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Based on observation, interviews, review of documentation in 6 of 6 medical records of patients who were transferred from the ED to other hospitals (Patients 6, 9, 13, 15, 17 and 18), review of hospital policies and procedures and other documentation, it was determined that the hospital failed to develop and enforce EMTALA policies and procedures in the following areas:
* Appropriate transfers of patients; and
* Required posting of EMTALA signs.

Findings included:

1. Appropriate Transfers: Refer to the findings identified under Tag A2409, CFR 489.24(e)(1)-(2), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to appropriate transfers.

2. Posting of Signs: Refer to the findings identified under Tag A2402, CFR 489.20(q), which reflects the hospital's failure to enforce EMTALA policies and procedures related to posting of the required EMTALA signs.

Based on observation, interview, and review of policies and procedures it was determined the hospital failed to ensure that EMTALA signage was posted conspicuously in places and areas that could be seen by all individuals presenting to the hospital for emergency services, including examination and treatment areas.

Findings include:

1. A tour of the ED was conducted on 07/19/2016 beginning at 1240 with the Regional Manager of Emergency Services Education & Quality and the ED Manager. The ED Manager indicated that the ED had one primary ambulatory entrance and one separate ambulance entrance, 20 treatment rooms, one seclusion room, and four isolation rooms.

Observations during the tour revealed that there was no EMTALA sign posted at the ambulance entrance to the ED and no EMTALA signage observed posted during observation of seclusion room 12. In addition, during observation of treatment rooms 2 and 20, EMTALA signage was posted in English language only and not in Spanish language. These observations were confirmed with the ED Manager during the ED tour.

2. During an interview with the Regional Manager of Emergency Services Education & Quality on 07/21/2016 at 1155, he/she confirmed that all individuals who presented to the hospital for emergency services, did not have the opportunity to visualize EMTALA signage, including all Spanish-speaking individuals.

3. The policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated last reviewed "07/2016" reflected the following: The Definitions section reflected "...Signage means the signs posted by the Hospital in its dedicated emergency department(s) and in a place or places likely to be noticed by all individuals entering the dedicated emergency department(s) that inform individual (sic) of their rights under EMTALA." The "General Policies" section reflected "...Each Hospital will post signage in the dedicated emergency department specifying the rights with emergency medical conditions and women in labor who come to the dedicated ED for health care services, and indicate on the signs whether the hospital participates in the Medicaid program."

Based on interview, documentation reviewed in 6 of 6 medical records of patients who presented to the hospital's ED and who were transferred to other facilities (Patients 6, 9, 13, 15, 17 and 18), and review of hospital policies and procedures, and other documentation it was determined that the hospital failed to enforce its EMTALA policies and procedures to ensure it effected appropriate transfers for patients for whom an EMC had not been removed or ruled out in the following areas:
The receiving facility had not agreed to accept the transfer; the transferring hospital had not sent to the receiving facility all medical records related to the emergency condition; the transfer was not effected through qualified personnel and transportation equipment; physician certification that the benefits of transfer outweighed the increased risk was not completed; and patient specific risks of transfer were not identified.
* For Patient 6 who was pregnant with possible labor contractions, and was transferred to another facility for further examination and treatment to rule out labor, the hospital failed to ensure the receiving facility agreed to accept the patient; all medical records available at the time of transfer were sent to the receiving facility; the transfer was effected through qualified personnel and transportation equipment; and the required physician certification that the benefits of the transfer outweighed the increased risks of transfer.
* For 5 of 6 patients (Patients 6, 13, 15, 17 and 18), the hospital failed to ensure the required physician certification that the benefits of the transfer outweighed the increased risks of transfer. Patient specific risks of transfer were not identified for those patients.
* For 5 of 5 patients who were pregnant (Patients 6, 9, 15, 17 and 18) and were transferred to other facilities for further examination and treatment, the documentation was contradictory, and did not clearly and consistently reflect the patient's transportation arrangements, including the use of qualified personnel and transportation equipment.

