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Based on review of facility documents and medical records (MR) and staff interviews (EMP), it was determined that the facility failed to provide an appropriate medical screening within its capabilities for two of 12 obstetrical patients (MR1 and MR14) prior to transfer.

Findings include:

Review of the Rules and Regulations of the Medical/Dental Staff reviewed December 2014 revealed, " I. Admission and Discharge of Patient ... 1. General ... b. Only patients who who can be cared for within the capabilities of the hospital shall be admitted ... B. Discharge/Discharge Planning ... 6. Transfer- A patient shall be transferred to another medical care facility upon the order of the attending physician, only after arrangements have been made for admission with the other facility, including its consent to receiving the patient, and only after the patient is sufficiently stabilized for transport."

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" on April 21, 2015, at 11:00 AM revealed, "Reviewed: 12/12 Revised: 9/13...Steps Subject: Emergency Medical Treatment and Active Labor Act (EMTALA) Policy: It is the policy of [Hospital] to provide a medical screening examination (MSE) to any individual, regardless of age, race, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation gender identity or expression, insurance, or ability to pay, who comes to the Emergency Department (ED) to determine whether or not an emergency medical condition (EMC) is a medical condition manifesting itself by acute symptoms of sufficient severity (including sever pain) such that the absence of immediate medical attention could reasonably be expected to result in: 1) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, 2) Serious impairment to bodily functions, or 3) Serious dysfunction of any bodily organ or part; or 4) With respect to a pregnant woman who is having contractions 1. That there is inadequate time to effect a safe transfer to another hospital before deliver, or b. That the transfer may pose a threat to the health or safety of the woman or the unborn child. The MSE will be performed by the physician or physician extender (PA-C, CRNP). The nursing process of triage does not constitute a MSE. Based on the MSE, if an EMC is determined to exist, [Hospital] will provide, within the capabilities of the staff and facilities available at Jameson Hospital, all necessary treatment to stabilize the EMC. If the treatment required to stabilize the EMC is beyond the capabilities of the staff and facilities available at [Hospital], the treating physician will arrange for transfer to a facility that has the capability to stabilize the condition if the medical benefits of doing s outweigh the risks to the patient. Off-Campus provide-based departments that do not routinely offer services for emergency medical conditions would not e subject to EMTALA. Obstetrical patient of 20 weeks or greater gestation age presenting for care will be provided a MSE in either the ED or Maternal Care Center (MCC). If the MSE is performed in the MCC, it will performed by an Obstetrician. If an EMC is determined to exist, Jameson Hospital will provide, within the capabilities of the staff and facilities available at [Hospital], all necessary treatment to stabilize the EMC ... Procedures will also conform to requirements regarding the maintenance of medical records and release of medical record information for patients treated at, or transferred to or from ..."

1. Review of MR1 revealed the patient presented to the facility at 3:15 AM with complaint of contractions. Vital signs and symptoms documented at 3:20 AM revealed blood pressure 120/61; heart rate 75; respirations 20 and Sp02 99% The nursing exam documented at 3:25 AM revealed the patient to be at 4cm dilation, 90% effacement and a negative two station. The note further documented contractions at 4 minutes with no vaginal bleeding and membranes intact (probable). The nursing documentation at 3:33 AM revealed, "[EMP20] notified of pt adm. orders obtained for transfer to [Receiving Acute Care Hospital]." At 3:54 AM the nursing record revealed,"[EMP20] here. spoke with patient about transfer to [Receiving Acute Care Hospital]. pt agreeable." The documentation revealed ambulance transport was notified of the need for transport. Review MR1 revealed the only physician documentation on the patient's condition to be handwritten on a "Physician's Order Sheet." Review of the order sheet, authenticated by EMP20 at 4:10 AM revealed,"16 yo G1P0 @ 38 3/7 weeks presents with c/o ctx's since midnight. (-)LOF (Leak of fluid) (-) VB (+)FM. Pt on [Brand Name Rx] for hsv suppression. No active lesions. cer 4/90/-2 ... FHT's 130's (+) Ctv ctx q 5 mins--irreg A/P: early labor transfer to [Receiving Acute Care Hospital] to primary OB for delivery." Orders on the same page also authenticated at 4:10 AM revealed, "Transfer to [Receiving Acute Care Hospital] to: [OTH2] Dx early labor." An order for lactated ringers was also on the order form timed at 4:10 AM. Review of the record revealed no other documentation of a medical screening examination and no other orders. Laboratory and diagnostic information included with the record were dated greater than 30 days prior to the patient's April 9, 2015, visit. The patient was transferred at 4:25 AM.

