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Based on staff interviews, record reviews, and review of the facility's policies, it was determined the facility failed to comply with 42 CFR 489.24(d)(1) and 42 CFR 489.24(e)(1-2) regarding not appropriately transferring an unstable patient within the capability of the hospital's emergency department to treat for one (1) of twenty (20) sampled patients, Patient #1, on 04/13/2021.

The findings include:

Refer to findings in Tag A-2407 and A-2409.

Based on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to ensure an individual with an emergency medical condition (EMC) within the capabilities of the facility to treat was provided treatment to stabilize his/her medical condition. One (1) of twenty (20) patients reviewed, Patient #1, who presented to Facility #1's Emergency Department (ED), on 04/13/2021 at 12:12 AM, was not provided treatment to stabilize an ectopic pregnancy, a condition for which the facility had an on-call provider capable of providing stabilizing treatment to Patient #1. Instead, Patient #1 was transferred to Facility #2, per ground ambulance, on 04/13/2021 at 2:47 AM, for emergency surgical treatment.

The findings include:

Review of the facility's policy titled, "EMTALA (Emergecy Medical Treatment and Labor Act)-Kentucky Provision of On-Call Coverage Policy," dated 05/2009 and last reviewed 07/2016, revealed the facility must maintain a list of physicians on its medical staff who have privileges at the hospital who must be available after the initial examination to provide on-call treatment necessary to stabilize individuals with emergency medical conditions (EMC) who are receiving services in accordance with the resources available to the hospital. In addition, the policy stated it was the on-call physician's duty and responsibility to provide specialty care services as needed to any individual who came to the ED, with an arrival within a reasonable timeframe, defined as generally within thirty (30) minutes.

Review of the facility's policy titled, "EMTALA Transfer," dated 06/2009 and last revised 04/2019, revealed individuals presenting to the ED with an EMC that had not been stabilized could only be considered an appropriate transfer if the transferring hospital provided medical treatment within its capacity that minimized the risks to the individual's health, and a higher level of care was required, such as specialized capabilities not available at the transferring hospital.

Review of Patient #1's ED medical record, from Facility #1, revealed Patient #1 presented to the ED, on 04/13/2021 at 12:12 AM, with abdominal cramping, bleeding, and was eight (8) weeks pregnant. The record revealed the patient woke up, on 04/12/2021 about 6:00 PM, with sharp moderate left lower quadrant pain radiating to the suprapubic area and onto the right lower and right upper quadrant; the patient vomited in the ED. Per review of the record, the patient's blood pressure (BP) at presentation was 55/34 mmHg (millimeters of mercury), with a pulse of 109 beats per minute (BPM) and room oxygen saturation of 99 percent; blood work revealed an elevated white blood cell count; ultrasound results showed a left adnexal (anatomical areas close to the uterus, for instance, the fallopian tubes and ovaries) ectopic pregnancy. In addition, the ultrasound result was communicated to Physician #1 at 2:22 AM. Continued review of Patient #1's ED medical record revealed Physician #1 communicated with Physician #3 at Facility #2 at 2:25 AM, with a recommendation from Physician #3 to call Facility #1's on-call Physician #2, who specialized in gynecology. Per review of the record, Physician #1 called Physician #2 at 2:30 AM; Physician #2 recommended transferring Patient #1 to Facility #2 for additional treatment. Then, per record, Physician #1 called Physician #3, at 2:38 AM, who accepted transfer of Patient #1 to Facility #2 at that time. In addition, the ED record showed Patient #1 was accepted for transfer to Facility #2 with the reason for transfer as requiring a higher level of care. Patient #1's vital signs at 2:45 AM were BP of 147/94 mmHg, pulse of 85 BPM, and room oxygen saturation of 100 percent.

Review of Patient #1's EMTALA Memorandum of Transfer (MOT), dated 04/13/2021 at 2:45 AM, revealed Patient #1 was diagnosed with a Ruptured Ectopic Pregnancy, and the reason for the transfer was that it was medically indicated due to the level of care not being available at Facility #1. Also, a box under the reason for transfer, "on-call physician refused or failed to respond within a reasonable period of time," was not checked.

Review of Patient #1's EMS (ground ambulance was method of the transport) documentation revealed EMS departed Facility #1, with Patient #1 at 2:48 AM, arriving at Facility #2, approximately three (3) miles away, at 2:53 AM. The EMS record revealed Patient #1 had significant abdominal pain and tenderness at the time of transport.