Findings include:

1. The Professional Staff Policies and Procedures dated as last revised 05/28/2016 was reviewed. "Article XVII. Additional Policies...Section E." reflected "Transfer of Patients: Once a patient is admitted to a Hospital (including the Emergency Room), the patient shall not be transferred to another medical care facility unless the following conditions are met...The attending Member has written a transfer order...Arrangements have been made for the patient's admission with the other facility, including concurrence of the receiving physician and the hospital's consent to receive the patient; and...All pertinent medical information necessary to insure continuity of care must accompany the patient...The above is also applicable when a transfer is necessitated due to the services not being available at the Hospital."

* The policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated last reviewed "07/2016" reflected the following: "...Transfers are made physician-to-physician...The patient may be transferred only when the receiving hospital or facility has consented to accept the patient...All pertinent medical information shall accompany the patient being transferred and the transfer shall be effected through qualified personnel and transfer equipment."

The "Definitions" reflected that "Transfer means the movement of an individual outside a hospital facility at the direction of any person authorized by (or affiliated or associated, directly or indirectly, with) the hospital..." The policy further reflected "...With respect to a pregnant woman who is having contractions, an EMC means...there is inadequate time to effect a safe transfer to another hospital before delivery, or...That transfer may pose a threat to the health or safety of the woman or the unborn child...Stabilized means...with respect to a pregnant woman who is having contractions, that the woman has delivered the child and the placenta...Capability of the hospital means that there is physical space, equipment, supplies, and specialized services that the hospital provides (e.g. surgery, psychiatry, obstetrics, intensive care). Capability of the staff of the hospital means the level of care that the personnel of the hospital can provide..."

The "Procedure" section reflected "Transferring a patient from a Providence hospital to any other hospital...Prior to transfer...Risks and benefits will be...documented on the Patient Transfer Form...Stabilized patients may be transferred to another facility...if physician or qualified care provider certifies in writing that the benefits of transferring the patient to another facility outweigh the risk...Arrangements for proper conveyance will then be made; a physician or qualified care provider will determine the safest method of transport...If a care provider or physician feels it is necessary for the patient's safety, they or their qualified designee will accompany the patient during transfer...The evaluating care provider will place a call to the receiving care provider and health care facility. The necessary information will be relayed. The receiving facility must (1) be informed of the transfer and (2) agree to accept the patient, provide appropriate medical treatment and have space and qualified personnel available...The referring and receiving care providers share the responsibility for patient transfer and they should consult regarding the arrangements and details of patient transfer, including the method of transportation. The care provider arranging transportation is responsible for determining what additional care is required before transfer, and what capabilities should be available en route...Accompanying records sent with patient...A copy of the Emergency Department treatment record (if applicable)...Flowsheet(s)...Laboratory results...X-rays...Progress notes...ECGs and/or other clinical monitoring recordings...Transfer form(s)...A 'Transfer Form'...must be completed for each transfer...copy sent with the patient's record to the receiving hospital...The nurse caring for the patient is responsible for calling a nursing report to the receiving facility unit. Report should be documented in nurses' notes including name of nurse receiving report. (Also listed on the Transfer Form.)...Documentation to occur on patient's chart ...Notification of acceptance by the receiving health care facility...Records that accompanied the patient..."

* The policy and procedure titled "Obstetric Patients," dated last revised "11/2013" reflected the following: "Pregnant patients more than 18 weeks gestation who present with obstetrical complaints (vaginal bleeding, uterine contractions, signs of labor)...PMH will not have the assistance of Labor and Delivery. Refer to PMH Guidelines for Care and Transport of Obstetrical Patients. Stabilization and Transport will be required."

* The policy and procedure titled "Care and Transfer of the Obstetrical Patient: Process and Decision-Making," dated last revised "05/2014" reflected the following: "Discharge/Transfer Process...The plan of care for transport will be based on issues of mother and infant safety Considerations include...Stability of the patient for transfer...Likelihood of deterioration during transport...Likelihood of delivery during transport...Availability of transport agency and bed availability at tertiary facility...Availability of appropriate medical providers, consultants, nursing personnel, ancillary services, and equipment at PMH...Imminent Delivery will be stabilized prior to transfer...Select obstetrical patients deemed stable for transfer and early in stages of delivery will be transported by ALS agency or a Children's transport team. Examples may include patients in early stages of active labor and high risk...Note: Non-critical patients with stable pregnancy requiring follow up OB exam only may transfer to an accepting facility by private vehicle."

