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Based on medical record review, policy review, obstetric guidelines review, standards of care review, and patient and staff interview, it was determined the facility failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24: Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Refer to A - 2406 as it relates to the facility's failure to provide an appropriate MSE for 9 of 20 patients (Patient #2, #5, #6, #7, #8, #10, #9, #15,and #18) whose records were reviewed.

Refer to A - 2408 as it relates to the facility's requirement for patients to sign binding financial consents as a condition to be treated in the ED for 20 of 20 patients (Patients #1 thru #20) whose records were reviewed.

Refer to A - 2409 as it relates to the facility's failure to ensure an appropriate transfer for 2 of 20 patients (Patients #17 and #3) whose records were reviewed.

Noncompliance with 42 CFR Part 489.24 had the ability to negatively affect all patients who presented to the ED seeking emergency care.

Based on record review, policy review, review of obstetric guidelines, patient interview, and staff interview, it was determined the hospital failed to provide an appropriate MSE for 9 of 20 patients (Patient #2, #5, #6, #7, #8, #9, #10, #15, and #18) whose records were reviewed. This failure had to the potential to result in EMC going un treated and patients not receiving appropriate stabilizing treatments. Findings include:

A hospital policy titled "EMTALA Guidelines" dated 2/12/24 stated: "The facility must: Provide for an appropriate medical screening examination that includes providing all necessary testing and on call services within the capability of the hospital to reach a diagnosis." The policy also included: "The Emergency Room provider on shift is the designated Medical Screen Examiner." The policy also included: "The patient has the right to leave without being seen by Medical Screening Provider (ED physician). In such cases, the hospital will: ... The hospital will take reasonable steps to follow up with the patient via phone call." This policy was not followed. Examples include:

1. Patient #2 was a 25 year old pregnant female who presented to the ED on 7/09/24 with a chief complaint of "pregnant 12 wk [week] bleeding." Patient #2 was listed as LWBS on the ED log. Patient #2's ED medical record included a signed consent to treat and an AMA form, signed by Patient #2 and the RN. The AMA form stated the reason for Patient #2 leaving was "went to [different hospital]." There was no medical screening exam to determine if an EMC existed for Patient #2. It was unclear why Patient #2 left the facility without an MSE despite her bleeding.

Patient #2's medical record from the receiving hospital's ED was requested and reviewed. It stated, "Patient presents emergency department today for pelvic pain and vaginal bleeding. Patient states that she is 13 weeks pregnant. She states that today she has had some nausea vomiting and diarrhea and felt like she had a stomach flu. She states that about an hour prior to arrival she began with cramping and heavy vaginal bleeding and so came here for evaluation." The record stated Patient #2 miscarried while in the ED and was given methylergonovine to control her bleeding. Patient #2 was discharged to home from the ED.

The nurse who was responsible for Patient #2 was interviewed on 9/17/24 beginning at 3:08 PM and Patient #2's medical record was reviewed with her. She confirmed she remembered seeing Patient #2 in July 2024. When asked to go over the details of what happened with Patient #2, the nurse stated she triaged Patient #2, and Patient #2 was concerned the ED waiting room was full and did not want to wait. The nurse stated she told Patient #2 the provider would see her as soon as possible and encouraged her to stay and be seen. When asked if she told Patient #2 about wait times, the nurse stated, "I don't ever tell people about wait times."

Patient #2 was interviewed by phone on 9/18/24 beginning at 8:59 AM. Patient #2 confirmed she presented to the ED on 7/09/24 and was asked to explain her visit. Patient #2 stated she presented with blood on her clothes and "down to my socks." She stated a nurse took her vitals and told her to go sit down. She stated when she asked if she would have to wait long a staff member told her, "Yeah I have a pretty full department," and the front desk told her the wait could be up to 2 hours. When asked if the nurse tried to encourage her to stay she said "no - not at all." She stated the nurse told her, "If you want to leave you're gonna [sic] have to sign this paper," and did not explain the AMA form. When asked why she left, Patient #2 stated, "The amount I was bleeding - I was afraid I was hemorrhaging. I knew something was seriously wrong."