Review of Patient #1's ED medical record, from Facility #2, revealed Physician #3 performed a Laparoscopic Left Salpingectomy (removal of the left fallopian tube where the ectopic pregnancy was located) for an Ectopic Pregnancy, on 04/13/21 at 3:30 AM. Continued review revealed Patient #1 was admitted to the facility, on 04/13/21 at 4:31 AM. Per review of the record, Patient #1's post-operative course was complicated by blood loss anemia (low red blood cells), and the patient received two (2) units of packed red blood cells (pRBC). In addition, Patient #1 was newly diagnosed with Human Immunodeficiency Virus (HIV). The record showed Patient #1 was discharged from Facility #2, on 04/14/2021 at 10:34 AM.

The distance between Facility #1 and Facility #2 was two and seven-tenths (2.7) miles.

Interview with the Vice-President (VP) of Quality and Safety, on 05/04/2021 at 10:04 AM, and again at 10:40 AM, revealed Patient #1 came to the facility, in the early morning hours of 04/13/2021, presenting with complaints of left lower quadrant pain, and Patient #1 revealed she was eight (8) weeks pregnant. She stated Physician #1 started the work-up for an ectopic pregnancy that included an intravenous (IV) access to give IV fluids for rehydration, blood work, and an ultrasound. The VP stated the facility did not have obstetrical (OB) services, only gynecological (GYN), and as a result of Patient #1's pregnancy, Physician #1 initiated a call to Facility #2 because Patient #1 had been receiving care at the clinic associated with Facility #2. Per interview, Physician #1 spoke with Physician #3, who told him Facility #1 should be able to treat Patient #1 with their on-call GYN Physician. The VP stated Physician #1 then reached out to Physician #2, the on-call GYN, who stated he did not take call for patients of Facility #2, and Physician #3 should treat Patient #1. Per interview, Physician #1 then called Physician #3 who accepted Patient #1. The VP stated Physician #2 told her he believed Facility #2 was calling him, and he was not on call for Facility #2. The VP stated the ED Clerk told her he placed the telephone call to Physician #2 and stated he introduced himself and where he was calling from when he spoke with Physician #2, prior to placing him on hold for Physician #1.

Continued interview with the VP of Quality and Safety, on 05/04/2021 at 10:40 AM, revealed Physician #1 should have called the House Supervisor and Administrator, after Physician #2 had refused to treat Patient #1, so they could have handled the situation and ensured Physician #2 responded to the call and came to the facility. She also stated additional information, such as whether anyone identified to Physician #2 the location of Patient #1, could have been determined if calls were recorded.

Interview with the ED Director, on 05/04/2021 at 10:26 AM and again at 11:39 AM, revealed she was informed of the situation when she came to work, on 04/13/2021 prior to 7:00 AM. Per interview, she knew in the past the facility had managed ectopic pregnancy cases through the GYN Physician and believed this instance could have been an EMTALA violation. She revealed ED staff had EMTALA training at least annually, and knew patients were not transferred to other facilities for services the facility could provide. The ED Director said the facility had access to Tristar Transfer Center, and although there was no formal policy regarding transfer center use, staff was supposed to make use of the transfer center. She revealed utilizing the transfer center would have potentially prevented the situation, as the transfer center had access to the facility's on-call information. She revealed part of the role of the transfer center was to catch possible EMTALA violations before they occurred.

Interview with the Chief Nursing Officer (CNO), on 05/04/2021 at 11:02 AM, revealed she found out, on the morning of 04/13/2021, the facility had transferred someone to another facility and had potentially created an EMTALA violation. She revealed she had spoken with the RN House Supervisor that morning, prior to 7:00 AM, who reported the incident as a troubling transfer because the patient could have been treated by the on-call GYN but was instead transferred. The CNO stated she expected the on-call physician to come to the facility to treat any patient with an emergent need, when the physician was able to provide treatment for the emergent condition.