2. The ED record for Patient 6 was reviewed. The record reflected the patient presented to the ED on 07/03/2016 at 0941 with a chief complaint of contractions. The patient's acuity was recorded "Emergent." The record reflected the patient arrived by "Wheelchair" and was escorted by a friend.

The "ED Triage Notes" recorded by the RN on 07/03/2016 at 0946 reflected "[Patient] arrives hyperventilating, possible contractions for past hour with associated rectal pressure...[Patient's] EDC is 08/01/2016, notes history of bleeding with pregnancy..."

On 07/03/2016 at 0947 the RN documented that the patient was complaining of pain that was rated ten on a numeric pain scale of 1-10.

The "Vital Signs" documented by the RN on 07/03/2016 at 0947 reflected that the patient's blood pressure was elevated at 195/81.

The "ED Quick Note" documentation by the RN on 07/03/2016 at 1000 reflected "...Patient placed on cardiac monitor, NIBP monitoring, and continuous pulse oximetry. Telemetry alarms on and set..."

The "Fetal Heart Tones" documentation by the RN on 07/03/2016 at 1000 reflected "...Fetal HR Baseline Rate (Beats/Min): 136; Fetal Heart Tones Located At: RLQ..."

The "Discharge Instructions" recorded by the ED Physician on 07/03/2016 at 1013 reflected "Go Directly to Providence Portland Medical Center Maternity Unit."

The "ED Provider Notes" electronically signed by the physician and dated 07/03/2016 at 1024 reflected the following: "[Patient]...is pregnant at 35w6d today, and this is [his/her] first pregnancy. [He/she] presents with onset of severe lower abdominal cramping that started earlier this morning. Patient states that it doesn't seem very regular, but the cramps are quite severe. [He/she] reports that there was a gush of fluid as well at about 8 am. Patient reports no bleeding..." The "ED Summary & Decision Making" section reflected "In summary, this is a [patient] who is 35 weeks and 6 days pregnant, with cramping and contraction pain. Patient apparently has had rupture of membranes as well. Sterile glove exam demonstrated a soft cervix admissible to fingertip only, with a very high station. I did feel that since this [was] the first pregnancy for this patient that [he/she] could be transported to Providence Portland Medical Center to the labor and delivery floor for further evaluation. Patient was briefly discussed with the family practice service here. They stated they would give report to the OB on call at PPMC..." The "Follow Up" section of the notes reflected "Go directly to PPMC Labor and Delivery floor."

An "After Visit Summary" form that was signed by the patient and dated 07/03/2016 at 1024 reflected the following: "...Your diagnosis was 35 Weeks Gestation of Pregnancy...Go Directly to [PPMC] Maternity Unit..."

The "Departure Condition" documented by the RN on 07/03/2016 at 1024 reflected "...Departure Mode: With friend..."

There was no documentation reflecting implementation of the hospital's policies and procedures including but not limited to ensuring:
* The receiving facility agreed to accept the patient;
* Appropriate transportation with qualified personnel was used;
* The physician identified specific risks of transfer to the patient and the unborn child, and certified that the benefits of the transfer outweighed those risks; and
* The patient's medical records were sent to the receiving hospital.

* Mapquest reflects PMH is approximately 9 miles from PPMC with an estimated driving time of 22 minutes.

* An interview was conducted on 07/19/2016 at 1615 with the ED Manager. The medical record of Patient 6 was reviewed electronically with the ED Manager during the interview. The ED Manager stated that the patient was pregnant and needed OB services. He/she stated that the hospital doesn't provide OB services and the process for pregnant patients that need OB services is that they are transferred to a hospital that provides those services. The ED Manager stated "The [ED Physician] should have called PPMC L&D to make sure they could accept the patient and [he/she] didn't." The ED Manager stated that the ED RN should have called PPMC and given a nurse to nurse report, and acknowledged that the ED RN did not. The ED Manager stated that a transfer form should have been completed and it was not. The ED Manager confirmed there was no documentation in the medical record that PPMC accepted the transfer of Patient 6. The ED Manager stated "There were gaps. This is not our standard practice."