Patient #2 was not provided an MSE. Additionally, it was unclear why Patient #2 signed an AMA form despite not being seen by an ED provider.

2. Patient #15 was a 41 year old female who presented to the ED on 8/13/24 with a chief complaint of uterine contractions. She was listed as a transfer to acute care hospital. The ED log stated from arrival to discharge time was 27 minutes.

According to American College of Obstetricians and Gynecologists, "Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed. A normal fetal heart rate can reassure both you and your obstetrician-gynecologist (ob-gyn) or other health care professional that it is safe to continue labor if no other problems are present." (https://www.acog.org/womens-health/faqs/fetal-heart-rate-monitoring-during-labor#:~:text=What%20is%20fetal%20heart%20rate,no%20other%20problems%20are%20present. Accessed 9/23/24)

Patient #15's ED note stated, "41-year-old female G4 P3 at 36 weeks 5 days gestation who presents with contractions that are currently 4 minutes apart, She states that her obstetrician is in Idaho Falls but she lives here so decided to come here instead. She denies loss of fluid, vaginal discharge, or vaginal bleeding." It also stated, "Patient presents with complaints of uterine contractions 4 minutes apart. Pelvic exam reveals no cervical changes so no definitive sign of active labor at this time. I called and spoke to [Physician A] and she recommends transfer to [nearby obstetric hospital] for fetal monitoring and further evaluation and management of possible progressing maternal labor. Discussed all this with patient and patient's spouse were in agreement to have patient transferred via ambulance to [nearby obstetric hospital]. Patient is in good condition at time of transfer."

The ED note did not include documentation of fetal heart tones. Due to the lack of fetal heart tones performed, it was unclear what the status of the fetus was at the time of transfer.

Patient #15's record from the receiving hospital was requested and reviewed. It stated her labor progressed slowly over 10 hours and she delivered the baby on 8/14/24.

The Acute Care Nurse Manager was interviewed on 9/18/24 at 12:16 PM and Patient #15's record was reviewed in her presence. She confirmed there were no fetal heart tones documented for Patient #15's fetus. When asked if she would have expected fetal heart tones in this scenario she said, "generally, yeah."

Patient #15 was not provided an MSE to determine status of the fetus.

3. Patient #7 presented to the ED on 3/23/24 at 1:37 PM with a chief complaint of "Abdominal pain." Patient #7 received a triage assessment at 2:59 PM, 1 hour and 22 minutes after arrival, from the on-duty RN that included: "Has increased abdomen pain and cramping that's been going on for several months. States having body aches, fevers, nausea, diarrhea, ab [abdominal] cramping. Reports weight loss." The triage assessment stated Patient #7 was currently experiencing a 7 out of 10 pain, with 10 being the worst pain. Additionally, the triage assessment included a full set of vital signs for Patient #7 which included a blood pressure of 212/159 mm/hg, and a pulse of 136 bpm. Patient was triaged at an acuity of "3 urgent."

Patient #7's medical record included an abdominal assessment done by an RN at 3:19 PM. The assessment included: "Nausea, vomiting, diarrhea, fever state[sic] abdomen cramping with diarrhea. Recently stopped Metformin and metoprolol which PCP felt may be contributing."

Patient #7's medical record did not include an ED provider note.

Patient #7's medical record included a form titled "Leaving Against Medical Advice." The section titled "Reason for Leaving" was blank. The form was checked as Patient #7 "did not read the form, just left." There was no documentation the risks of leaving without being seen were explained to Patient #7.

The Acute Care Nurse Manager was interviewed on 7/17/24 beginning at 3:45 PM, and Patient #7's medical record was reviewed in her presence. When asked if an MSE was provided to Patient #7 she confirmed there was no documentation the ED provider provided an MSE. Additionally, she confirmed there was no additional documentation on why Patient #7 was not provided an MSE. When asked what the facility's expectation for Patient #7 out of range vital signs, she stated she would expect the on duty provider to be notified of the elevated blood pressure and pulse. She confirmed Patient #7 should have been reassessed within 20 minutes after discovering the out-of-range vital signs.

