HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to appropriately transfer a patient requiring a higher level of care for 1 of 2 (Patient #4) sampled patients requiring a higher level of care, out of 20 total patients reviewed.

The findings included:

Medical record review revealed Patient #4 presented to the Emergency Department (ED) at Hospital #1 on 9/6/2025 at 6:12 PM as a "walk-in". The patient presented with the chief complaint of Abdominal Cramping and Lower Back Pain that began the previous night. Patient #4 is 27 weeks pregnant. The patient also reports having a fever earlier and shortness of breath.

A note written by Physician #1 on 9/6/2025 at 8:17 PM documented the patient had a past medical history of colitis (inflammation of the colon) and kidney stones. Over the past 24-48 hours, Patient #4 has developed more significant back pain. She was 27 weeks pregnant and stated the baby had been moving more and her abdomen felt more tense but it was not hurting. The patient had experienced no vaginal bleeding or leakage and her temperature had been 102 degrees Fahrenheit at the most today. The Fetal Heart Rate was 175 which was mildly elevated, had an elevated white blood cell count of 12,000 (normal value is 4000 - 11,000). The ED Physician communicated with Patient #4's obstetrician for likelihood of inpatient treatment. The Obstetrician agreed and accepted the patient and she was to be transferred to Hospital #2 to receive further treatment in Labor and Delivery due to Hospital #1 did not have these services on its campus. Patient #4 was transferred to Hospital #2 via private vehicle on 9/6/2025 at 9:32 PM.
Patient #4 did not transfer with qualified, trained personnel or equipment to address the medical condition requiring a higher level of care. There was no documentation Patient #4 signed a form of refusal for transfer by ambulance.

Cross Refer to A - 2409.

Based on policy review, medical record review and interview, the facility failed to appropriately transfer a patient requiring a higher level of care for 1 of 2 (Patient #4) sampled patients requiring a higher level of care, out of 20 total patients reviewed.

The findings included:

1. Review of Hospital #1's "EVALUATION AND TRANSFER OF PATIENTS WITH EMERGENCY MEDICAL CONDITIONS/EMTALA" policy (revised 12/24) revealed, "...If the physician, or other qualified medical personnel...determines, based on the information available at the time of transfer, that reasonably expected medical benefits of the transfer outweigh any increased risks from transfer to the patient...and the following criteria are met...The receiving facility...Has agreed to accept transfer of the individual and to provide appropriate medical treatment...Transfer is affected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer..."

2 Medical record review revealed Patient #4 presented to the Emergency Department (ED) at Hospital #1 on 9/6/2025 at 6:12 PM via "walk-in". A triage assessment beginning at 6:16 PM documented the chief complaint as abdominal cramping, back pain and patient was 27 weeks pregnant. Further triage assessment revealed "Patient to er [emergency room] c/o [complains of] abdominal cramping and lower back pain that began last night. Reports fever earlier. Also admits to sob [shortness of breath]. States she is approximately 27 weeks IUP [intra uterine pregnancy - a pregnancy where the fertilized egg implants and develops in the uterus], 4th pregnancy, states OBGYN [obstetrician/gynecologist] with [named physician] at [named Hospital #2]. Denies any vaginal bleeding. The patient's heart rate was 110 and temperature was 99.2 degrees Fahrenheit.

A Medical Screening Exam (MSE) was initiated on 9/6/2025 at 8:17 PM by Physician #1 with documentation that revealed "...female with past medical history of colitis (inflammation of the colon), nephrolithiasis (kidney stones)...currently at 27 weeks pregnant who comes in for bilateral back pain, fever and some generalized fatigue. She denies any overt urinary symptoms but states over last 24-48 hours she has developed some significant lower back pain more so bilaterally. She is currently 27 weeks pregnant and states the baby has been moving more...abdomen feels more tense but it is not hurting per se [by or in itself]...She has also felt very lightheaded and dizzy today but otherwise denies any significant actual syncopal [dizziness or passing out] episodes, nausea, chest pain, shortness of breath or other symptoms. She has had no vaginal bleeding or leakage. T-max [temperature-maximum] of 102 [degrees Fahrenheit] today".
MSE review of systems revealed positive for fatigue, fever and flank pain. MSE physical exam revealed "...Gravid abdomen [a pregnant uterus with baby growing inside] with absolutely no left lower quadrant or right lower quadrant tenderness. Bilateral flank and CVA [costovertebral angle- the area where the ribs and the spine meet at the back of the chest] tenderness. Fetal heart rate of 175..."

Physician #1's Medical decision making revealed the patient was "...coming in for evaluation for bilateral flank pain, fever, general fatigue and dizziness. She is 27 weeks pregnant. Fetal heart rate of 175 which is mildly elevated. She has a mild leukocytosis [elevated white blood cell count] of 12,000 but urine is very infected. Given her objective fever with bilateral flank pain I am concerned about possible pyelonephritis [kidney infection] and pregnancy so will reach out to her OB [Obstetrician- physician who provides care to both mother and fetus during pregnancy] to discuss likely transfer for inpatient treatment. Ceftriaxone [brand name Rocephin- antibiotic used to treat infections] will be provided. Urine culture and blood cultures will be obtained..."

Review of Physician #1's ED course revealed, "...Spoke with [named physician] her OB and he agrees for transfer accepting physician to labor and delivery at [named Hospital #2]. Discussed with the patient, she is comfortable with plan for transfer. She is adamant on having her partner drive her. I offered and encouraged ambulance transfer as being the safest, but after discussion of risks and benefits she is still refusing and would like to go personal vehicle."

Review of ED nursing note on 9/6/2025 at 9:30 PM revealed, "Patient being transferred to [named Hospital #2], patient transferring via private vehicle, see EMTALA for [form] for details..."

Review of EMTALA transfer form signed by Patient #4 dated 9/6/2025 at 9:26 PM revealed, "...Reason for Transfer...Hospital resources not available...Benefits of Transfer...Specialized services/specialist; Higher level of care...Risks of Transfer...Worsening of patients EMC [emergency medical condition] or death en route; Additional pain/trauma to existing injuries...Transport Mode...Private Car Offered encourage ambulance in transfer but after risks and benefits discussion patient has opted for private vehicle...I have been told and understand the risks and benefits of my (the Patient) transfer. [X marked in a box] I hereby CONSENT to transfer..." There was no documentation Patient #4 signed a form of refusal for transfer by ambulance.

Discharge Information documented, "Date/Time: 09/06/2025 2132 [9:32 PM]...Disposition: Acute Care Facility..."

In an interview on 9/23/2025 at 2:40 PM, the Chief Nursing Officer (CNO) verified Patient #4 was transferred to another facility and went by private vehicle. CNO verified Hospital #1 does not have labor and delivery services.

In an interview on 9/23/2025 at 2:45 PM, the ED Medical Director stated each transfer case was different. "Every once in a while a case could not have to go by ambulance. Sometimes a patient refuses to go by ambulance. You would have them sign a refusal form."

Patient #4 was discharged from Hospital #1 per private vehicle on 9/6/2025 at 9:32 PM. Patient #4 required a higher level of care not available at Hospital #1. Patient #4 required transfer to another facility. Patient #4 did not transfer with qualified, trained personnel or equipment to address the medical condition requiring a higher level of care. There was no documentation Patient #4 signed a form of refusal for transfer by ambulance.