* An interview was conducted on 07/20/2016 at 1430 with the ED Physician. The ED Physician stated Patient 6 presented to the ED, was pregnant, and was "late" in his/her third trimester. The ED Physician stated he/she performed a vaginal examination and the patient was having cramping but he/she did not know if the patient was having labor contractions because the hospital did not have OB services and did not have the necessary equipment to rule out labor. The ED Physician stated he/she made a phone call to a "family practice service" and spoke to Physician A. The ED Physician stated that Physician A told the ED Physician to discharge the patient and send the patient to PPMC for further evaluation. The ED Physician acknowledged he/she discharged the patient and told the patient to go to PPMC so that PPMC could further evaluate him/her and rule out labor. The ED Physician acknowledged he/she did not make physician to physician contact with anyone at PPMC, or contact anyone else at PPMC who accepted the patient for transfer. He/she stated "I thought [Physician A] would do that. I thought I was speaking with the physician who was managing this patient. I found out later he/she was not the patient's physician. I was wrong." The ED Physician acknowledged that the record contained no documentation reflecting that labor was ruled out before the patient left the hospital. The ED Physician confirmed the patient's record contained no physician certification addressing the risks versus benefits of transfer. He/she stated "Normally risks versus benefits of transfer would be documented on the EMTALA form and I did not fill it out." The ED Physician acknowledged the record contained no documentation reflecting that PPMC accepted the patient for transfer.

* An interview was conducted on 07/19/2016 at 1030 with Physician A, the physician who the ED Physician spoke to on 07/03/2016 regarding Patient 6. Physician A stated he/she was a family practice physician and was working at the hospital overseeing "residents" when one of the residents received a page from the ED Physician. Physician A stated that the resident did not call the ED Physician, but instead Physician A responded to the page and called the ED Physician. Physician A stated that the ED Physician told Physician A that he/she had a "preterm approximately 34-35 week" pregnant patient in the ED. Physician A stated that the ED Physician was concerned that the patient's membranes were ruptured. Physician A said he/she told the ED Physician that the patient needed to go to PPMC to get further evaluated because PMH does not have OB services. Physician A stated "I think [ED Physician] called us because [he/she] thought the patient was our patient." Physician A stated "I let [ED Physician] know [Patient 6] was not my patient." Physician A stated he/she called the L&D department at PPMC and talked to "a nurse" and let him/her know they could expect a patient. Physician A stated that he/she couldn't remember if he/she asked the nurse if the hospital could accept the patient, or if the nurse said the hospital could accept the patient for transfer. Physician A stated he/she did not talk to any provider at PPMC about Patient 6.

* An interview was conducted on 07/20/2016 at 1130 with the ED RN who was assigned to care for Patient 6 on 07/03/2016. The ED RN stated the patient was pregnant, in his/her third trimester, and came to the ED with complaints of abdominal pain and vaginal fluid leakage. The ED RN stated he/she put an IV in the patient's arm and the ED Physician performed a vaginal examination. The ED RN stated that later he/she saw that the patient was "up for discharge." The ED RN stated that the plan was for the patient to leave the hospital and go to PPMC for further evaluation. The ED RN stated that when he/she brought the patient's discharge paperwork to the patient, he/she overheard a conversation between the patient and his/her friend indicating that the friend would drive the patient to PPMC. The ED RN stated that the patient still had an IV in his/her arm when he/she left the hospital because the plan was for the patient to go to PPMC and be further evaluated. The ED RN stated he/she did not give a nurse to nurse report or have any other contact with PPMC to let them know the patient was coming to PPMC. The ED RN stated he/she did not know if the ED Physician communicated with anyone at PPMC about the patient.

* An interview was conducted on 07/21/2016 at 0940 with the L&D CN at PPMC. The L&D CN stated he/she was familiar with the 07/03/2016 incident involving Patient 6. The L&D CN stated that on 07/03/2016, the triage nurse told him/her that Physician A called and wanted to give the triage nurse a "heads up" that a patient who was 35 weeks pregnant was on his/her way to PPMC from PMH. The L&D CN stated that he/she then called the ED Physician at PMH and the ED Physician told the L&D CN that Patient 6 had already left the ED and was on his/her way to PPMC. The L&D CN stated that after the phone call with the ED physician, the patient presented to the L&D department at PPMC by private car with an IV in his/her arm. The L&D CN stated he/she did not know of any physician to physician communication or any nurse to nurse report received by PPMC prior to the patient leaving PMH. The L&D CN stated he/she did not know of anyone at PPMC that accepted the patient before the patient left PMH.