On April 22, 2015, at 9:55 AM, an interview was conducted with EMP20. When asked if he/she evaluated the patient personally (MR1), EMP1 stated, "I was called 3:15 or 3:30 (AM). The patient's cervix was 4cm and 90% effaced and seemed to be contracting irregularly. I had only been asleep 15 minutes or so. I came in and checked her in half an hour or 45 minutes. She was about the same dilation and contractions. ..."

On April 22, 2015, at 9:58 AM, when again asked if she had examined the patient, EMP20 stated, "I believe I did."

On April 22, 2015, at 10:00 AM, when asked if the patient [MR1] was in labor or false labor, EMP20 stated, "Early labor." When asked to clarify, EMP20 stated, "At 90% (effacement) and 4cm (dilation) in a primary pregnancy, that's labor."

On April 22, 2015, at 10:10 AM, when asked how he/she determines the patient's condition and stability, EMP20 stated, "I'm not sure if [MR1] (prenatal records) are accurate. ... It should take six hours of tests and observations to be able to tell." When asked about documentation of his/her examination, EMP20 stated that it depended. "If they are going to be here an hour, I write a note on whatever they give me to write on. If they are going to be here a couple hours or more, we do a short form H&P. A 23 hour Observation."

On April 22, 2015, at 3:25 PM an interview was conducted with EMP19. When asked if he/she recalled the patient [MR1] he/she stated yes. "She was a patient of [OTH2] ... I put her on a monitor, took a history and checked her. I called [EMP20] and said she might be having contractions. [EMP20] said he/she would probably transfer her and get her ready. [EMP20] came in within a half an hour." When asked if EMP20 examined the patient, EMP19 stated, "I don't think [EMP20] checked her. ..."

On April 22, 2015, at 3:25 PM when asked if the physician always did a medical screening exam, EMP19 stated, "They don't always examine the patient. Most patients transferred have nothing going on so not all of them get examined by the physician." When asked if it would be abnormal for physician documentation of the patient's condition to have been documented as it was on MR1, EMP19 stated, "No. It hadn't been that long since I checked her (MR1) so you wouldn't expect a lot of changes. If it's active labor and is one of our patients it (examination) would be done."

On April 22, 2015, at 3:35 EMP19 confirmed there was no lab work or testing ordered for MR1. "Sometimes they will (order lab work). Sometimes they won't if they are thinking about transferring."

2. Review of MR14 revealed the patient was brought to Jameson by ambulance because her water broke. She was having no pain, just a "heavy feeling" according to an ambulance trip sheet. Triage in the OB unit at 1:25 AM revealed "Stage of Pregnancy 'Labor'" on the LD-Flowsheet (completed by nursing). The patient was 2 cms dilated with 50% effacement at 1:30 AM. At 2:00 AM it was documented that the patient had intermittent pain and cramping in the lower abdomen. Uterine activity was listed as "frequency (min) 2-5" and "Duration (sec) 80-120 " at 1:45 AM. Review of the Facility Transfer Summary/Transport Worksheet revealed, "Referring Doctor [EMP20]" "Attending Doctor ____" "Receiving Doctor Dr. [doctor at receiving hospital] Notified By [EMP21] RN" Receiving Hospital [receiving hospital name] Notified by [EMP21] RN." "Diagnosis and Physical Assessment ... 37 weeks SROM [spontaneous rupture of membranes] @ home @ 0100 VE: 2cm 50% -3 ruptured" "History G3 P2 NKA" Dr. EMP20 arrived at 2:35 AM and determined the patient was to be transferred to [another hospital] according to nursing documentation. The patient was transferred by ambulance at 3:03 AM. No documentation of a screening exam by the physician was found in the medical record.

