HospitalInspections.org

Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA when:

1. Patient (Pt) 1 arrived in the emergency department on 5/30/23 at 8:21 p.m. and was diagnosed with ruptured ectopic pregnancy (a life- threatening condition where a fertilized egg implants outside of the uterus, in this case the fallopian tube which is the slender tube connected to the uterus) on 5/31/23 at 2:06 a.m. and was not immediately transferred for a higher level of care. The Emergency Room medical doctor (MD 1) performed a medical screen exam, obtained laboratories, and confirmed an emergency medical condition existed for Pt 1 and ordered transfer to Hospital B. Transfer to Hospital B did not occur until 11:16 a.m. on 5/31/23, 9 hours after the life-threatening emergency was identified. Pt 1 arrived at Hospital B and underwent an emergency surgical procedure and suffered significant blood loss related to the delay. Cross reference to A2409.

2. Pt 6 was brought into Hospital A ED by car for abdominal pain and vaginal bleeding on 5/31/23 at 12:58 p.m. and an emergency medical condition was not identified until over 7 hours after admission to the ED. The Qualified Medical Person (QMP- a healthcare professional designated to perform a MSE) who first examined Pt 6 was a Physician Assistant with laboratory results indicating positive for pregnancy. The ED physician was not assigned to Pt 6 until 7:52 p.m. and an ultrasound was not done until 8:24 p.m., approximately 7 hours after admission to the ED. The ultrasound was indicative of an ectopic pregnancy. Cross reference to A2406.

Because of the serious potential harm related to patients in Hospital A who required emergency transfer for a higher level of care and the lacked of appropriate Medical Screening Exam to identify patients Emergency Medical Condition an Immediate Jeopardy (IJ) situation was called for A2406 on 8/30/23 at 2:50 p.m. and A2409 at 2:55 p.m. with the Interim Chief Executive Officer, Chief Financial Officer, Vice President of Nursing and Performance Improvement Manager. Interim Chief Executive Officer, Chief Financial Officer, Vice President of Nursing and Performance Improvement Manager were provided the IJ template which documented the immediate actions necessary to address the IJ situation. The IJ remained in place and the exit conference occurred Interim Chief Executive Officer, Chief Financial Officer, Vice President of Nursing and Performance Improvement Manager on 8/31/23 at 3:15 p.m.

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Based on interview, policy review and record review, Hospital A failed to provide an appropriate Medical Screening Exam for one of 20 patients, Patient (Pt) 6, when Pt 6 was brought to Hospital A ED by car for abdominal pain and vaginal bleeding on 5/31/23 at 12:58 p.m. and was not provided with an appropriate medical screening examination (MSE) 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 existed until over 7 hours after presentation to the ED. The Qualified Medical Person (QMP- a healthcare professional designated by the hospital's governing body to perform an MSE) who first examined Pt 6 was Physician Assistant (PA) 1 on 5/31/23 at 1:55 p.m. Laboratory results indicated positive for pregnancy. There was not documentation that PA 1 took any action on the basis of the positive pregnancy test, and an ED physician was not assigned to Pt 6 until 7:52 p.m. An ultrasound done at 8:24 p.m., approximately 7 hours after arrival to the ED, was indicative of ruptured ectopic pregnancy requiring transfer to a facility with the capability to stabilize the identified emergency medical condition (EMC).

This failure resulted in a delay in identifying the EMC as a ruptured ectopic pregnancy and could have resulted in serious harm. Pt 6 was transferred to Hospital C on 5/31/23 at approximately 10:52 p.m. for the appropriate stabilization of the ectopic pregnancy.

Because of the serious potential harm related to patients in Hospital A who required emergency transfer and an appropriate Medical Screening Exam to identify Emergency Medical Condition, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called for A2406 on 8/30/23 at 2:50 p.m. and A2409 at 2:55 p.m. with the Interim Chief Executive Officer, Chief Financial Officer, Vice President of Nursing and Performance Improvement Manager. The IJ template was provided to the facility. The IJ remained in place and the exit conference occurred with the Interim Chief Executive Officer, Chief Financial Officer, Vice President of Nursing and Performance Improvement Manager on 8/30/23 at 3:15 p.m. The hospital submitted an acceptable IJ Plan of Correction (Version 2) on 9/26/23. On 9/27/23 the components of the IJ Plan of Correction were validated onsite through observations, interviews, and record review. The IJ was removed on 9/27/23 at 5:30 p.m. with the facility Manager of Performance Improvement.