Patient #7 was interviewed by phone on 9/18/24 beginning at 9:55 AM . When asked about he ED visit on 3/23/24 she stated she presented with severe abdominal pain, and was dissatisfied with the care she received. She stated she was brought into the triage room and assessed by the RN and then placed in the lobby. Patient #7 stated she asked how long it would be and the front desk receptionist told her "we don't know." She stated she was frustrated after waiting for "a long time" and left. Surveyors asked if anyone at the facility discussed the risks of leaving without being seen with her and she stated "no."

There was no documentation an MSE was provided for Patient #7.

4. Patient #8 presented to the ED on 3/30/24 at 6:20 PM with a chief complaint of "right side pain." Patient #8 received a triage assessment from the on-duty RN that included: "Pt reports intermittent stabbing and throbbing pain up to 9/10 [9 out of 10 pain with a 10 being the worst]. Does not appear in distress. Pt reports no activities which exacerbate pain. She reports it can even wake her from a deep sleep." The triage assessment included that Patient #8 was currently experiencing a 9 out of 10 pain, with 10 being the worst pain.

Patient #8's medical record included a ED provider note. The narrative included "Patient left without being seen."

Patient #8's medical record included a form titled "Leaving Against Medical Advice." The form was timed at 8:18 PM. 1 hour and 58 minutes after Patient #8's triage assessment. In the section titled "Reason for Leaving" was written, "Taking too long to see the doctor."

The Acute Care Nurse Manager was interviewed on 9/17/24 beginning at 3:45 PM, and Patient #8's medical record was reviewed in her presence. When asked if an MSE was provided to Patient #8 she confirmed there was no documentation the ED provider provided an MSE. Additionally, she confirmed there was no additional documentation on why Patient #8 was not provided an MSE.

There was no documentation an MSE was provided for Patient #8

5. Patient #6 presented to the ED on 3/27/24 at 12:31 PM with a chief complaint of "worsening back pain". Patient #6 received a triage assessment at 13:18 from the on-duty RN that included: "mid and lower back pain. Radiates to bilat [bilateral] legs x 3wks [ for three weeks]. Worse today." The triage assessment included that Patient #6 was currently experiencing a 8 out of 10 pain, with 10 being the worst pain.

Patient #6's medical record did not include an ED provider note.

Patient #6's medical record included a form titled "Leaving Against Medical Advice." The form was timed at 12:31 PM. 49 minutes before Patient #6's triage assessment. In the section titled "Reason for Leaving" was written, "Pt made appt [appointment] with PCP." The form was checked as Patient #6 "did not read the form, just left." There was no documentation the risks of leaving without being seen were explained to the patient.

The Acute Care Nurse Manager was interviewed on 9/17/24 beginning at 3:45 PM, and Patient #6's medical record was reviewed in her presence. When asked if a MSE was provided to Patient #6 she confirmed there was no documentation the ED provider provided an MSE. Additionally, she confirmed there was no additional documentation on why Patient #6 was not provided an MSE. She stated there was no documentation the risks of leaving without being seen by the provider were documented. When asked why the "Leaving Against Medical Advice" form was signed before Patient #6's triage she stated that she did not know why.

There was no documentation an MSE was provided for Patient #6. Additionally, there was no documentation the risks of leaving without receiving an MSE were explained to Patient #6.

6. Patient #9 presented to the ED on 5/15/24 at 9:14 PM with a chief complaint of "diarrhea." Patient #9 received a triage assessment at 9:19 PM from the on-duty RN that included: "pt reports diagnosed with c-diff 1 week ago is currently taken [sic] home medications for treatment unable to get abdominal cramping under control would like info and set up for fecal transplant due to several times of having c-diff pt reports pain 7-10 nausea vomiting." The triage assessment included that Patient #9 was currently experiencing a 7 out of 10 pain, with 10 being the worst pain.

