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Based on medical Record review, policy and procedure review, Physician on-call schedule review, and staff interviews Union General Hospital (Facility #1) which had specialized Obstetrical capabilities and capacity refused to accept from from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required obstetrical services for 1 (Patient #1) of 20 sampled medical records reviewed. Refer to findings in Tag A-2411.

Based on medical Record review, policy and procedure review, Physician on-call schedule review, and staff interviews Union General Hospital (Facility #1) which had specialized Obstetrical capabilities and capacity refused to accept from from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required obstetrical services for 1 (Patient #1) of 20 sampled medical records reviewed.

The findings included:

1. Medical Record Review for patient #1


A review of the medical record from Facility #2 (referring hospital) revealed that Patient #1 arrived to the emergency department (ED) on 12/13/18 at 8:30 p.m. with complaints of abdominal cramping and low back pain. Patient #1 had a triage assessment by registered nurse (RN) and was placed in a patient room. A medical screening exam (MSE) was completed by Nurse Practitioner (NP) DD beginning at 9:35 p.m. and revealed that the patient reported that she was 33 weeks pregnant and had received routine prenatal care. Physician CC documented that Patient #1 complained of diffuse abdominal and low back pain as well as nausea and vomiting. A vaginal exam performed by Physician CC revealed that Patient #1 was approximately 33 weeks pregnant and her cervix was not dilated. The record further revealed that fetal heart tones (FHT) were assessed every 15 minutes. At 9:38 p.m. Physician CC documented that Patient #1 had a certified emergency medical condition (EMC). Physician CC spoke with Physician BB at 9:44 p.m. and requested to transfer Patient #1 to Facility #1. Physician CC documented that (Physician BB) " refuses transfer " . The record revealed that Patient #1 was transferred to Facility #3 at 11:53 p.m.


2. Staff Interviews:

During an interview with Obstetrician (OB) BB on 01/22/19 at 11:40 a.m. in the Administration Conference Room, the OB stated that he had been the facility ' s (facility #1) OB Director since 2006. OB BB stated that he remembered the call regarding Patient #1. OB BB stated that he received a call from facility ' s (facility #2) Emergency Department (ED) in December. Patient #1 had been staying at a local cabin for the holidays and was pregnant. OB BB recalled that he returned the call to Facility #2 and spoke with the ED Medical Doctor (MD) CC. OB BB revealed that the ED MD CC explained to him that Patient #1 was 33 weeks pregnant and had presented to their facility ED with a complaint of contractions. Per ED MD CC, the patient was given a pelvic exam and had not been found to be in active labor. ED MD CC felt that despite the patient not being in labor, the patient and fetus needed to be monitored. OB BB stated that he explained to ED MD CC that there was a facility that offered NICU and high-risk pregnancy care, and that facility was approximately the same distance away. OB BB stated that he explained to ED MD CC that facility #1 was a Level 1 obstetrics facility. He added that if the patient or the baby needed a higher level of care, they would have to be transferred to a facility that could treat patients that required a NICU or high-risk pregnancies. OB BB stated that ED MD CC asked, " Will you take the patient? " , and OB BB replied by stating, " Well, I think you have better choices. " OB BB stated ED MD CC hung up the phone without saying anything further. OB BB stated that he did not refuse the patient, and he thought they were in the middle of a conversation. OB BB stated that if ED MD CC had stated that they were Patient #1 over, he would not have refused the patient. OB BB stated that he did not call ED MD CC back. OB BB stated that his understanding of EMTALA was that if a facility had the available services, an accepting MD, and an open bed, the facility must accept the patient. OB BB stated again that he would have accepted the patient. He explained that he was only attempting to ensure that the patient and the unborn fetus received the level of care that they needed. OB BB confirmed that the facility had open beds on the day that ED MD CC called. OB BB stated that he lives approximately two (2) miles away, and the OB staff is always able to respond to the facility within thirty (30) minutes.
During a telephone interview with facility #2 ' s ED MD CC on 1/23/19, at 2:30 p.m. in the Administration Conference Room, the ED MD CC confirmed that he was working the 7:00 p.m. to 7:00 a.m. shift on 12/13/18. He indicated that he remembered the patient. The ED MD CC stated that Patient #1 presented the ED with a complaint of possibly being in labor. He added that the patient reported being approximately 33 weeks pregnant, and the patient had a history of a previous delivery. ED MD CC stated the patient indicated that the contractions were like the labor pains she experienced during her previous delivery. ED MD CC stated that he assessed the patient, and the labs and the pelvic exam were negative. He stated that his differential diagnosis was that the patient was more than likely experiencing Braxton Hicks (false labor). ED MD CC stated that he was not entirely sure that the patient was not in premature labor, so he believed the patient should be monitored. He revealed that Facility #2 was not able to provide the appropriate care for a premature baby or high-risk pregnancy. ED MD CC explained that he attempted to contact the patient ' s obstetrician, but he was unable to reach anyone and left a message with the answering service. ED MD CC stated that at 9:49 p.m. he spoke with OB BB at the facility Facility #1, and OB BB stated that they were not equipped to care for a 33 gestational pregnancy. ED MD CC stated that OB BB refused the transfer. He revealed that he was unaware of what facility #1 ' s capabilities were regarding a NICU or high-risk pregnancy patient. He stated that he was unsure if the refusal of the transfer by facility #1 was an EMTALA violation. ED MD CC stated that he understood the reluctance of OB BB to accept Patient #1 if they were not capable of treating a premature labor at 33 weeks gestation. ED MD CC stated that he did not recall how the call ended. He stated that he was concerned about the patient, and he wanted to get back to her treatment room. He explained that an MD that who was on-call for Patient #1 ' s obstetrics group called him back and stated that it would be acceptable to send the patient to the nearest hospital for monitoring. ED MD CC stated he contacted Facility #3, and they accepted Patient #1. ED MD CC revealed that he was unaware of what Facility #3 ' s capabilities were regarding for a patient in premature labor. ED MD CC stated that the accepting MD at facility #3 did not sound concerned about the patient ' s gestation or presenting complaint.