Findings include:

During a review of Pt 6's "Facesheet," dated 5/31/23, the "Facesheet" indicated Pt 6 was a 33-year-old female who arrived in the hospital emergency department on 5/31/23 at 12:58 p.m.

During a review of Pt 6's "History and Physical (H&P)," dated 5/31/2023 at 9:25 p.m., the "H&P" indicated, "The patient [Pt 6] was a 33-year-old female with a complaint of abdominal pain. The patient stated she has been having abdominal pain for the past two days, but today her symptoms worsened. She believes that she has diverticulitis as she has a history of such. However, she has been bleeding for the past 16 days. She stated her last menstrual period was 4/15/23. This afternoon she had worsening symptoms. She denies any fevers or chills ... The patient was admitted to the emergency department. Labs were ordered ..."

During a review Pt 6's "Orders," dated 5/31/23, the "Orders" indicated, PA 1 ordered Human Chorionic Gonadotropin Serum testing (hCG- a hormone produced in the body during pregnancy) at 1:25 p.m. MD 4 ordered an obstetrical ultasound at approximately 1953 (7:53 p.m.) (an obstetrical ultrasound is medical equipment that produces images within the body which could provide valuable information for diagnosis and direct treatment).

During a review of Pt 6's "EDM Patient Record," 5/31/23, the "EDM Patient Record" indicated, "Patient Notes ... [PA 1] On 5/31/23 - 1:26 p.m. Initial MSE started at the time of triage... Appropriate orders placed and patient is to be further evaluated by ED physician ... 1:55 p.m. HCG Serum Positive ..."

During an interview on 7/7/23 at 10:04 a.m. with the Manager of Performance Improvement (MPI), The MPI stated the ED protocol was for patients to be seen and assessed by the physician within 20 minutes upon arrival in the ED.

During a concurrent interview and record review, on 7/12/23 at 12 p.m. with Physician Assistant (PA), Pt 6's "Electronic Health Record" dated 5/31/23 was reviewed. The EHR indicated, Pt 6 came to the ED for abdominal pain and vaginal bleeding on 5/31/23 at 12:58 p.m. The PA stated the process in the ED was for patients to sign in at the front desk, and the triage (the initial assessment of patients to determine the urgency of their need for treatment, and the treatment required) nurse would see the patient. The PA stated, "that triage would not order diagnostic imaging because we do not follow the patient in the ED." The PA stated after triage the patient would be placed in an ED room, and the physician would do a patient assessment and orders for imaging. The PA stated he initiated the MSE for Pt 6. The PA stated Pt 6 came in for abdominal pain and vaginal bleeding with a history of diverticulitis (inflammation of the intestines). The PA stated, "I did an abdominal pain work up," and Pt 6 was triaged at 1:25 p.m. and her MSE started at 1:26 p.m. The PA stated the hCG was positive, "but it was not a critical value" so the laboratory did not call to report Pt 6 was pregnant. The PA stated, "Pt 6 did not say she was pregnant." The PA stated "I rarely had time to review lab result[s] for patient[s] waiting in the lobby because I was busy with other patients." The PA stated Pt 6 was sent back to the lobby waiting area. The PA stated the next documented medical intervention for Pt 6 was when MD 4 saw her at 7:52 p.m. The PA stated "I did not know if the facility had time frames when the MD would see the patient after the PA assessment." The PA stated, "it would depend on the situation; some MDs are fast, and some are not."

During a review of Pt 6's "Emergency Physician Record (EPR)," dated 5/31/23 at 7:46 p.m., Pt 6's "EPR" indicated Pt 6 was assessed by MD 4 for left lower quadrant abdominal pain. MD 4 ordered an ultrasound for findings that were concerning for ectopic pregnancy.