Patient #9's medical record did not include an ED provider note.

Patient #9's medical record included a form titled "Leaving Against Medical Advice." The form was timed at 11:30 PM, 2 hours and 16 minutes after her arrival. In the section titled "Reason for Leaving" was written, "Not worth the wait."

The Acute Care Nurse Manager was interviewed on 9/17/24 beginning at 3:45 PM, and Patient #9's medical record was reviewed in her presence. When asked if an MSE was provided to Patient #9 she confirmed there was no documentation the ED provider provided an MSE. Additionally, she confirmed there was no additional documentation on why Patient #9 was not provided an MSE.

There was no documentation an MSE was provided for Patient #9.

7. Patient #10 was a 28 year old female who presented to the ED on 8/10/24 at 10:56 PM with a chief complaint of "possible ruptured cyst" and abdominal pain. Patient #10 was triaged at 11:22 PM with a triage status of "3 urgent." There was no MSE provided and Patient #10 LWBS at 12:53 AM on 8/11/24.

It was unclear why Patient #10 was not provided an MSE in the 1 hour and 57 minutes she waited in the ED despite her "urgent" triage status. Additionally, there was no documentation of follow up via phone call per facility policy with Patient #10.

There was no documentation an MSE was provided for Patient #10.

8. Patient #18 was a 20 year old female who presented to the ED on 9/06/24 at 2:46 AM with a chief complaint of "36 wks [weeks] abd [abdominal] pain."

Patient #18's record included a provider note which stated, "Patient is a 20-year-old female presenting to the emergency department complaining of intermittent abdominal pain. Patient states she woke up at 150 with pain of her abdomen, She states while coming to the hospital she has had 3 contractions. She states that she thinks they are approximately 5 minutes apart but admits that she is not exactly tract how long the contractions are lasting nor how
far apart they really are. Patient states she feels very anxious as 'I am not ready to deliver this baby yet'. She states she follows with Dr. Black. She denies that her water has broke."

The provider note included a section titled "Medical decision making narrative," which stated, "Patient is seen and examined. Patient presents with contractions and is at risk for preterm labor. Her water has not broken. Fetal heart tones are 131. I discussed the case with Dr. [name] at 0251 who accepts patient for transfer to [name] Medical Center. EMS is called and transported patient to [hospital name] without further incident."

Patient #18's medical record did not include documentation of a pelvic exam to check for cervical dilation or fetal crowning. It was unclear how the provider determined patient #18 was in preterm labor without a pelvic exam.

Patient #18 did not receive a complete MSE to determine labor status.

9. Patient #5 was a 25 year old female who presented to the ED on 3/21/24 with a chief complaint of "6 mths preg. [months pregnant] abdominal pain."

Patient #5's record included a provider note which went over the course of treatment for her stay in the ED. It stated, "Patient seen and examined. Differential diagnosis includes but is not limited to urinary tract infection, STI, bacterial vaginosis, threatened miscarriage in any of the various stages, and other. Patient denies any dysuria or urinary urgency after urination. Labs will be obtained. Patient is given a liter of IV fluids. Ultrasound is performed. Per the ultrasound tech no acute abnormalities were seen on the ultrasound. Fetal heart rate is 141. Cervix is closed. I reviewed the ultrasound results with the patient and encouraged her to follow-up with her OB/GYN regarding the definitive ultrasound results. Patient is positive for Gardnerella. She is given a prescription for Flagyl 500 mg twice daily for 7 days. Remainder of labs were reviewed as part of the MDM process and considered in the treatment plan. All questions and concerns were addressed and patient is discharged home in improved and stable condition."

Patient #5's medical record did not include documentation of interventions within the capabilities of the hospital to determine whether the pelvic pain was a manifestation of contractions to determine if the discharge would pose a threat to the health or safety of the patient or fetus. There was no documentation additional physical exam was done, additional history was taken, or observation for further evaluation of the progression/resolution of the pain symptoms was done to determine if Patient #5 was in labor.