* An interview was conducted on 07/21/2016 at 1230 with the Quality Management Coordinator. The Quality Management Coordinator stated the hospital had no evidence of EMTALA training for the ED Physician.

3. The ED record for Patient 9 was reviewed. The record reflected the patient presented to the ED on 07/15/2016 at 2334 with a chief complaint of "Motor Vehicle Crash (Pregnant)." The "Means of Arrival" was recorded "Walk-in."

The RN notes dated 07/15/2016 at 2344 reflected "[Patient] c/o...MVC frontal impact at 1200, approx 27 wks preg, high risk r/t miscarriage 1 yr prior, c/o pain cramping/contraction type pain onset 1500..."

The "ED OB Assessment" recorded by the RN on 07/15/2016 at 2359 reflected "...Fetal HR Baseline Rate (Beats/Min): 158...Vaginal Bleeding: spotting."

The "ED Provider Notes" electronically signed by the physician and dated 07/16/2016 at 0054 reflected "...[Patient] with a history pregnancy at 27 weeks and was the restrained driver of a vehicle...the patient started experiencing lower abdominal pain and cramping, bright red vaginal bleeding, and decreased fetal movements. The patient presents with these complaints. Nothing made the symptoms any better or any worse, the abdominal pain radiates [his/her] lower abdomen, symptoms severity is moderate...Our Hospital no longer provides obstetrical services and arrangements were made to transfer the patient...The patient went via private vehicle for prolonged fetal monitoring at [PSVMC].

An untitled transfer form dated 07/16/2016 was reviewed. The "Provider Documentation" section reflected the following:
* "Reason for Transfer: Service Unavailable."
* "Summary of Transfer Benefits: Higher level of service available at receiving facility."
* "Comments: Worsening vaginal bleeding, fetal demise."
* "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* "Accepting/Receiving Facility: [PSVMC]"
* "Mode of Transportation is: Private Auto."
* "The mode of transportation has been discussed and agreed with the receiving provider. The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures."
* The form was electronically signed by the "transfering (sic) Provider" and dated 07/16/2015 at 0059.

The "Departure Condition" recorded by the RN on 07/16/2016 at 0124 reflected "...Departure Mode: With family...[patient] transferred to [PSVMC] for follow up care..."

The transfer was not conducted as required, and in consideration of the documented risks, using qualified personnel and transportation equipment as Patient 9, who was pregnant with vaginal bleeding, was sent by private vehicle at 1330 in the morning to another hospital.

Mapquest reflects PMH is approximately 12 miles from PSVMC with an estimated driving time of 26 minutes.

4. The ED record for Patient 13 was reviewed. The record reflected the patient presented to the ED on 06/15/2016 at 1839 with a chief complaint of chest pain.

The RN notes dated 06/15/2016 at 1845 reflected "[Patient] states [he/she] began to have [chest pain] at 1830 and [shortness of breath]. [Patient] states [he/she] just got out of the hospital with a diagnosis of an MI. [Patient] states [his/her] pain is constant and mid sternal."

The "ED Provider Notes" electronically signed by the physician and dated 06/15/2016 at 1939 reflected "Patient...presents to the emergency department primary complaint of having onset of chest discomfort that radiates into both shoulders and into [his/her] back. Patient states that this is exact same pain [he/she] had when [he/she] presented a week ago and was subsequently found to have coronary artery dissection. ...I discussed the case with [cardiology physician]. At that time it was felt the patient should be transferred over to...[PPMC] for continued management...The patient continued to have chest discomfort...[Patient] was transferred code 3 at that time."