MD 4 was not interviewed as they have been out of the country during the review.

During a concurrent interview and record review, on 7/10/23 at 10:05 a.m. with Medical Doctor (MD) 1, Pt 6's "Emergency Department and Medical Decision Making (EDMDM)," dated 5/31/23, the "EDMDM" indicated, "This is a 33 YO [year old] female initially seen, examined, worked up, and treated by [MD 4] and signed out to me [MD 1] at 9 p.m. She presented with LLQ [left lower quadrant] abdominal pain for 2 days. She had vaginal bleeding for 16 days ... She was found to be pregnant and OBUS [obstetric ultrasound] has been ordered and is pending ... The patient requested [Hospital C] for transfer. I spoke with OB [obstetrician]/GYN [gynecologist] who accepted the case. He requested the patient be transferred ER [emergency room] to ER ... The patient will be transferred [emergent] ... DX [diagnosis] ... Ruptured Ectopic Pregnancy ..." MD 1 stated, "Pt 6 had an emergent transfer to hospital C because I consulted with the OB/GYN at hospital C, and made my decision based on the consultation." MD 1 stated, "a ruptured ectopic pregnancy was a pregnancy outside of the uterus, typically in the fallopian tube and considered a medical emergency and required emergent surgery." MD 1 stated, "an ultrasound would determine if patient had an ectopic pregnancy." MD 1 stated Pt 6 "had definitive ultrasound result for ectopic pregnancy and if ruptured it would have been life threatening" for Pt 6.

During a review of Pt 6's "Final Radiology Report (FRR)," dated 5/31/23 at 10:07 p.m., the "FRR" indicated, " ... US [ultrasound] Duplex Artery or Vein of the Abdominal and/or Reproductive Organs, Limited Ovaries. Exam date and time: 5/31/23 8:24 PM ...Clinical indication: Pregnancy complicated by abdominal or pelvic pain; Left lower quadrant; First trimester (< [less than] 14 weeks 0 days); Gestational age (the period of time between conception and birth) ... 6 weeks 4 days ...Left ovary ... appears to demonstrate a yolk sac ... Intraperitoneal space: Hemorrhagic free fluid is noted within the pelvis, moderate in volume ... Impression: Findings are concerning for ectopic pregnancy in the left adnexal [ovaries] region ..."

During a review of Pt 6's "Discharge Summary (DS)," dated 5/3/1/23, the "DS" indicated, PA 1 initial evaluation was performed at 1:25 p.m. and the MD evaluation was performed at 7:52 p.m.

During a review of Pt 6's "Prehospital Care Report (PCR)," [in this case, pertaining to the ambulance transfer between Hospital A and Hospital C], dated 5/31/23, the "PCR" indicated, "...Arrived at Patient Time 10:55 p.m. Unit Left Scene Time 11:03 p.m. Patient Arrived at Destination 11:16 p.m. ... Responded to an interfacility Transport per EMD [Emergency Medical Dispatch] dispatch ... for a 33 years [years old] patient ... Patient's chief complaint was 'Ab [abdominal] pain ... Pt found to have ruptured ectopic pregnancy in the left fallopian tube with bleeding present. Pt transfer to [Hospital C] for a higher level of care and surgical interventions ..."

During a review of the "Emergency Department Manual (EDM)," undated, the EDM indicated, "Medical Screening Examination. Policy Statement. A medical screening examination will be offered to any individual who comes to the emergency department. The medical screening examination must be provided within the capability of the dedicated emergency department, including ancillary services routinely available to the dedicated emergency departments (including the availability of on call physicians). The medical screening examination must be the same appropriate examination that the Hospital would perform on any individual with similar signs and symptoms... Scope. The scope of the medical screening examination must be tailored to the presenting complaint and the medical history of the individual. The process may range from a simple examination (such as a brief history and physical) to a complex examination that may include ... diagnostic imaging ...Continuous monitoring. The medical screening examination is a continuous process reflecting ongoing monitoring in accordance with an individual's' needs. Monitoring will continue until the individuals stabilized or appropriately transferred. Revaluation of the individual must occur prior to discharge or transfer ..."