During a telephone interview with Facility #2 ' s Nurse Practitioner (NP) DD on 1/23/19, at 4:08 p.m. in the Administration Conference Room, NP DD confirmed that she had been working in the facility ' s ED, from 3:00 p.m. to 11:00 p.m. on 12/13/18. NP DD indicated that she remembered Patient #1. She explained that she assessed the patient within minutes of the patient ' s arrival. She recalled that Patient #1 presented to the ED with a complaint of nausea, vomiting, and lower back pain. The patient reported being 33 weeks pregnant and stated that she had received prenatal care. The patient added that she had a history of placenta previa (when the placenta covers the opening in the cervix) earlier in the pregnancy, but she stated that was resolved. NP DD stated that after the patient ' s assessment, she apprised ED MD CC of the patient ' s status, and ED MD CC assumed care of Patient #1. NP DD stated that ED MD CC performed a pelvic exam on Patient #1 and started arranging for a transfer for the patient. She added that Facility #2 did not have OB services or any OB providers on staff. NP DD recalled that she overheard ED MD CC attempting to reach the patient ' s private OB. After speaking with the patient ' s OB group, ED MD CC revealed that the patient had been discharged from the OB practice due to illicit drug use. NP DD added that she remembered that precisely because the patient had not offered that information during the assessment. NP DD stated that she overheard ED MD CC say that the Facility #1 had refused to accept the patient, but she stated she did not know what the reason was for the refusal. She added that for the remainder of the patient ' s ED encounter, she had no interaction with Patient #1, and she was unaware of where the patient was transferred. NP DD stated she was unaware of what level of OB care Facility #1 offered. NP DD remembered that Facility #2 had transferred a patient with an ectopic pregnancy to facility #1 in the past, and the facility readily accepted the patient.

During an interview with the Chief Executive Officer (CEO) AA on 01/22/19 at 11:23 a.m. in the Administration Conference Room, the CEO AA explained that the facility ' s Director of Quality and Risk Management informed him that the Chief Officer of Quality at Facility #2 was reporting Facility #1 for an EMTALA violation. The CEO stated that the complaint was related to an allegation that the Facility #1 refused to accept an obstetrics patient, on or about, 12/13/18. The CEO stated that Patient #1 was approximately 33 weeks pregnant and was from the Atlanta area. CEO AA revealed that Facility #1 ' s obstetrician, OB BB, believed that based on the patient ' s presentation and the gestation of the pregnancy, Patient #1 would receive a higher level of care at another facility. CEO AA explained that OB BB determined that the distance to a facility that offered Neonatal Intensive Care Unit (NICU) and high-risk obstetrics care was comparable to the distance to their facility. CEO AA stated that Facility #2 claimed they had no OB services. CEO AA added that he did not believe that OB BB had denied the transfer, but he felt that OB BB needed to explain the sequence of events, as the CEO was not present during the encounter. The CEO stated that Facility #1 does not record calls that come into the facility, and the facility does not have a call center.

3. Facility #1's OB/GYN Physician On-Call Schedule - 12/2018.

The facility's physician On-Call schedule 12/2018 for Womens Health was reviewed. The review verified that that OB/MD -BB was on call on 12/13/2018 when a request was made from the referring hospital (Hospital #2) requesting the transfer of Patient #1 on 12/13/2018.

4. Review of Facility #1 ' s policies and procedures included but was not limited to:

The facility's Policy titled "EMTALA" policy # 2401805, originated 8/12/13, last approved 6/17/16 was reviewed. The policy revealed in part, "XI. Receipt of Transfer's from other facilities. A. The hospital shall accept Transfer of an individual who requires specialized capabilities or facilities if the hospital has such specialized capabilities or facilities and also has the capacity to treat the individual."

Facility #1 failed to ensure that their policy and procedure was followed as evidenced by refusing to accept Patient #1 on 12/13/2018. The facility had the specialized capabilities(OB on call MD) and services (Capacity) (not available at the refereeing facility) to accept Patient #1 on 12/13/2018.