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Based on policy review, record review, and interview, the critical access hospital (CAH) failed to enforce policies to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 for 3 of 20 emergency department patient records (Patients #1, #2, and #3) reviewed.

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of §489.24. Failure of the CAH to enforce their Emergency Medical Treatment and Labor Act policy limited the CAH's ability to ensure safe care of patients transferred from the emergency department.

Findings include:

The CAH failed to ensure an appropriate transfer of a pregnant patient in labor; failed to ensure a physician signed a certification stating the medical benefits of transfer outweighed the risks for patients with unstabilized medical conditions; and failed to ensure staff sent the emergency department records of unstable, transferred patients to the receiving hospital. (Refer to C2409)

Based on policy review, record review, and interview, the critical access hospital (CAH) failed to ensure an appropriate transfer for three of three patients' emergency department records reviewed (Patients #1, #2, and #3) of unstabilized transfers. Failure to ensure an appropriate transfer limited the CAH's ability to ensure the safety of the patient and the unborn child; failure to ensure a physician signed or countersigned a certification that the benefits outweighed the risks of transfer limited the CAH's ability to ensure an appropriate transfer; and failure to send the patients' medical records had the potential of limiting the receiving hospital's ability to provide appropriate care.

Findings include:

Review of the undated policy "St. Aloisius Medical Center Policies and Procedures Subject: EMTALA (Emergency Medical Treatment and Labor Act)" occurred on 11/01/21. This policy stated,
". . . Procedure:
A patient seeking emergency services will be provided with an appropriate medical screening examination sufficient to determine whether he or she has an emergency medical condition, as defined by statute. . . .
If the person is determined to have an emergency medical condition, the hospital is required to stabilize the medical condition of the individual, within the staff and facilities available at the hospital, prior to discharge or transfer.
If a patient's medical condition cannot be stabilized before a transfer requested by the patient (or determined to be in the patient's best interest by the responsible medical personnel), the hospital is required to follow very specific statutory requirements designed to facilitate a safe transfer to another facility. . . ."

Review of the policy "St. Aloisius Medical Center Administrative Statement - Policies and Procedures Subject: Transport to Another Facility," revised March 2018, occurred on 11/01/21. This policy stated,
". . . Procedure:
Transfer to a Nursing Home or Tertiary Hospital:
1. Medical/Surgical and ER
1. The attending physician/midlevel provider will:
a. Make arrangements for admission to receiving hospital.
b. Explain reason for transport and time element involved to patient and family.
c. Assess the patient's condition to determine type of transport needed for the patient's condition . . . If a nurse would be needed potentially for a patient in labor . . .
5. . . . Have . . . the transferring provider sign the 'Physician Certification for Transfer'. . . .
7. Make copies of the patient's medical records as specified by the physician/midlevel provider or as pertinent to their care. . . .
B. For Another Hospital: . . .
5. Copy complete ER [emergency room] record if transferring from ER.
6. Copy transfer form. . . .
9. After the patient has left our ER, the nurse shall: . . .
b. The Transfer Checklist shall be completed and remain a part of the patient's medical record."

Review of the following records of patients transferred in unstabilized condition occurred on 11/01/21:
- Patient #1's ER visit on 10/28/21: The emergency room record stated, ". . . Emergency Room Report . . . History: The patient is a 32-year-old gravida 3, who is 36 weeks gestation. She has been having backpain and some abdominal pain every 5 to 10 minutes. . . . She has a history of fairly rapid deliveries. . . . Vaginal examination shows her to be 75% [effaced] and 2.5 cm [centimeters] dilated with the head engaged. She had some leakage of amniotic fluid while in the emergency department. I recommend that she be taken to [name of receiving hospital]. Her husband can drive her. We do not have a transfer ambulance available at this time; so, transfer by private vehicle with her husband will take place. I did contact [name of receiving hospital] and informed them that she will be coming." A form titled "Physician Certification For Transfer By Private Vehicle" stated, "I certify that I have examined the patient and based upon the information available at the time of the examination, it is my medical opinion that [name of Patient #1] (patient name) may safely be transferred by private vehicle." Physician #1 signed the form on 10/28/21 at 20:45 [8:45 p.m.]. Nurses Notes stated, ". . . Provider here at 2020 [8:20 p.m.], FHT [fetal heart tones] assessed by [initials of Physician #1] at bedside. Vaginal exam done [with] 2-3 cm dilation. [Name of Physician #1] talked to pt [patient] & [and] husband to transfer patient ASAP [as soon as possible]. Provider called [name of receiving hospital] L&D [labor and delivery] & pt. was accepted. . . . Water broke @ [at] 2040 [8:40 p.m.], [initials of Physician #1] at bedside. Contraction interval @ this time is 3-5 mins [minutes]. Transferred pt. to [name of receiving hospital] via private vehicle @ 2045 [8:45 p.m.]. - [initials of Staff #1], RN [registered nurse]." The record lacked evidence a physician signed a certification the benefits of transfer outweighed the risks and lacked evidence the CAH sent the patient's medical records to the receiving hospital.
- Patient #2's ER visit on 07/14/21: The form "[Name of Air Ambulance] Physician Certificate of Necessity for Air Transport" stated, "Pt [patient] [with] uncontrolled chest pain likely cardiac in etiology." The record lacked evidence a physician signed a certification the benefits of transfer outweighed the risks.
- Patient #3's ER visit on 10/24/21: The provider's "Emergency Room Report" stated, ". . . Physical Examination: . . . Neurological: He is unable to feel anything when we touch or try to apply pressure or a little pain from above the nipple line on down to the toes. . . . Assessment: Acute fracture involving interior inferior aspect of C5 [cervical spine vertebra #5]." The record lacked evidence a physician countersigned a certification the benefits of transfer outweighed the risks and lacked evidence the CAH sent the patient's medical records to the receiving hospital.