Interview with Physician #2, on 05/04/2021 at 12:56 PM, revealed he received a call, on 04/13/2021 at 2:30 AM. He revealed Physician #1 informed him the ED had an unstable patient with an ectopic pregnancy and had reached out to Physician #3, who was on-call for Facility #2, who said she could not take care of Patient #1 and asked that he, Physician #2, do so. He revealed he had been informed Patient #1 was a patient of the clinic across town near Facility #2, and he could not remember anyone identifying which facility was calling. Physician #2 stated he informed Physician #1 to encourage Physician #3 to contact him if she needed to do so, but he was not going to step in and care for another physician's patient unless asked to by that physician. Physician #2 emphasized, based on the information he was provided, he thought he was being called by Facility #2, and had he known he was being called by Facility #1, he would have come in. Physician #2 revealed he had just dozed off prior to receiving the call, and although he was feeling a little under the weather, he was capable of and able to come to work.

Continued interview with Physician #2, on 05/04/2021 at 12:56 PM, revealed since this incident, he has had additional EMTALA training, as well as attended meetings to ensure nothing like this happened again. He stated no one wanted to see anyone hurt, and luckily in this instance, no one was. He stated the facility was really interested in addressing this issue to ensure nothing like this happened again.

Interview with Physician #1, on 05/04/2021 at 3:35 PM, revealed Patient #1 came to the ED, after midnight on 04/13/2021, and he was informed by the nurse that the patient was having abdominal pain. He stated the patient reported she was pregnant, and after the medical examination, he was afraid she could be experiencing an ectopic pregnancy. Physician #1 stated the ED Clerk called Facility #2 and got in touch with Physician #3, their on-call OB/GYN, for him, as Patient #1 was pregnant. Physician #1 stated he spoke with Physician #3, who informed him the GYN on call for Facility #1 could handle Patient #1's case. Physician #1 stated he then had the ED Clerk telephone Physician #2, and when he, Physician #1, spoke with Physician #2, Physician #1 informed Physician #2 about the situation with Patient #1. Furthermore, Physician #1 stated Physician #2 asked who Patient #1's primary Obstetric (OB) Physician was, and Physician #2 informed Physician #1 that he did not cover for that OB Physician . Physician #1 stated Physician #2 instructed him to speak again with Physician #3. Physician #1 stated he was certain he identified himself to Physician #2; however, usually the ED Clerk identified the facility to the person being called. Physician #1 revealed he then called Physician #3 again, who agreed to the transfer of Patient #1. Physician #1 stated Patient #1 was stable for transfer at that point, and there was nothing else he could do to further stabilize her, as the facility did not have in-house access to GYN care for the patient. Physician #1 revealed, following this incident, there had been additional EMTALA training, as well as training regarding the use of Tristar Transfer Center any time a patient needed to be transferred.

Interview with the ED Clerk, on 05/05/2021 at 7:24 AM, revealed his first involvement was receiving a call at 2:22 AM from radiology needing to speak with Physician #1 regarding Patient #1's ultrasound results. The ED Clerk revealed he turned the call over to Physician #1, who went into Patient #1's room, came out, and said he needed to speak to whoever was on call for labor and delivery at Facility #2 and that he needed EMS priority one. The ED Clerk revealed he got in touch with bed placement at Facility #2, informed them Physician #1 needed to speak with the on-call labor and delivery physician for active labor. The ED Clerk stated he then called EMS dispatch requesting an ambulance priority one for a patient in active labor. The ED Clerk revealed he had not seen Patient #1 and believed it to be an active labor situation based on information he had been provided. The ED Clerk stated he received a call back a few minutes later from Facility #2, informing him they had Physician #3 on the line, and he alerted Physician #1, who took the call. Per interview, after the conversation with Physician #3, Physician #1 stated he needed to speak with Physician #2, who was on-call for GYN services that night. The ED Clerk stated he looked up Physician #2's contact preference, and called his cell phone. He revealed Physician #2 sounded lethargic, and he informed Physician #2 who he was and that he was calling from Facility #1 on behalf of Physician #1. The ED Clerk stated he always said the same thing, "This is (name of caller) from the ER at (name of facility)." He revealed he placed Physician #2 on a brief hold until Physician #1 could get on the line, at which point EMS had arrived and were walking through the door. The ED Clerk stated EMS assessed Patient #1, and Physician #1 asked to speak to Physician #3 again, after completing the call with Physician #2. He revealed he placed the call to Physician #3, who immediately returned the call to Physician #1, at which point Patient #1 was placed in the ambulance and transferred to Facility #2.