Interview on April 21, 2015, at approximately 11:30 AM with EMP18 when questioned if there was any more information that was not included in MR14, revealed, "You have the complete medical record."

Interview on April 22, 2015, at 10:10 AM, with EMP20 when asked about documentation of his/her examination,stated, "That depends." EMP20 stated if it looked like the patient would be inpatient, there was one completed one way. If it is done for an outpatient that was being transferred, there was a written note that was sent with the patient. If it looked like the patient would be in a couple hours or more or was a 23 hour observation patient, it would be documented in a summary. "If they are going to be here an hour, I write a note on whatever [form] they give me to write on. If they are going to be here a couple hours or more, we do a short form H&P. A 23 hour Observation." EMP 20 was unable to say why there was no copy of a screening exam for MR14.

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to make appropriate transfers by not having appropriately completed certifications signed by a physician containing a summary of the risks and benefits upon which the transfer is based in ten of 12 medical records (MR1, MR14,MR15, MR16, MR17, MR18, MR21, MR22, MR23, and MR24), failed to send copies of medical records related to the patient's emergency medical condition to the receiving hospital for one of 12 medical records (MR1), failed to ensure the transfer was effected through qualified personnel in nine of 12 medical records (MR1, MR14, MR15, MR16, MR17, MR18, MR23, MR22, and MR24.) and failed to provide medical treatment within its capacity to minimize the risks to the individual's health and the health of a newborn child in two of 12 medical records (MR1 and MR14).

Findings include:

Review of the procedure for "Transfer of Acute Patient to Another Acute Care Facility" revised November 2010, revealed, "[Steps] 1. Appropriate physician to discuss transfer with patient/significant other, identifying potential risks/benefits involved... 2. Notify Administrative Supervisor ... 3. Obtain appropriate consents: A. #140 Physician Certification for Transfer and Patient Consent/Refusal for Transfer [Key Points] 3. Use original consent form(s). A. Parts 1&2 must be completed by transferring physician. Back of form to be signed by family as appropriate. 1. Refusal of Transfer 2. Consent to Transfer 3. Needed for any medical record a. Complete and specify if Behavioral health, AIDS/HIV, drug & alcohol ... [Steps] B. #141 Patient Request for Transfer as Appropriate [Key Points] B. #140, #1421 needed for circumstances when patient is requesting transfer... 6. Unit/department staff must confirm arrangements with receiving hospital by contacting receiving facility/appropriate staff. A. Nursing should provide nursing report to admitting unit/department [Key Points] A. Nursing staff should contact Admitting Department of receiving hospital to verify bed availability/placement... 9. When transfer is confirmed, Photocopy/scan entire chart including all consents/transfer packet information... 13. If ground ambulance is required as patient condition warrants, appropriate personnel should accompany patient at physician direction..."

1. Review of MR1 (outpatient) revealed a physician order, signed by EMP20 for transfer to another facility to the patient's primary physician for delivery. The patient was diagnosed with early labor. Review of the Physician Certification for Transfer and Patient Consent/Refusal for Transfer form revealed the section of the Physician Certification for transfer stating, "Jameson has provided medical treatment within its capacity that minimizes the risks to the patient's health (and in the case of a woman in labor, to the health of the unborn child) and for the following reasons, that as of the time of transfer, the medical benefits reasonably expected from treatment at another facility outweigh any risks to the patient (and, if pregnant, to the unborn child) from the transfer, (reasons for transfer, including summary of risks and benefits): " The section was not checked and there was no documented reason for transfer or summary of risks and benefits for the patient. The name of the physician at the receiving facility was left blank with only the facility name indicated. The certification was signed by EMP20. Further review of the Physician Certification for Transfer and Patient Consent/Refusal for Transfer form revealed the section of the Patient Consent stating, "I acknowledge that I have been screened, examined and evaluated by Dr.______ who has concluded that the medical benefits reasonably expected from treatment at another facility outweigh any risks to me (and if pregnant, to my unborn child) from the transfer," to have been left blank.