The MSE for Patient #5 was not reasonably calculated to identify if an emergency was present.


42316

Based on patient and staff interview and review of medical records and facility policies, it was determined patients were required to sign binding financial consents as a condition to be treated in the ED. This directly affected 20 of 20 patients (Patient #1 - #20) whose records were reviewed, and 3 of 4 patients (Patient #7, #10, #3) who had Medicaid as their insurance provider and whose record was reviewed. This systemic failure had the potential to discourage patients from receiving an MSE due to financial costs, insurance status, and associated financial stipulations. Findings include:

1. Patients had to agree to a financial agreement established by the hospital, including interest rates, agreement to a credit report for collection of bills, and payment legal fees, in order to recieve an MSE in the hospital's dedicated ED. Examples include:

a. A form titled, "Conditions of Admission to Bingham Memorial Hospital" was reviewed. The form included a section to be filled out by the patient including the patient's name, date of birth, social security number, and their presenting chief complaint. The form included a signature line and date.

The form included a section for consent to treat for services rendered in the ED.

The form also included a section titled "FINANCIAL AGREEMENT AND ASSIGNMENT OF INSURANCE BENEFITS." The section included, "I understand that I am financially responsible for charges not covered by my hospitalization plan. If this account is not paid according to the terms of the hospital's credit policy, I agree to pay interest at the rate of 18% APR and/ or costs of collection, not to exceed 50% of reasonable legal fees and court costs. I Authorize Bingham Memorial Hospital to pull my credit report for collection of my bill."

A front desk registration clerk, working in the ED, was interviewed on 9/17/24 beginning at 2:27 PM. When asked the process for registration of patients presenting the ED she stated she takes the patients name, birthday, and has them sign the consents to be seen. She confirmed the consent to be seen was the above described "Conditions of Admission to Bingham Memorial Hospital."

A second front desk registration clerk, who was working in the ED, was interviewed on 9/18/24 beginning at 10:05 AM. When asked the process for registration of patients presenting to the ED, she stated she gets their name and chief complaint, and has patients sign the "Conditions of Admission to Bingham Memorial Hospital" consent form. When asked how she explains the "FINANCIAL AGREEMENT AND ASSIGNMENT OF INSURANCE BENEFITS" portion of the form to patients, she stated, she has not had anyone ask about it so she is "not sure on the explanation." Additionally, she stated the form must be signed to be seen in the ED.

Twenty of 20 ED records reviewed included the form titled "Conditions of Admission to Bingham Memorial Hospital." All patients whose records were reviewed were required to sign the financial agreement as described above as a condition to receive an MSE in the hospital's Emergency Department.

2. Patients with Medicaid insurance coverage were required to sign financial agreements prior to recieving an MSE in the facility's ED. Examples included:

a. Patient #7 was a 52 year old female who presented to the ED on 3/23/24 with a chief complaint of abdominal pain. She left without being seen after waiting for 2 hours and 18 minutes in the ED.

Patient #7's record included a form titled "Advance Notice Waiver of Liability" which was signed by Patient #7 on 3/23/24. The form stated, "Medicaid will only pay for services that they determine to be reasonable and necessary or covered under your personal plan; In the case of an Emergency room visits, Medicaid only covers 6 per year (unless you are on a Healthy connections for this date of service); If the criteria Is not met, It Is likely that Medicaid will deny payment for your Emergency room visit and you will be responsible for services not covered during this visit," and, "I have been notified that Medicaid can deny payment for my Emergency Room visit for any of the reasons mentioned above. If Medicaid denies payment for my Emergency Room visit ... I agree to be personally and fully responsible for payment."

It was unclear why Patient #7 signed a financial agreement to pay despite an ED provider not seeing her. It was unclear if this form caused Patient #7 to leave without being seen.

The Acute Care Nurse Manager was interviewed on 9/17/24 beginning at 3:45 PM and Patient #7's record was reviewed with her. She confirmed Patient #7 was not seen by an ED provider but still had signed the financial agreement.

b. Patient #10 was a 28 year old female who presented to the ED on 8/10/24 with a chief complaint of abdominal pain. She left without being seen after waiting for 108 minutes in the ED.