Continued interview with the ED Clerk, on 05/05/2021 at 7:24 AM, revealed, after he heard Patient #1 had an ectopic pregnancy, later that morning, he understood it was potentially an inappropriate transfer. He stated the facility has had patients with ectopic issues before, although he was only able to recall a few that arrived during his shifts. The ED Clerk revealed he had EMTALA training yearly and had received more training following this incident. He revealed use of the Tristar Transfer Center was also reinforced. The ED Clerk stated a log book was kept of communications made by clerks, but it only showed who had been contacted and when, and did not have details on what information was provided.

Interview with the ED Charge Nurse, on 05/05/2021 at 7:38 AM, revealed he was not aware of anything regarding Patient #1 on the night of 04/13/2021 until after the fact; he was unaware of Patient #1 being transferred until EMS arrived. He stated Physician #2 had just come in for an ectopic pregnancy recently, with Patient #3, and ectopic pregnancies typically were not transferred to other facilities. The ED Charge Nurse stated he had yearly EMTALA training and had received refresher EMTALA training following this incident. He stated the importance of using the Tristar Transfer Center was also reinforced in the recent training.

Interview with RN #1, on 05/05/2021 at 7:44 AM, revealed he was the primary nurse for Patient #1 on 04/13/2021. He revealed initially Patient #1's BP was low and she had been vomiting, but a recheck showed the BP had increased to a normal level. He stated Physician #1 saw Patient #1 approximately fifteen (15) minutes after arrival and ordered an ultrasound. Per interview, Patient #1 went for an ultrasound, which took approximately forty-five (45) minutes; the BP was lower on return to the ED, and Patient #1 was in pain. RN #1 stated IV fluids were started, and Physician #1 performed a bedside ultrasound and informed Patient #1 there was free fluid in the abdomen, bleeding, and she would need to be transferred to another facility. Per interview, Patient #1 became anxious at hearing this, so he stayed with the patient to calm her. In addition, RN #1 stated, at 2:30 AM, Patient #1's BP had increased to approximately 111/60 mmHg, and as he was leaving the room, he noticed the EMS crew arriving. He revealed he tried to call Facility #2 to give report to nursing, but was left on hold twice, and no one answered. RN #1 stated he checked Patient #1's BP once more, and it was approximately 140/70 mmHg. RN #1 revealed he did not see patients with ruptured ectopic pregnancies often in the ED.

Continued interview with RN #1, on 05/05/2021 at 7:44 AM, revealed he started working in the ED a little over a year ago, had EMTALA training in orientation, and had received a yearly refresher course, as well as additional training following this incident. Further, he revealed ED staff had received training on ectopic pregnancies, as well as training on use of the Tristar Transfer Center.

Based on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to ensure an individual with an emergency medical condition (EMC) within the capabilities of the facility to treat was transferred appropriately to another facility. One (1) of twenty (20) patients reviewed, Patient #1, who presented to Facility #1's Emergency Department (ED), on 04/13/2021 at 12:12 AM, was unstable due to a ruptured ectopic pregnancy, a condition for which the facility had an on-call provider capable of providing stabilizing treatment to Patient #1 and where a higher level of care was not required.

Instead, Patient #1 was inappropriately transferred to Facility #2, per ground ambulance, on 04/13/2021 at 2:47 AM, for emergency surgical treatment. The inappropriate transfer provided risk for Patient #1 without any additional benefit as Facility #1 could have provided the emergency surgical treatment if the on-call provider had agreed to come to the facility to provide treatment.

The findings include:

Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) Transfer," dated 06/2009 and last revised 04/2019, revealed individuals presenting to the ED with an EMC that had not been stabilized could only be considered an appropriate transfer if the transferring hospital provided medical treatment within its capacity that minimized the risks to the individual's health, and a higher level of care was required, such as specialized capabilities not available at the transferring hospital.

Review of Patient #1's EMTALA Memorandum of Transfer (MOT), dated 04/13/2021 at 2:45 AM, revealed Patient #1 was diagnosed with a Ruptured Ectopic Pregnancy, and the reason for the transfer was that it was medically indicated due to the level of care not being available at Facility #1. Also, a box under the reason for transfer, "on-call physician refused or failed to respond within a reasonable period of time," was not checked.