On April 22, 2015, at 10:13 AM when asked if specific benefits risks of the transfer, including a vaginal delivery with a HSV outbreak was discussed with the patient, EMP20 stated, "No. Not on this visit. ... I don't write that out."

On April 22, 2015, at 10:14 AM, EMP20 confirmed the missing documentation in the Physician Certification Form (MR1). When asked about a name of a doctor not being filled out on the medical record, EMP20 stated said, "I didn't know it at the time. It was not the most important thing. Nobody ever brought it back to me to sign. ... I only have to take care of a patient [that was not his/her patient] if they are in active labor. I'm not responsible to take care of every patient. I just determine that the patient is not in active labor."

Review of MR1 revealed a form titled, "Facility Transfer Summary." Review of the form revealed the signature of EMP19 below a section reading, " Worksheet Completed and Entire medical Record including test results sent by: "

On April 22, 2015, at 2:23 PM when asked if it was possible to tell from the record (MR1) what information was sent to the receiving hospital, EMP17 stated, "It's marked here (Facility Transfer Summary Transport Worksheet) that the whole record was sent." When asked if the information sent could be specifically identified, EMP17 stated, "In this case, you cannot."

Review of materials requested/received from the receiving facility (MR1) revealed the Labor and Delivery Flowsheet, including nursing documentation, was not included in documentation received from Jameson Hospital.

2. Review of MR1 revealed no documentation designating the level of qualifications or equipment needed for the transfer of the patient (MR1).

On April 22, 2015, at 10:15 AM, when asked if he/she had designated what level of qualifications the transport staff needed to have when transporting the patient EMP20 said, "We just call the ambulance the patient requests... Either an ambulance or flight. No one ever discusses ambulette or whatever else you said ..."

3. Review of MR1 revealed the patient presented to the facility at 3:15 AM with complaint of contractions. Vital signs and symptoms documented at 3:20 AM revealed blood pressure 120/61; heart rate 75; respirations 20 and Sp02 99% The nursing exam documented at 3:25 AM revealed the patient to be at 4cm dilation, 90% effacement and a negative two station. The note further documented contractions at 4 minutes with no vaginal bleeding and membranes intact (probable). The nursing documentation at 3:33 AM revealed, "[EMP20] notified of pt adm. orders obtained for transfer to [Receiving Acute Care Hospital]." At 3:54 AM the nursing record revealed,"[EMP20] here. spoke with patient about transfer to [Receiving Acute Care Hospital]. pt agreeable." The documentation revealed ambulance transport was notified of the need for transport. Review MR1 revealed the only physician documentation on the patient's condition to be handwritten on a "Physician's Order Sheet." Review of the order sheet, authenticated by EMP20 at 4:10 AM revealed,"[patient] G1P0 @ 38 3/7 weeks presents with c/o ctx's since midnight. (-)LOF (Leak of fluid) (-) VB (+)FM. Pt on [Brand Name Rx] for hsv suppression. No active lesions. cer 4/90/-2 ... FHT's 130's (+) Ctv ctx q 5 mins--irreg A/P: early labor transfer to [Receiving Acute Care Hospital] to primary OB for delivery." Orders on the same page also authenticated at 4:10 AM revealed, "Transfer to [Receiving Acute Care Hospital] to: [OTH2] Dx early labor." An order for lactated ringers was also on the order form timed at 4:10 AM. Review of the record revealed no other documentation of a medical screening examination and no other orders. Laboratory and diagnostic information included with the record were dated greater than 30 days prior to the patient's April 9, 2015, visit. The patient was transferred at 4:25 AM.

On April 22, 2015, at 9:55 AM, an interview was conducted with EMP20. When asked if he/she evaluated the patient personally (MR1), EMP1 stated, "I was called 3:15 or 3:30 (AM). The patient's cervix was 4cm and 90% effaced and seemed to be contracting irregularly. I had only been asleep 15 minutes or so. I came in and checked her in half an hour or 45 minutes. She was about the same dilation and contractions. ..."

On April 22, 2015, at 9:58 AM, when again asked if she had examined the patient, EMP20 stated, "I believe I did."