Patient #10's record included a form titled "Advance Notice Waiver of Liability" which was signed by Patient #10 on 8/10/24 at 11:28 PM. The form stated, "Medicaid will only pay for services that they determine to be reasonable and necessary or covered under your personal plan; In the case of an Emergency room visits, Medicaid only covers 6 per year (unless you are on a Healthy connections for this date of service); If the criteria Is not met, It Is likely that Medicaid will deny payment for your Emergency room visit and you will be responsible for services not covered during this visit," and, "I have been notified that Medicaid can deny payment for my Emergency Room visit for any of the reasons mentioned above. If Medicaid denies payment for my Emergency Room visit ... I agree to be personally and fully responsible for payment."

It was unclear why Patient #10 signed a financial agreement to pay despite not an ED provider not seeing her. It was unclear if this form caused Patient #10 to leave without being seen.

The Acute Care Nurse Manager was interviewed on 9/18/24 beginning at 12:16 PM and Patient #10's record was reviewed with her. She confirmed Patient #10 was not seen by an ED provider but still had signed the financial agreement.

c. Patient #3 was a 17 year old female who presented to the ED on 5/31/24 with a chief complaint of abdominal pain. She was transferred to an area hospital on 6/01/24 at 2:00 AM.

Patient #3's record included a form titled "Advance Notice Waiver of Liability" which was signed by Patient #3 on 5/31/24 but there was no time on the form. The form stated, "Medicaid will only pay for services that they determine to be reasonable and necessary or covered under your personal plan; In the case of an Emergency room visits, Medicaid only covers 6 per year (unless you are on a Healthy connections for this date of service); If the criteria Is not met, It Is likely that Medicaid will deny payment for your Emergency room visit and you will be responsible for services not covered during this visit," and, "I have been notified that Medicaid can deny payment for my Emergency Room visit for any of the reasons mentioned above. If Medicaid denies payment for my Emergency Room visit ... I agree to be personally and fully responsible for payment."

It was unclear if Patient #3 signed the Medicaid financial agreement before being seen by the provider due to the form not being timed.

The Acute Care Nurse Manager was interviewed on 9/18/24 beginning at 12:16 PM and Patient #3's record was reviewed with her. She confirmed there was no time on the form and therefore could not confirm if the form was signed before or after Patient #3 was seen by an ED provider.



42316

Based on medical record review, patient interview, and staff interview, it was determined the facility failed to ensure an appropriate transfer for 2 of 20 patients (Patients #17 and #3) whose records were reviewed. This caused one patient with imminent delivery to be transferred, and another patient to be transferred by personal vehicle despite the benefits of an ambulance transfer not being explained. This had the potential to result in deterioration of pregnant patients and their fetuses during the transfer. Findings include:

1. Patient #17 was a 23 year old female who presented to the ED on 8/31/24 at with a chief complaint of uterine contractions. She was listed as a transfer to acute care hospital. The ED log stated from arrival to discharge time was 26 minutes. Patient #17 was transferred at 8:26 AM.

Patient #17's ED note stated, "Patient presents to the emergency department concern for contractions, approximately 3 minutes apart. 39 weeks pregnant, does see an OB/GYN up in Burley Idaho. Had some leakage of fluid but has not had any since arriving to the ER. Denies any previous OB history or any difficulty with pregnancy. No other symptoms." It also stated, "Patient brought to bed #3 immediately upon arrival, she was placed in a dorsolithotomy position, utilizing sterile gloves I checked her cervix but does appear to be fully effaced and approximate 9 to 10 cm dilated. There is a present bulging bag with what feels as though palpable fetal crown. Fetal heart rate of 145 on Doppler. Dr. [physician A name] arrived to the emergency department immediately and helped assist. Patient was found to be 9 cm with a bulging placenta and a ruptured membranes yet. Dr.[physician A name] and I decided the patient was not at a risk for imminent delivery and she was transferred to [obstetric hospital] to labor and delivery for delivery. Patient transferred via ground EMS." It did not say what type of equipment or monitoring was needed for the transfer. It did not say what personnel rode with Patient #17 in the ambulance.