Review of Patient #1's ED medical record, from Facility #1, revealed Patient #1 presented to the ED, on 04/13/2021 at 12:12 AM, with abdominal cramping, bleeding, and was eight (8) weeks pregnant. The record revealed the patient woke up, on 04/12/2021 about 6:00 PM, with sharp moderate left lower quadrant pain radiating to the suprapubic area and onto the right lower and right upper quadrant; the patient vomited in the ED. Per review of the record, the patient's blood pressure (BP) at presentation was 55/34 mmHg (millimeters of mercury), with a pulse of 109 beats per minute (BPM) and room oxygen saturation of 99 percent; blood work revealed an elevated white blood cell count; ultrasound results showed a left adnexal (anatomical areas close to the uterus, for instance, the fallopian tubes and ovaries) ectopic pregnancy. In addition, the ultrasound result was communicated to Physician #1 at 2:22 AM. Continued review of Patient #1's ED medical record revealed Physician #1 communicated with Physician #3 at Facility #2 at 2:25 AM, with a recommendation from Physician #3 to call Facility #1's on-call Physician #2, who specialized in gynecology. Per review of the record, Physician #1 called Physician #2 at 2:30 AM; Physician #2 recommended transferring Patient #1 to Facility #2 for additional treatment. Then, per record, Physician #1 called Physician #3, at 2:38 AM, who accepted transfer of Patient #1 to Facility #2 at that time. In addition, the ED record showed Patient #1 was accepted for transfer to Facility #2 with the reason for transfer as requiring a higher level of care. Patient #1's vital signs at 2:45 AM were BP of 147/94 mmHg, pulse of 85 BPM, and room oxygen saturation of 100 percent.

Review of Patient #1's EMS (ground ambulance was method of the transport) documentation revealed EMS departed Facility #1, with Patient #1 at 2:48 AM, arriving at Facility #2, approximately three (3) miles away, at 2:53 AM. The EMS record revealed Patient #1 had significant abdominal pain and tenderness at the time of transport.

Review of Patient #1's ED medical record, from Facility #2, revealed Physician #3 performed a Laparoscopic Left Salpingectomy (removal of the left fallopian tube where the ectopic pregnancy was located) for an Ectopic Pregnancy, on 04/13/21 at 3:30 AM. Continued review revealed Patient #1 was admitted to the facility, on 04/13/21 at 4:31 AM. Per review of the record, Patient #1's post-operative course was complicated by blood loss anemia (low red blood cells), and the patient received two (2) units of packed red blood cells (pRBC). In addition, Patient #1 was newly diagnosed with Human Immunodeficiency Virus (HIV). The record showed Patient #1 was discharged from Facility #2, on 04/14/2021 at 10:34 AM.

The distance between Facility #1 and Facility #2 was two and seven-tenths (2.7) miles.

Interview with the Vice-President (VP) of Quality and Safety, on 05/04/2021 at 10:04 AM, and again at 10:40 AM, revealed Patient #1 came to the facility, in the early morning hours of 04/13/2021, presenting with complaints of left lower quadrant pain, and Patient #1 revealed she was eight (8) weeks pregnant. She stated Physician #1 started the work-up for an ectopic pregnancy that included an intravenous (IV) access to give IV fluids for rehydration, blood work, and an ultrasound. The VP stated the facility did not have obstetrical (OB) services, only gynecological (GYN), and as a result of Patient #1's pregnancy, Physician #1 initiated a call to Facility #2 because Patient #1 had been receiving care at the clinic associated with Facility #2. Per interview, Physician #1 spoke with Physician #3, who told him Facility #1 should be able to treat Patient #1 with their on-call GYN Physician. The VP stated Physician #1 then reached out to Physician #2, the on-call GYN, who stated he did not take call for patients of Facility #2, and Physician #3 should treat Patient #1. Per interview, Physician #1 then called Physician #3 who accepted Patient #1. The VP stated Physician #2 told her he believed Facility #2 was calling him, and he was not on call for Facility #2. The VP stated the ED Clerk told her he placed the telephone call to Physician #2 and stated he introduced himself and where he was calling from when he spoke with Physician #2, prior to placing him on hold for Physician #1.

Continued interview with the VP of Quality and Safety, on 05/04/2021 at 10:40 AM, revealed Physician #1 should have called the House Supervisor and Administrator, after Physician #2 had refused to treat Patient #1, so they could have handled the situation and ensured Physician #2 responded to the call and came to the facility. She also stated additional information, such as whether anyone identified to Physician #2 the location of Patient #1, could have been determined if calls were recorded.