Reviewed on 11/01/21, a list of services, dated 11/01/21, provided by the CAH did not include obstetrical services.

Review of the following credentialing records occurred on 11/02/21:
- Provider #1 (ER provider on 10/28/21): privileges for the emergency room and emergency deliveries approved on 10/18/21.
- Provider #2 (ER provider on 07/14/21): privileges for the emergency room approved 05/18/20.
- Provider #3 (ER provider on 10/24/21): privileges for the emergency room approved 08/16/21.

During interview at 5:00 p.m. on 11/01/21, an administrative nursing staff member (Staff #2) stated the CAH had transferred two inpatients with Ambulance #1 before Patient #1 came to the ER. She said that only two rigs can be out on transfers during the same timeframe. A third ambulance is to remain in town.

During interview at 7:50 a.m. on 11/02/21, an administrative nursing staff member (Staff #2) confirmed the following:
- Records for Patient #2 and Patient #3 did not include the condition of the patient upon transfer (stable versus unstable).
- Records for Patient #1, Patient #2, and Patient #3 did not include a certification signed or countersigned by a physician that the benefits of transfer outweighed the risks.
- Records for Patient #1 and Patient #3 did not include evidence the CAH sent the patients' emergency department records to the receiving hospital.

During interview at 10:30 a.m. on 11/02/21, Physician #1 stated Patient #1 came in with back pain. He said the hospital does not have internal or external fetal monitoring available. He stated he had many years of experience in OB [obstetrics]. Fetal heart tones were good when he listened through the stethoscope. He said in retrospect he should have done things differently, but he felt the patient had plenty of time. He called the receiving hospital where the patient had received prenatal care and talked to the OB physician. There was no available ambulance from Harvey at the time of the patient's departure. He said he gave the patient's husband instructions to call 911 on the way if there were problems. Physician #1 stated the hospital discontinued obstetrical services eight to ten years ago.

During interview at 8:00 p.m. on 11/02/21, Staff #1 stated she was working the evening of 10/28/21 when Patient #1 came to the hospital with back pain. She roomed the patient, took vitals, and notified Physician #1. She stated Physician #1 performed a vaginal examination and assessed fetal heart tones. She said she and Physician #1 left the exam room. Physician #1 called [name of receiving hospital] who accepted the patient. The patient's husband notified Physician #1 that Patient #1's water had broken after they left the exam room. Physician #1 reassessed Patient #1. Staff #1 said they had just transferred two other patients. Physician #1 said Patient #1 could go by private vehicle.

During interview at 9:51 a.m. on 11/04/21, Patient #1 stated she had back cramps the afternoon of 10/28/21 and went to the hospital in Harvey. She said Physician #1 checked her and said she was dilated 2-2.5 cm. Physician #1 called [name of receiving hospital] and told her she could make it since she was at a 2. Then her water broke and Physician #1 said she had plenty of time. Her husband thought she should go by ambulance. Physician #1 said a flat out no to an ambulance transfer and said she had plenty of time to get there. Physician #1 said two ambulances were out on transfers already. Patient #1 left with her husband to go to the receiving hospital (73 miles away). By Anamoose (17 miles from Harvey), her contractions were one on top of another and her husband called the state emergency radio. Ambulance #2 was dispatched and two first responders met them in Drake (eight miles past Anamoose and 25 miles from Harvey) and escorted them to intercept with Ambulance #2. They had to pull off the highway at mile marker #130 (about 18 miles past Drake and about two miles from Ambulance #1). The two first responders helped deliver the baby in the vehicle. Ambulance #2 arrived shortly after the delivery. Patient #1 and the baby were assisted into Ambulance #2 where the ambulance staff clamped the cord and continued the transfer to the receiving hospital (about 30 miles away). Patient #1 said her first child was born at home with ambulance staff present and her third child was born in an ambulance on the way to the receiving hospital.