Patient #17's medical record included a document titled "Interfacility Transfer Consent and Checklist," dated 8/31/24 at 8:26 AM. It stated, "I understand that I am being transferred because ... I require specialized services which are not available at this time at this facility." It also stated, "Medical condition that warrants transport: delivery ... risks (including but not limited to): death/disability." It did not include monitoring needed in the ambulance.

Patient #17's record from the receiving hospital was requested and reviewed. It stated the delivery was unremarkable. It did not say how many cm dilated Patient #17 was. It did not say if Physician A rode in the ambulance with Patient #17. The note was documented by Physician A at 10:24 AM on 8/31/24.

Physician A, an obstetrician, was interviewed on 9/17/24 beginning at 4:27 PM and Patient #17's record was reviewed in her presence. She stated she has privileges at Bingham Memorial Hospital and the nearby obstetric hospital. She was asked what she considers active labor and she said beyond 6 cm dilation. She stated when she sees patients in the ED she decides if they have time to get to the obstetric hospital or need to deliver in the ED. When asked why they would decide to transfer Patient #17 who was 9-10 cm dilated, fully effaced, and with a palpable fetal crown she stated, "She was only 7 cm." When reviewing the documentation that stated Patient #17 was 9-10 cm, Physician A stated, "they were incorrect in their check." She stated she rode in the ambulance with Patient #17 to the obstetric hospital. When asked if she documented that Patient #17 was only 7 cm dilated, she stated she did not at the time. Physician A reviewed the documentation in the presence of the surveyor and was not able to find documentation that Patient #17 was 7 cm and was not able to find documentation that she rode in the ambulance with Patient #17 to the obstetric hospital. When asked why Patient #17 was transferred with documentation showing delivery was imminent, Physician A stated, "I knew I had time to get to a hospital with a better setup."

2. Patient #3 was a 17 year old female who presented to the ED on 5/31/24 with a chief complaint of abdominal pain. She was transferred to an area hospital on 6/01/24 at 2:00 AM.

Patient #3's medical record included a form titled, "Transport by Private Vehicle Consent and Checklist," dated 6/01/24 and signed by Patient #3, Physician B, and the RN. It stated the following:
- Risks of transfer by private vehicle included "MVC [motor vehicle collision]."
- Benefits of the personal vehicle transfer included, "faster, cheaper."
- "I request to be transported by private vehicle."
- "By refusing the ambulance transfer and requesting to be transported by private vehicle, I understand that I am acting against medical advice and my payer may not pay for this visit."
- "I understand I need to be seen at another facility because I require specialized services which are not available, at this time, at this facility."

Patient #3's medical record included a form titled "ER TRANSFER SUMMARY," signed by the nurse on 6/01/24 at 1:19 AM. It stated, "diagnosis/reason for transfer ... fetal monitoring / abd [abdominal] pain."

It was unclear if Patient #3 consenting to the transfer was acting against medical advice. It was unclear what the medical benefit of going by personal vehicle was. It was unclear what the medical risks of transferring by personal vehicle were.

Patient #3 was interviewed by phone on 9/18/24 beginning at 9:39 AM. She confirmed she remembered her ED visit on 5/31/24. She confirmed she went in her own car. When asked how she decided to go in her own car she stated, "I was told it would be easier that way."

Physician B was interviewed on 9/18/24 beginning at 11:30 AM and Patient #3's record was reviewed in his presence. He stated the nearby obstetric hospital was roughly 1.5 miles away. He stated he offers patients to go by ambulance and they usually just go in their own car. When reviewing the documentation for Patient #3 which stated a personal vehicle transfer was "faster, cheaper," he stated "I don't know if I discussed it with the patient but that's the benefits."

It was unclear if the medical benefits outweighed the risks of the personal vehicle transfer for Patient #3.