During a concurrent interview and record review on 7/7/23 at 10:04 a.m. with Charge Nurse (CN) 1, Patient 1's (comparator patient) "Patient Record (PR)", dated 5/30/23, the PR indicated, Patient 1 arrived in the ED at 8:21 p.m., was triaged at 8:49 p.m., with a chief complaint (the patient's reason for visiting the ED) of right-side abdominal pain and heavy bleeding for 3 weeks. The PR indicated, MD 1 placed orders at 9:29 p.m. (1 hour 8 minutes after arrival).

Review of the medical record for Patient 6 revealed she had Medicaid insurance. Review of the medical record for Patient 1 (comparator patient) revealed she had commercial insurance.

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Based on interview and record review, Hospital A failed to provide an appropriate transfer for one of twenty sampled patients (Patient 1), when Patient (Pt) 1 arrived in the emergency department (ED) on 5/30/23 at 8:21 p.m. and was diagnosed with ruptured ectopic pregnancy (a life- threatening condition where a fertilized egg implants outside of the uterus, in this case the fallopian tube which is the slender tube connected to the uterus) on 5/31/23 at approximately 2:06 a.m. and was not transferred appropriately to a facility with the capability to stabilize the identified emergency medical condition (EMC). The medical doctor (MD 1) performed a medical screening exam, obtained laboratory and ultrasound tests, and confirmed an emergency medical condition existed for Pt 1 and ordered transfer to Hospital B. Transfer to Hospital B did not occur until 11:16 a.m. on 5/31/23, 9 hours after the life-threatening emergency was identified. Pt 1 arrived at Hospital B and underwent an emergency surgical procedure and suffered significant blood loss related to the delay.

This failure resulted in a nine-hour delay in transferring Pt 1 to Hospital B and resulted in or was likely to result in Pt 1 experiencing serious harm at the time of surgery on 5/31/23, when she was found to have a large amount of dark brown blood and clots in the pelvic cavity and significant blood loss requiring transfusion.

Because of the serious potential harm related to patients in Hospital A who required emergency transfer and an appropriate Medical Screening Exam to identify Emergency Medical Condition, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called for A2406 on 8/30/23 at 2:50 p.m. and A2409 at 2:55 p.m. with the Interim Chief Executive Officer, Chief Financial Officer, Vice President of Nursing and Performance Improvement Manager. The IJ template was provided to the facility. The IJ remained in place and the exit conference occurred with the Interim Chief Executive Officer, Chief Financial Officer, Vice President of Nursing and Performance Improvement Manager on 8/30/23 at 3:15 p.m. The hospital submitted an acceptable IJ Plan of Correction (Version 2) on 9/26/23. On 9/27/23 the components of the IJ Plan of Correction were validated onsite through observations, interviews, and record review. The IJ was removed on 9/27/23 at 5:30 p.m. with the facility Manager of Performance Improvement.

Findings include:

During a concurrent interview and record review on 7/7/23 at 10:04 a.m. with Charge Nurse (CN) 1, Patient 1's "Patient Record (PR)", dated 5/30/23, the PR indicated, Patient 1 arrived in the Emergency Department (ED) at 8:21 p.m., was triaged at 8:49 p.m., with a chief complaint (the patient's reason for visiting the ED) of right-side abdominal pain and heavy bleeding for 3 weeks. The PR indicated, MD 1 placed orders at 9:29 p.m. which included blood and urine laboratory studies, intravenous (IV-uses a type of tiny plastic tubing that goes into the vein to deliver IV fluids and/or medications) therapy, urinalysis, and hCG (Human chorionic gonadotropin- a hormone secreted during pregnancy), Qualitative Urine test (detects whether the hCG hormone was in urine, which would be considered a positive sign of pregnancy). MD 1 ordered additional orders at 10:02 p.m. including hCG, Serum (measures hCG in blood), and at 10:15 p.m. an OB (Obstetrics- care throughout pregnancy) Ultrasound (US-a procedure that uses high-energy sound waves to look at tissues and organs inside the body), hydromorphone (an opioid drug used to treat moderate to severe pain), normal saline (NS-a solution of electrolytes), and IV ondansetron (a drug used to treat nausea). At 11:11 p.m. hCG, Quantitative (measures the specific level of hCG in the blood) and at 11:22 p.m. cardiac monitoring (a device use to monitor the heart) and pulse oximetry (a device used to measure the oxygen level in blood).