On April 22, 2015, at 10:00 AM, when asked if the patient [MR1] was in labor or false labor, EMP20 stated, "Early labor." When asked to clarify, EMP20 stated, "At 90% (effacement) and 4cm (dilation) in a primary pregnancy, that's labor."

On April 22, 2015, at 10:10 AM, when asked about he/she determines the patient's condition and stability, EMP20 stated, "I'm not sure if [MR1] (prenatal records) are accurate. ... It should take six hours of tests and observations to be able to tell." When asked about documentation of his/her examination, EMP20 stated that it depended. "If they are going to be here an hour, I write a note on whatever [form] they give me to write on. If they are going to be here a couple hours or more, we do a short form H&P. A 23 hour Observation."

On April 22, 2015, at 3:25 PM an interview was conducted with EMP19. When asked if he/she recalled the patient [MR1] he/she stated yes. "She was a patient of [OTH2] ... I put her on a monitor, took a history and checked her. I called [EMP20] and said she might be having contractions. [EMP20] said he/she would probably transfer her and get her ready. [EMP20] came in within a half an hour." When asked if EMP20 examined the patient, EMP19 stated, "I don't think [EMP20] checked her. ..."

On April 22, 2015, at 3:25 PM when asked if the physician always did a medical screening exam, EMP19 stated, "They don't always examine the patient. Most patients transferred have nothing going on so not all of them get examined by the physician." When asked if it would be abnormal for physician documentation of the patient's condition to have been documented as it was on MR1, EMP19 stated, "No. It hadn't been that long since I checked her (MR1) so you wouldn't expect a lot of changes. If it's active labor and is one of our patients it would be done."

On April 22, 2015, at 3:35 EMP19 confirmed there was no lab work or testing ordered for MR1. "Sometimes they will (order lab work). Sometimes they won't if they are thinking about transferring."

4. Review of MR14 revealed this gravida 3, para 2, patient was 37 weeks pregnant, had a spontaneous rupture of membranes at home, and was brought to the hospital by ambulance. The physician was notified of the patient's arrival at 1:25 AM. At 1:30 AM nursing documented that the patient was 2 cm dilated with 50% effacement. At 1:45 AM nursing documented uterine activity frequency as 2-5 minutes and that an IV was unable to be started by a nurse anesthetist. At 2:00 AM nursing documented the patient was having pain identified as a "4" on a scale of 1-10 and had intermittent cramping in the lower abdomen. Documentation at 2:35 AM revealed, "[Physician] here....updated on pt's status..... states will transfer pt to [another hospital]. There was no documentation of a medical screening by a physician. The record included a Physician Certification for Transfer and Patient Consent/Refusal for Transfer form that included, "Based on this examination, the information available to me at this time, and my assessment of the risks and benefits to the patient, I have concluded: - No material deterioration of the patient's condition is likely, within reasonable medical probability, to result from or occur during the transfer of the patient (or, if applicable, that the patient has delivered the child and placenta); or - [the hospital] has provided medical treatment within its capacity that minimizes the risks to the patient's health (and in the case of a woman in labor, to the health of the unborn child) and for the following reasons, that as of the time of transfer, the medical benefits reasonably expected from treatment at another facility outweigh any increased risks to the patient (and if pregnant, to the unborn child) from the transfer, (reasons for transfer, including summary of risks and benefits): _____ Transfer to [another hospital]..." No box was checked by either of the two statements. The form also included, "I acknowledge that I have been screened, examined and evaluated by Dr. _____ [not completed] who has concluded that the medical benefits reasonably expected from treatment at another facility outweigh any increased risks to me (and if pregnant, to my unborn child) from transfer. I acknowledge I have been informed of a. The reason for the transfer, b. The risks that may result from the transfer, c. The risks that may result from refusing the transfer, d. The benefits of the transfer, e. The benefits of remaining at [this hospital], and f. Alternatives to the transfer. 4. (Check one) ___ [blank] I refuse the transfer ... ___ [blank] I consent to the transfer and hereby authorize the release of my medical records ... 5. I declare that I have read and understood all of the information contained on this form and sign it knowingly and voluntarily ..." The form, which included no reason for the transfer, nor risks or benefits of the transfer, was unsigned by the patient and there was no witness name on the form. The Facility Transfer Summary Transport Worksheet contained a blank that was not completed for the type of qualified personnel that were to accompany the patient during the ambulance transport. The form also noted that the receiving physician was notified by an RN. The patient was transferred to another hospital at 3:03 AM.