Interview with the ED Director, on 05/04/2021 at 10:26 AM and again at 11:39 AM, revealed she was informed of the situation when she came to work, on 04/13/2021 prior to 7:00 AM. Per interview, she knew in the past the facility had managed ectopic pregnancy cases through the GYN Physician and believed this instance could have been an EMTALA violation. She revealed ED staff had EMTALA training at least annually, and knew patients were not transferred to other facilities for services the facility could provide. The ED Director said the facility had access to Tristar Transfer Center, and although there was no formal policy regarding transfer center use, staff was supposed to make use of the transfer center. She revealed utilizing the transfer center would have potentially prevented the situation, as the transfer center had access to the facility's on-call information. She revealed part of the role of the transfer center was to catch possible EMTALA violations before they occurred.

Interview with the Chief Nursing Officer (CNO), on 05/04/2021 at 11:02 AM, revealed she found out, on the morning of 04/13/2021, the facility had transferred someone to another facility and had potentially created an EMTALA violation. She revealed she had spoken with the RN House Supervisor that morning, prior to 7:00 AM, who reported the incident as a troubling transfer because the patient could have been treated by the on-call GYN but was instead transferred. The CNO stated she expected the on-call physician to come to the facility to treat any patient with an emergent need, when the physician was able to provide treatment for the emergent condition.

Interview with Physician #2, on 05/04/2021 at 12:56 PM, revealed he received a call, on 04/13/2021 at 2:30 AM. He revealed Physician #1 informed him the ED had an unstable patient with an ectopic pregnancy and had reached out to Physician #3, who was on-call for Facility #2, who said she could not take care of Patient #1 and asked that he, Physician #2, do so. He revealed he had been informed Patient #1 was a patient of the clinic across town near Facility #2, and he could not remember anyone identifying which facility was calling. Physician #2 stated he informed Physician #1 to encourage Physician #3 to contact him if she needed to do so, but he was not going to step in and care for another physician's patient unless asked to by that physician. Physician #2 emphasized, based on the information he was provided, he thought he was being called by Facility #2, and had he known he was being called by Facility #1, he would have come in. Physician #2 revealed he had just dozed off prior to receiving the call, and although he was feeling a little under the weather, he was capable of and able to come to work.

Continued interview with Physician #2, on 05/04/2021 at 12:56 PM, revealed since this incident, he has had additional EMTALA training, as well as attended meetings to ensure nothing like this happened again. He stated no one wanted to see anyone hurt, and luckily in this instance, no one was. He stated the facility was really interested in addressing this issue to ensure nothing like this happened again.

Interview with Physician #1, on 05/04/2021 at 3:35 PM, revealed Patient #1 came to the ED, after midnight on 04/13/2021, and he was informed by the nurse that the patient was having abdominal pain. He stated the patient reported she was pregnant, and after the medical examination, he was afraid she could be experiencing an ectopic pregnancy. Physician #1 stated the ED Clerk called Facility #2 and got in touch with Physician #3, their on-call OB/GYN, for him, as Patient #1 was pregnant. Physician #1 stated he spoke with Physician #3, who informed him the GYN on call for Facility #1 could handle Patient #1's case. Physician #1 stated he then had the ED Clerk telephone Physician #2, and when he, Physician #1, spoke with Physician #2, Physician #1 informed Physician #2 about the situation with Patient #1. Furthermore, Physician #1 stated Physician #2 asked who Patient #1's primary Obstetric (OB) Physician was, and Physician #2 informed Physician #1 that he did not cover for that OB Physician . Physician #1 stated Physician #2 instructed him to speak again with Physician #3. Physician #1 stated he was certain he identified himself to Physician #2; however, usually the ED Clerk identified the facility to the person being called. Physician #1 revealed he then called Physician #3 again, who agreed to the transfer of Patient #1. Physician #1 stated Patient #1 was stable for transfer at that point, and there was nothing else he could do to further stabilize her, as the facility did not have in-house access to GYN care for the patient. Physician #1 revealed, following this incident, there had been additional EMTALA training, as well as training regarding the use of Tristar Transfer Center any time a patient needed to be transferred.

