination of medical treatment to determine if the individual has an EMC, whether eligible for insurance benefits and regardless of ability to pay.

11. If it is determined that the individual has an EMC, medical examination and treatment will be provided, as required to stabilize the EMC, within the capability of the hospital, or to arrange for transfer of the individual to another medical facility, in accordance with the procedures set forth.

12. The provision of MSE, stabilizing treatment, or appropriate transfer will not be delayed to inquire about the individual ' s method of payment or insurance status.

13. The hospital will provide emergency services and care without regard to an individual's preexisting medical condition, insurance status or ability to pay for medical services.

14. Policy applies to all individuals in any ambulance subject to the policies and procedures of the local EMS authority that is on the hospital property, even if instructed not to come to the hospital.

15. Within the capability of the ED, the MSE shall determine within reasonable medical probability, whether an EMC exists. The MSE shall be performed by a physician or by a qualified medical person and must be documented.

16. After an initial MSE, the physician determines that the individual requires the services of an on-call physician, the on-call physician shall be contacted.

17. The hospital may transfer an individual with no EMC to another facility for non-medical reason. Before transferring the individual, the hospital shall the individual for a preferred contact person to be notified of the transfer and contact the individual and alert the individual about the proposed transfer.

18. When it is determined that the individual has an EMC, the hospital shall, within the capability of the staff and facilities available, stabilize the individual to the point where the individual is either stable for discharge or stable for transfer.

19. The facility shall provide for an appropriate transfer of the unstabilized individual to another medical facility.

20. The facility shall provide an appropriate transfer of the unstabilized individual to another medical facility, only pursuant to patient request, or when a physician in consultation with a physician, certifies that the expected benefits to the patient from the transfer outweigh the risks of transfer.

21. The transfer from this facility to a receiving medical facility of an individual with an unstabilized EMC shall be carried out, within the facility's capabilities, provide medical treatment, which minimizes the risks to the individual's health, and the in the case of a woman who is having contractions, the health of the woman and the unborn fetus.