An untitled transfer form dated 06/15/2016 was reviewed. The "Provider Documentation" section dated 06/15/2016 at 1943 reflected the following:
* "Reason for Transfer: Services Unavailable."
* "Summary of Transfer Benefits: Higher level of service available at receiving facility.
* "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* "Summary of Transfer Risks: Risks and benefits of transfer for this individual have been considered, and no other risks beyond those listed above are anticipated."
* "Accepting/Receiving Provider: [cardiology physician]."
* "Accepting/Receiving Facility: PPMC."
* "Mode of Transportation is: ALS."
The form was electronically signed by the "transfering (sic) Provider" and dated 06/15/2016 at 1943.

The record reflected the patient discharged by ambulance on 06/15/2016 at 2117.

There was no documentation to reflect that the physician had identified patient specific transfer risks, and certified that the benefits of the transfer outweighed those patient specific risks.

5. The ED record for Patient 15 was reviewed. The record reflected the patient presented to the ED on 05/20/2016 at 1921 with a chief complaint of "Abdominal Pain (Pregnant)." The acuity was recorded "Emergent." The record reflected the patient arrived by "Walk-in" and was escorted by a family member.

The RN notes dated 05/20/2016 at 1935 reflected "[Patient] reports low abdominal cramping [times] 3 days, [patient] denies fluid leakage or passing mucous. [Patient] confirms fetal activity."

The "ED Provider Notes" electronically signed by the physician and dated 05/20/2016 at 2020 reflected "...Patient has lower abdominal pain in the setting of 32 weeks of pregnancy. Non-peritoneal abdomen with fetal heart tones...on bedside ultrasound with good fetal movement...Discussed case with ObGyn on-call at [KSMC]...[KSMC] agrees with accepting patient by private vehicle. Patient is sent in stable condition with directions to go directly to labor and delivery for fetal monitoring."

An untitled transfer form dated 05/20/2016 was reviewed. The "Provider Documentation" section dated as recorded "05/20/2016 at 2030" reflected the following:
* "Reason for Transfer: Service Unavailable."
* "Summary of Transfer Benefits: Higher level of service available at receiving facility...Fetal Monitoring."
* "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* "Summary of Transfer Risks: Risks and benefits of transfer for this individual have been considered, and no other risks beyond those listed above are anticipated."
* "Accepting/Receiving Facility: Labor and Delivery [KSMC]."
* "Mode of Transportation is: Private Auto."
* "The mode of transportation has been discussed and agreed with by the receiving provider. The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures."
The form was electronically signed by the "transfering (sic) Provider" and dated 05/20/2016 at 2030.

The bottom portion of the form reflected "I acknowledge that my medical condition has been evaluated and explained to me. It is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer, and I consent to be transferred for further care." The "Patient Signature" date and time space on the form was blank.

The record reflected the patient was discharged by private vehicle on 05/20/2016 at 2128.

There was no documentation to reflect that the physician had identified patient specific transfer risks, and certified that the benefits of the transfer outweighed those patient specific risks and risks to the unborn child.

In addition, the transfer was not conducted as required, and in consideration of the documented risks, using qualified personnel and transportation equipment as Patient 15, who was 32 weeks pregnant with complaints of abdominal pain and cramping, was sent by private vehicle to another hospital.

6. The ED record for Patient 17 was reviewed. The record reflected the patient presented to the ED on 04/28/2016 at 1649. The chief complaint was "Abdominal Pain (Pregnant)." The record reflected the patient arrived by "Walk-in" and was escorted by "Self."

The RN notes on the "Patient Care Timeline" dated 04/28/2016 at 1655 reflected the patient's pain was "9" on a numeric pain scale of 1-10.

The "ED Provider Notes" electronically signed by the physician and dated 04/28/2016 at 1726 reflected "...[Patient]...is 6 weeks pregnant and presents with severe, intermittent lower abd pain onset a few days ago. [Patient] states the pain is exacerbated by ambulation...Urine was...positive for pregnancy...US showed a live...ectopic pregnancy...I consulted with the Ob/Gyn on-call at PPMC...who recommended transferring the [patient] to PPMC ED for further evaluation. I discussed with the ED doctor at PPMC...who agreed to accept the [patient]. Patient will travel by POV to PPMC ED for further evaluation."

The RN notes dated 04/28/2016 at 1914 reflected [Patient] ambulated to [bathroom with stand by assist]...[Patient] reports pain...requesting tylenol..."