Interview with the ED Clerk, on 05/05/2021 at 7:24 AM, revealed his first involvement was receiving a call at 2:22 AM from radiology needing to speak with Physician #1 regarding Patient #1's ultrasound results. The ED Clerk revealed he turned the call over to Physician #1, who went into Patient #1's room, came out, and said he needed to speak to whoever was on call for labor and delivery at Facility #2 and that he needed EMS priority one. The ED Clerk revealed he got in touch with bed placement at Facility #2, informed them Physician #1 needed to speak with the on-call labor and delivery physician for active labor. The ED Clerk stated he then called EMS dispatch requesting an ambulance priority one for a patient in active labor. The ED Clerk revealed he had not seen Patient #1 and believed it to be an active labor situation based on information he had been provided. The ED Clerk stated he received a call back a few minutes later from Facility #2, informing him they had Physician #3 on the line, and he alerted Physician #1, who took the call. Per interview, after the conversation with Physician #3, Physician #1 stated he needed to speak with Physician #2, who was on-call for GYN services that night. The ED Clerk stated he looked up Physician #2's contact preference, and called his cell phone. He revealed Physician #2 sounded lethargic, and he informed Physician #2 who he was and that he was calling from Facility #1 on behalf of Physician #1. The ED Clerk stated he always said the same thing, "This is (name of caller) from the ER at (name of facility)." He revealed he placed Physician #2 on a brief hold until Physician #1 could get on the line, at which point EMS had arrived and were walking through the door. The ED Clerk stated EMS assessed Patient #1, and Physician #1 asked to speak to Physician #3 again, after completing the call with Physician #2. He revealed he placed the call to Physician #3, who immediately returned the call to Physician #1, at which point Patient #1 was placed in the ambulance and transferred to Facility #2.

Continued interview with the ED Clerk, on 05/05/2021 at 7:24 AM, revealed, after he heard Patient #1 had an ectopic pregnancy, later that morning, he understood it was potentially an inappropriate transfer. He stated the facility has had patients with ectopic issues before, although he was only able to recall a few that arrived during his shifts. The ED Clerk revealed he had EMTALA training yearly and had received more training following this incident. He revealed use of the Tristar Transfer Center was also reinforced. The ED Clerk stated a log book was kept of communications made by clerks, but it only showed who had been contacted and when, and did not have details on what information was provided.

Interview with the ED Charge Nurse, on 05/05/2021 at 7:38 AM, revealed he was not aware of anything regarding Patient #1 on the night of 04/13/2021 until after the fact; he was unaware of Patient #1 being transferred until EMS arrived. He stated Physician #2 had just come in for an ectopic pregnancy recently, with Patient #3, and ectopic pregnancies typically were not transferred to other facilities. The ED Charge Nurse stated he had yearly EMTALA training and had received refresher EMTALA training following this incident. He stated the importance of using the Tristar Transfer Center was also reinforced in the recent training.

Interview with RN #1, on 05/05/2021 at 7:44 AM, revealed he was the primary nurse for Patient #1 on 04/13/2021. He revealed initially Patient #1's BP was low and she had been vomiting, but a recheck showed the BP had increased to a normal level. He stated Physician #1 saw Patient #1 approximately fifteen (15) minutes after arrival and ordered an ultrasound. Per interview, Patient #1 went for an ultrasound, which took approximately forty-five (45) minutes; the BP was lower on return to the ED, and Patient #1 was in pain. RN #1 stated IV fluids were started, and Physician #1 performed a bedside ultrasound and informed Patient #1 there was free fluid in the abdomen, bleeding, and she would need to be transferred to another facility. Per interview, Patient #1 became anxious at hearing this, so he stayed with the patient to calm her. In addition, RN #1 stated, at 2:30 AM, Patient #1's BP had increased to approximately 111/60 mmHg, and as he was leaving the room, he noticed the EMS crew arriving. He revealed he tried to call Facility #2 to give report to nursing, but was left on hold twice, and no one answered. RN #1 stated he checked Patient #1's BP once more, and it was approximately 140/70 mmHg. RN #1 revealed he did not see patients with ruptured ectopic pregnancies often in the ED.

Continued interview with RN #1, on 05/05/2021 at 7:44 AM, revealed he started working in the ED a little over a year ago, had EMTALA training in orientation, and had received a yearly refresher course, as well as additional training following this incident. Further, he revealed ED staff had received training on ectopic pregnancies, as well as training on use of the Tristar Transfer Center.

Patient #1 presented to the ED with complaints of abdominal pain and was eight weeks pregnant. Patient #1 was diagnosed with an ectopic pregnancy on ultrasound and required transfer to facility number two, since the on-call GYN provider refused to come in and care for the patient. Patient #1 was then transferred to facility #2 for emergency GYN surgery for a ruptured ectopic pregnancy. This delay in care posed an immediate and serious threat to Patient #1's health and safety.