During a review of Patient 1's "Emergency Physician Record (EPR)", dated 5/30/23 and Patient 1's "ED Course and Medical Decision Making (EDC)", dated 5/31/23 were reviewed. The EPR indicated labs, pain and nausea medication, and an US were ordered. The EDC indicated, " ...Right pelvic/RLQ abdominal pain for 3 hours. She describes the pain as sometimes bloated and then with cramping and even stabbing pains that are at worst 9/10 in severity and then wane to 6/10 in severity. She states she had a heavy period starting 3 weeks ago and stopped 3 days ago when she passed a large blood clot. She denies pregnancy ...DDX [differential diagnosis]: Ruptured Ectopic Pregnancy ...Hemorrhagic Ovarian Cyst [an ovarian cyst is a sac that forms on the ovary and swells up with fluids. If the cyst bleeds it is called a hemorrhagic ovarian cyst] ...Ruptured Appendicitis [blockage in the lining of the appendix that results in infection. The bacteria multiplies causing the appendix, a small, finger-shaped pouch of the intestine tissue, to become inflamed, swollen and filled with pus causing the appendix to rupture]..."

During a review of Patient 1's "Patient Record (PR)", dated 5/30/23, the PR indicated, Patient 1's hCG Serum was positive and the hCG Quantitative resulted 2774.7 at 9:50 p.m., indicating a positive pregnancy.

During a concurrent interview and record review on 7/7/23 at 10:15 a.m. with CN 1, Patient 1's PR, dated 5/30/23 and Patient 1's "Final Radiology Report with Addendum (Report)", dated 5/31/23 were reviewed. CN1 stated, the PR indicated at 10:15 p.m. an US was ordered by MD 1. CN 1 stated the Report indicated the US was completed at 10:52 p.m. and resulted on 5/31/23 at 2:06 a.m. with verbal communication to MD 1 of US findings suggestive of ruptured ectopic pregnancy.

During a review of Patient 1's "Interfacility Transfer Summary (Summary)", dated 5/31/23, the Summary indicated at 2:02 a.m. a call was made to Hospital B to request Patient 1 be transferred for stabilization of ruptured ectopic pregnancy, and the receiving physician MD 5 accepted the transfer at 2:04 a.m. The Summary indicated the reason for the transfer was OB services were not available at Hospital A and that Patient 1 was "stable" at the time of transfer. The record reflects that Registered Nurse (RN) 4 "Called and spoke to [name of ambulance dispatcher]" at 2:12 am, and "She states the ETA is 0830." There is no further documentation of an attempt to effect the transfer more expeditiously nor identify any other available qualified personnel and transportation equipment. The Summary indicated the discharge time was 10:40 a.m. During a review of Patient 1's "Physician Certification of Risks and Benefits of Transfer (Certification)", dated 5/31/23, the Certification indicated MD 1 signed and dated the form, but no time was documented.

During a concurrent interview and record review on 7/7/23 at 2:05 p.m. with Manager of Ambulance (MOA) (ambulance is owned and operated by the facility), Patient 1's "Prehospital Care Report (Report)", dated 5/31/23 was reviewed. The Report indicated, at 2:30 a.m. there was a request for a non-emergent transfer for Patient 1 from Hospital A to hospital B. The MOA stated when they received emergent or priority calls (911 calls), they "had an obligation to respond to those calls first, whereas non emergent transfer requests took a longer time due to the availability of ambulances and if requests for transports were made after 1 a.m. and the patient was deemed stable, the patient would have to wait until 8:30 a.m. to be transferred."