The RN notes dated 04/28/2016 at 1923 reflected "[Patient] requests Tylenol, spoke with [Physician] and [patient] is NPO at this time. [Patient] may transfer to PPMC ED via private auto with IV in-place.

The RN notes on the "Patient Care Timeline" dated 04/28/2016 at 1938 reflected the patient's pain continued to be "9" on a numeric pain scale of 1-10.

An untitled transfer form dated 04/28/2016 was reviewed. The "Provider Documentation" section dated as recorded "04/28/2016 1912" reflected the following:
* "Summary of Transfer Benefits: Higher level of service available at receiving facility."
* "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* "Summary of Transfer Risks: Risks and benefits of transfer for this individual have been considered, and no other risks beyond those listed above are anticipated."
* "Accepting/Receiving Facility: [PPMC]"
* "Mode of Transportation is: ALS"
* "The mode of transportation has been discussed and agreed with by the receiving provider. The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures."
The form was electronically signed by the "transfering (sic) Provider" and dated 04/28/2016 1912.

The RN notes dated 04/28/2016 at 1946 reflected "[Patient] reports increasing anxiety, SO [at] bedside."

The RN notes dated 04/28/2016 at 2012 reflected the patient's pain was "8" on a numeric pain scale of 1-10 and that "[Patient] reports pain tolerable for transport to PPMC, SO to drive [patient] there. [Patient] reports on-going pain...denies any change in quality of pain...IV to remain in-place for private auto transport."

The RN notes recorded on the "Patient Care Timeline" dated 04/28/2016 at 2013 reflected "...slight nausea...reports low abd pain 8/10 at this time, denies vag bleed..."

The "Departure Condition" recorded by the RN on 04/28/2016 at 2015 reflected "...Mobility at Departure: Wheelchair...Follow-up care reviewed...[Patient] to go straight to PPMC ED...Departure Mode: With family (SO to drive [patient] directly to PPMC ED)."

There was no documentation to reflect that the physician had identified patient specific transfer risks, and certified that the benefits of the transfer outweighed those patient specific risks.

The transfer was not conducted as required, and in consideration of the documented risks, using qualified personnel and transportation equipment as Patient 17, who was pregnant with on-going complaints of pain and an IV in place, was sent by private vehicle with a significant other, to another hospital. In addition, although the transfer form indicated the patient was transferred by ALS, the transfer was actually not conducted as required by qualified personnel and transportation equipment.

7. The ED record for Patient 18 was reviewed. The record reflected the patient presented to the ED on 03/31/2016 at 1118. The chief complaint was severe vaginal bleeding and the acuity was recorded "Urgent." The record reflected the patient arrived by "Walk-in" and was escorted by "Other."

The RN notes dated 03/31/2016 at 1124 reflected "[Patient] is 22Weeks Pregnant. [He/she] woke up with blood in [his/her] underwear c/o spotting that jhas (sic) continued since this am and states [he/she] feels like [his/her] abdomen is contracting."

The "Genitourinary Assessment" documented by the RN on 03/31/2016 at 1140 reflected "...Vaginal bleeding: present...this am [patient] woke up with spotting."

The "ED Provider Notes" electronically signed by the physician and dated 03/31/2016 at 1846 reflected "[Patient] presents with vaginal bleeding. [He/she] is 22 weeks pregnant...[He/she] has some crampy abdominal pain...I do not think [he/she] has any impending delivery and I have a low suspicion for labor, however given the patient's bleeding and abdominal discomfort I believe [he/she] needs to be transferred to a OB facility." The "ED Summary & Decision Making" reflected "I discussed the case with patient and the patient's partner. I explained that we do not have OB facility here and that [he/she] would need to be transferred to an OB facility for full evaluation to rule out labor and other significant problems that could threaten [his/her] health and the pregnancy as well...they prefer to go by private vehicle. I do not believe the patient has impending delivery and I think it would be safe to go by private vehicle at this time. They voiced their intention to go directly to PPMC OB department."

An untitled patient transfer form dated 03/31/2016 was reviewed. The "Provider Documentation" section dated as recorded "03/31/2016 1205" reflected the