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Based on review of twenty-one emergency department/obstetrical emergency records from hospital #1, including patient #1's 3/8/18 ED record, a review of patient #1's 3/9/18 inpatient record from hospital #2, review of hospital #1's bylaws, and review of the policies and procedures for patients who present to the emergency department. It was determined that in one (patient #1) of twenty-one patients who presented to hospital #1 requesting emergency services, hospital #1 failed to ensure compliance with 489.24. Patient #1's ED record from hospital #1 indicated patient #1 presented to the ED late in the evening of 3/8/18 with ruptured membranes and in labor. Patient #1's due date was 3/21/18, and patient #1 was considered a high risk pregnancy due to having a prior C-Section delivery. Prior to unexpectedly going into labor, patient #1 had scheduled a planned C-Section delivery at hospital #2 on 3/14/18. The patient was provided a medical screening examination upon arrival at hospital #1, and patient #1's physician (G) was consulted via telephone related to patient #1's condition. Physician (G) advised the ED that even though patient #1 was 1 centimeter dilated and having contractions every 1-2 minutes, patient #1 was stable for discharge and did not require and emergent C-Section at hospital #1. Physician (G) advised the ED staff that patient #1 could travel by car, with a driver, to hospital #2 and deliver the baby at hospital #2.

Based on review of patient #1's ED record from hospital #1, review of patient #1's in-patient record from hospital #2 and interviews, hospital #1 failed to ensure that each patient who presented to the emergency department or was triaged to the obstetrical unit with an emergency medical condition, received appropriate stabilization and treatment prior to discharge, in one of twenty-one patients reviewed (patient #1). Patient #1 presented to hospital #1's ED in labor and with a due date of 3/21/2018 and a C-Section scheduled for 3/14/2018 at hospital #2. The hospital completed a medical screening examination and identified that the patient had an emergency medical condition and was a high risk pregnancy related to a prior C-Section. Hospital #1 instructed patient #1 to go via a private vehicle to hospital #2, which was forty-two miles away, for further care and delivery of her baby.

Findings include:

Review of patient #1's 3/8/2018 ED record from hospital #1 indicated patient #1 arrived via private vehicle at the ED at 11:25 p.m. Patient #1 was thirty-eight weeks and two days pregnant and considered a high risk pregnancy, presented at the ED for evaluation of spontaneous labor and ruptured membranes. The patient was triaged to the obstetric unit where she was evaluated by nurse (F). The medical screening examination revealed that patient #1's membranes had ruptured and that her contractions were regular and occurring every one to two minutes. The patient was dilated to 1 centimeter. Nurse (F) called physician (G), patient #1's primary obstetrician and informed physician (G) about patient #1's arrival and condition. Physician (G) determined that patient #1 was stable and did not require an emergent C-Section at hospital #1. Physician (G) recalled that patient #1 had previously mentioned during clinic visits that patient #1 wanted to deliver her baby at hospital #2. Physician (G) advised nurse (F) that patient #1 was medically stable to go to hospital #2 via private vehicle for delivery and advised nurse (F) that patient #1 did not need to be transported by ambulance to hospital #2. Patient #1 was discharged from hospital #1 on 3/9/2018 at 12:08 a.m. with instructions to go to hospital #2. Patient #1 and her significant other drove to hospital #2 which was forty-two miles from hospital #1 and arrived at hospital #2 at 1:08 a.m. on 3/9/2018 (a one hour drive).

Review of a late entry progress note dictated by physician (G) on 3/16/2018 and pertaining to patient #1's 3/8/2018 ED admission to hospital #1 was reviewed. The note verified that nurse (F) advised physician (G) of patient #1's medical condition and that physician (G) determined that patient #1 was medically stable to go to hospital #2 via private vehicle and without being transported via an ambulance.

Review of patient #1's ED and in-patient records from hospital #2 indicated patient #2 arrived at hospital #2 at 1:08 a.m. on 3/9/18. A repeat C-Section was performed at hospital #2 per patient #1's request, and patient #1's baby was delivered on 3/9/18 at 2:51 a.m.

When interviewed by phone on 3/21/2018 at 1:30 p.m., nurse (F) stated she performed patient #1's medical screening examination on 3/8/2018 when patient #1 arrived at hospital #1's ED/obstetric unit. Nurse (F) stated patient #1 was a high risk pregnancy and was having contractions which were occurring every one to two minutes, and patient #1 was dilated to one centimeter. Nurse (F) stated after receiving EMTALA training related to the incident involving patient #1, she realizes patient #1 should have either stayed at hospital #1 and delivered at hospital #1 or have been transported to hospital #2 (if necessary) only via ambulance and not via a private vehicle.

When interviewed in person on 3/21/2018 at 2:15 p.m., physician (G) stated she was patient #1's obstetrician during her pregnancy and said she saw patient #1 during clinic visits at hospital #1. Patient #1 had a high risk pregnancy due to having a prior C-Section and delivery at hospital #1. Patient #1 had also received prior services at hospital #2 pertaining to possibly having a trial of labor with her second pregnancy. However, following evaluation, hospital #2 told patient #1 that she was not a candidate for a trial of labor with the pregnancy and that patient #1 would require a delivery by C-Section. Physician (G) stated patient #1 told (G) that she wanted to deliver at hospital #2, and a C-Section had been scheduled for 3/14/2018 at hospital #2. Physician (G) stated she now realizes that patient #1 should have been transported to hospital #2 via ambulance or remained at hospital #1 for the delivery. She stated she made a mistake and realizes that the incident was a violation of EMTALA regulations.

When interviewed by phone on 3/22/2018 at 10:00 a.m., patient #1 stated nurse (F) had a phone conversation with physician (G) following her medical screening examination at hospital #1. Patient #1 said physician (G) told nurse (F) that she should drive via private vehicle to hospital #2 for follow-up and delivery of her baby. Patient #1 said she was not offered a transport via ambulance from hospital #1 to hospital #2. It was a "long and upsetting" drive to hospital #2. She stated she and her significant other still do not understand why they had to drive to hospital #2. Patient #1 said the drive to hospital #2 was dangerous.

The hospital's EMTALA policy, revised in November 2015, states "To stabilize means to to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual, or with respect to a pregnant woman having contractions, the woman has delivered the child and the placenta. A patient will be deemed stabilized if the attending provider has determined within reasonable clinical confidence, that the emergency medical condition has been resolved."