A comparator patient with similar signs and symptoms and a similar EMC was identified upon record review. During a concurrent interview and record review on 7/10/23 at 9:35 a.m., with RN 2, Patient 6's "Interfacility Transfer Summary (Summary)", dated 5/31/23 was reviewed. The Summary indicated at 10:40 p.m. a call was made to Hospital C, and the receiving physician accepted the transfer at 10:44 p.m. The Summary indicated the reason for the transfer was OB services were not available to stabilize ruptured ectopic pregnancy and that Patient 6 was "stable" at the time of transfer. The Summary indicated the discharge time was 10:52 p.m. (8 minutes after transfer was accepted). RN 2 stated when she reviewed Patient 1 and Patient 6's transfer summaries, both patients had the same diagnosis, yet Patient 6 was transferred out almost immediately, whereas Patient 1's transfer was delayed for more than 8 hours.

During a concurrent interview and record review on 7/10/23 at 10:05 a.m. with Medical Doctor (MD) 1, Patient 1's "Final Radiology Report with Addendum (Report)", dated 5/31/23 was reviewed. The Report indicated, " ...on 5/31/23 2:06 AM ...THIS REPORT CONTAINS FINDINGS THAT MAY BE CRITICAL TO PATIENT CARE. The findings were verbally communicated via telephone conference with [name of MD 1] at 2:06 AM ...The findings were acknowledged and understood." The Report indicated, " ... significant amount of echogenic [referring to a brighter appearance on ultrasound] free fluid noted in the pelvis bilaterally [both sides] including anterior and posterior cul-de-sac [front between the bladder and uterus and back between the uterus and the rectum] of the abdominal cavity seen ..." MD 1 stated a ruptured ectopic pregnancy was when pregnancy was outside of the uterus, typically in the fallopian tube; if ruptured, there was leakage into the abdominal cavity and was "considered a medical emergency." MD 1 stated when she decided between "emergent" or "non-emergent" transfer for a patient, she would "first look to see if the patient's vital signs were stable and if there was a definitive diagnosis of ectopic pregnancy." MD 1 stated the ultrasound report "did not indicate a definitive diagnosis of ectopic pregnancy;" therefore she requested a "non-emergent" transfer, which would not occur until after 8:30 a.m. MD 1 stated Patient 1's vital signs were stable and if the vital signs became unstable, [she] "would request an emergent transfer."

During a record review on 7/10/23 at 10:25 a.m. with MD 1, Patient 1's "ED Course and Medical Decision Making (Progress Note)" dated 5/31/23 was reviewed. The Progress Note indicated, " ... The patient presents with RLQ [right lower quadrant]/Pelvic pain. Exam shows a VSS [vital signs stable] female in NAD [no acute distress]. ABD [abdominal] exam shows mild diffuse TTP [tender to palpation] with moderate RLQ/Pelvic TTP with guarding [to protect] and rebound [spring back] ...While in US her hCG Qual returned positive. US showed free fluid in the pelvis and visualization of the right fallopian tube suggesting ruptured ectopic pregnancy. The patient will be transferred to [Hospital B] ER [emergency room] to ER, [name of receiving physician] accepting. She is stable for transport ... Dx [diagnosis]: Ruptured Ectopic Pregnancy ..."

During a concurrent interview and record review on 7/10/23 at 10:35 a.m. with MD 1, Patient 6's (comparator patient) "ED Course and Medical Decision Making (Progress Note)" dated 5/31/23 was reviewed. The Progress Note indicated, " ...This is a 33 yo [year old] female initially seen, examined, worked up, and treated by MD 4 and signed out to me at 2100 [9 p.m.] hours. She presented with LLQ [left lower quadrant] pain for 2 days. She had vaginal bleeding for 16 days, starting as spotting then heavier. She was found to be pregnant and an OBUS [obstetrical ultrasound] has been ordered and is pending. At this time, the patient is VSS and resting comfortably on the gurney. ABD exam shows mild LLQ TTP, nondistended [not swollen] ... The patient requested [Hospital C] for transfer. I spoke with OB/GYN [name of OB/GYN] who accepted the case. He requested the patient be transferred ER to ER. I then spoke with EDP [Emergency Department Physician] [name of EDP] who accepted transfer. The patient will be transferred Code III ["emergent"] ...Dx: Acute LLQ Abdominal Pain ...Ruptured Ectopic Pregnancy ...Hemoperitoneum [internal bleeding in the space between organs and lining of abdominal wall] ..." MD 1 stated PT 6's "vital signs were stable but had an emergent transfer because she consulted with the OB/GYN at Hospital C, and [she] made [her] decision based on [her] consultation with the OB/GYN."