5. Review of MR15 revealed this 32.5 weeks pregnant woman was brought to the MCC from the ED after having an epidural at 9:00 AM, with low back pain and abdominal cramping. At 9:15 AM nursing documented the pain level as an "8" on the scale of 1-10. At 9:24 AM the patient was documented as having a closed, thick, cervix. At 10:26 AM there was a speculum exam performed. Additional diagnostic testing was performed. At 4:00 PM the patient was given pain medication. At 9:00 PM the pain was described as an "8". prior to transfer. A physician progress note at 9:16 PM revealed there was fetal tachycardia and the patient would be transferred to another hospital. The Facility Transfer Summary/Transport Worksheet revealed the level of qualified personnel to accompany the patient for the transfer was not completed.

6. Review of MR16 revealed this gravida 2 para 0 patient was brought to the MCC at 5:20 AM with a complaint of cervical pain, urinary urgency, and voiding small amounts. She had been told by her out of town obstetrician to come to this hospital for an evaluation. The physician was notified of the patient's symptoms at 6:22 AM. At 7:00 AM the answering service for an obstetrical group outside of the area was contacted with a request for a physician to return the call. At 7:20 AM the physician for the outside group of obstetricians returned the call and was instructed the physician at this hospital would be contacting him/her "for transfer." At 7:36 AM it was noted that the physician at this hospital was at the patient's bedside speaking with the patient. At 7:39 AM it was documented that the patient was 1 cm dilated with 60% effacement according to an exam by this physician (after the receiving physician had already been notified of the transfer). At 7:51 AM this hospital physician contacted the physician from the obstetrical group outside the hospital regarding the transfer. The patient was transferred at 8:52 AM. The physician certification for Transfer noted that the facility had provided medical treatment within its capacity that minimized the risks to the patient's health and to the health of the unborn child with no explanation of the reason for transfer nor of any risks and benefits of the transfer that were presented to the patient. The Facility Transfer Summary/Transport Worksheet revealed the level of qualified personnel that were to accompany the patient was "medic."

7. Review of MR17 revealed the gravida 3, para 2, patient with a twin pregnancy of 31 weeks arrived at the MCC unit at 3:45 AM with a complaint of cramping of the lower pelvic and back for four days. She had a history of having a a C-section for a breech birth with premature rupture of membranes and a C-section for an 8 pound 2 oz baby. At 4:05 AM the patient was checked by nursing and found to have dilation of 0 and effacement of 20% with membranes intact. At 4:31 AM the physician was notified of the patient being at the hospital and nurse's findings. At 5:02 AM nursing documented, "[Physician] in to see patient and discuss pt complaints, history, and plan of care." At 6:30 AM the patient was transferred to another hospital. The physician Certification for Transfer and Patient Consent/Refusal for Transfer noted that the patient had been provided medical treatment within its capacity that minimized risk to health of the mother and baby. The reason for transfer was noted, "31 Weeks/twins/preterm ..." There was no documentation of the risks and benefits of the transfer. The Facility Transfer Summary/Transport Worksheet revealed, "Transport Service used: [Ambulance company] Accompanying personnel requested: No."

8. Review of MR18 revealed the gravida 5, para 3, 24 week pregnant patient presented to the MCC unit at 9:47 AM with possible premature rupture of membranes and intermittent cramping. At 9:57 AM fetal heart tones were down to the 80s and 90s. At 10:30 AM an IV was started. At 11:25 AM a stat portable ultrasound was ordered. At 11:55 AM the fetal heart tones were down to the 70s for 20 seconds. The physician was notified at that time of the patient's test results. At 12:02 PM the nursing supervisor was advised of a "probable" transfer. The patient was dilated 1.5 cm with 60% effacement. The physician arrived to see the patient at 12:30 PM. A speculum exam was performed by the physician at 12:48 PM. The patient was transferred at 1:54 PM. The Physician Certification for Transfer and Patient Consent/Refusal for Transfer revealed neither of the boxes for the certification of transfer were marked. The reason for transfer was handwritten as "Preterm. Premature Rupture of Membrane. No active labor." There was no documentation of what risks and benefits of the transfer were. The Facility Transfer Summary/Transport Worksheet revealed the space for the designation of the qualified personnel to accompany the patient was blank.