During an interview on 7/10/23 at 11:20 a.m. with the Chief Medical Officer (CMO), The CMO stated he had "occasionally encountered the dispatch center pushing back, and they had to fly patients out or try other ways to get the patient transferred." The CMO stated he "had occasionally encountered situations where the patient needed care quicker to the point where it was not considered emergent or non-emergent either." The CMO stated they have instituted protocol "to not tie up ambulances, but ...nighttime transfers have been an issue. "

During a review of the EMR document for Patient 1 from Hospital B titled "Operative Report" dated 5/31/23, the document indicated, " ...There was a large amount of dark brown blood, and clots in the pelvic cavity, which were evacuated [removed]. The right [Fallopian] tube was fully filled with blood, and there were a number of very large clots covering the right ovary and extending into the cul-de-sac [a space next to the uterus]. These were evacuated ...Pelvis was then irrigated [washed out] copiously. More clots were removed ...Estimated blood loss was about 400 mL [milliliters - there are 240 mL in one cup]".

During an interview on 7/11/23 at 11 a.m. with the Vice President of Administrative Services (VAS) for Hospital A, the VAS stated if an ED physician called for an emergent transfer, "there would have been no issues in getting the transport, but the transfer was requested as non-emergent; the patient must wait until 8:30 a.m. in the morning to be transferred." The VAS stated during the night they have one ambulance in [name of city] and one ambulance between [name of city] and [name of other nearby city 6 miles away]. The VAS stated "they have more staff now, but they do not have an extra ambulance to respond to non-emergent transfers at night." The VAS stated to his knowledge, "there had not been any denials for emergent transfer requests."

During an interview on 7/11/23 at 11:20 a.m. with the Emergency Department Tech (EDT- not involved with Patient 1's transfer), the EDT stated once she was notified a patient had been accepted at the receiving facility, she called [name of commercial ambulance provider] dispatch center to request transport, and "the physician would determine if the transfer request was a non-emergent or emergent." The EDT stated when she requested transport for a patient, she provided the patient's information, any treatments the patient required, monitoring, IV fluids, oxygen, and other resources to determine if an ALS (Advanced Life Support) or BLS (Basic Life Support) ambulance was required. The EDT stated once she made transfer arrangements for a patient, she documents in the patient's chart. The EDT stated emergent transfers "were for very sick patients who needed immediate transfers" and non-emergent transfers were "for patients who can wait for an hour to 8 hours for transfer." The EDT stated "if a patient was arranged for a non-emergent transfer and becomes unstable while waiting for transport, the ED physician would request an emergent transfer, and in the past, this has happened many times.

During an interview on 7/11/23 at 1 p.m. with the Manager of the Emergency Department (MED), the MED stated patients with a ruptured ectopic pregnancy "could die; they need immediate surgery; they could hemorrhage" (severe blood loss). The MED stated that her experience is that when a patient was diagnosed with possible ruptured ectopic pregnancy, the on-call surgeon would not necessarily be consulted. Instead, the patient should be transferred out to another facility with an OB who can do the surgical procedure.

During a review of the facility's policy and procedure (P&P) titled, "Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA)", dated 6/2/22, the P&P indicated, " ...The Hospital will not transfer an individual with an unstabilized emergency medical condition unless ...a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the individual from transfer ...The method of transfer will be determined by the transferring physician and based on the patient's condition ...[Hospital A] will call [Name of Ambulance Service called for Patient 1] for all transfers unless ...ETA [estimated time of arrival] is greater than 60 minutes and patient needs to transfer sooner ...The following services are not available at [Hospital A] and would require a transfer to a higher level of care: Burn Units, Trauma Center, Cardiac Cath Services, Interventional Radiology, Labor and Delivery/OB/GYN, Inpatient Psychiatric Care ..."