9. Review of MR21 on April 22, 2015, at approximately 2:00 PM revealed that the patient presented to the MCC unit on April 10, 2015, for complaints of nausea, vomiting and pain; and review of MR23, revealed that the patient presented to the OB unit on January 22, 2015, with complaints of "continuous leaking fluid." ; and review of MR24 revealed that the patient presented to the OB unit on April 1, 2015, with complaints of nausea, vomiting and dehydration. The facility form, "Physician Certification for Transfer and Patient Consent/refusal for Transfer" indicated, " ...Based on this examination, the information available to me at this time, and my assessment of the risks and benefits to the patient, I have concluded: [box to be checked]- No material deterioration of the patient's condition is likely, within reasonable medical probability, to result from or occur during the transfer of the patient (or, if applicable, that the patient has delivered the child and placenta); or -[box to be checked]- [the hospital] has provided medical treatment within its capacity that minimizes the risks to the patient's health (and in the case of a woman in labor, to the health of the unborn child) and for the following reasons, that as of the time of transfer, the medical benefits reasonably expected from treatment at another facility outweigh any increased risks to the patient (and if pregnant, to the unborn child) from the transfer, (reasons for transfer, including summary of risks and benefits: ... " The physician checked both boxes on each of these forms. None of the medical records included the summary of risks and benefits on the lines provided for this documentation or anywhere in the medical records.
During an interview of April 22, 2015 at approximately 2:15 PM, EMP17 confirmed that MR21 and MR23 did not include a summary of risks and benefits. EMP17 further indicated, " Yes, that is where the summary should go, [pointing to the three lines provided for the summary of risks]. " EMP17 confirmed that only one box should have been checked, and confirmed that the summary of risks were not included in the medical record.
10. Review of MR22 on April 22, 2015, at approximately 2:15 PM revealed that the patient presented to the OB unit on February 20, 2015, for complaints of contractions for past ½ hour and admits to drinking vodka daily. The facility form, " Physician Certification for Transfer and Patient Consent/refusal for Transfer " indicated, " ...Based on this examination, the information available to me at this time, and my assessment of the risks and benefits to the patient, I have concluded: [box to be checked]- No material deterioration of the patient's condition is likely, within reasonable medical probability, to result from or occur during the transfer of the patient (or, if applicable, that the patient has delivered the child and placenta); or -[box to be checked]- [the hospital] has provided medical treatment within its capacity that minimizes the risks to the patient's health (and in the case of a woman in labor, to the health of the unborn child) and for the following reasons, that as of the time of transfer, the medical benefits reasonably expected from treatment at another facility outweigh any increased risks to the patient (and if pregnant, to the unborn child) from the transfer, (reasons for transfer, including summary of risks and benefits: ... " The physician checked the second box indicating that the benefits from treatment at another facility outweighed any increased risks to the patient. The medical record did not include the summary of risks and benefits on the lines provided for documentation.
11. Review of MR22, MR23, and MR24 on April 22, 2015, at approximately 2:00 PM revealed that these patients required transfer to another facility for treatment. All medical records contained a facility form, "Facility Transfer Summary Transport Worksheet ...13. Transport Service used: ...Accompanying personnel requested ... " None of the forms for MR22, MR23, or MR24 indicated which accompanying personnel was requested. The medical records did not indicate the type of medical specifically was required or that the transport service was capable of transport was needed.
12. Interview on April 22, 2015, at 1:09 PM, with EMP1 revealed, "I was just at a meeting and spoke with some of our doctors. They did not know about the regulation about transferring the patient and qualified personnel." When asked if any of the records reviewed would reflect the qualifications of personnel required for the transfer, EMP1 stated, "No. Just what is on our form."