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Based on record review and interview, the facility failed to document the risks and benefits of driving in a private vehicle to another facility for a higher level of care, failed to contact the receiving facility prior to sending the patient and failed to complete a transfer form in 1 of 20 medical records reviewed of patients who presented with an emergent obstetrical condition (Patient #1).

Findings include:

Facility staff failed to comply with EMTALA (Emergency Medical Treatment and Labor Act) requirements for sending a patient to an alternate facility for a higher level of care. See tag C2409.


The cumulative effect of this systematic failure has the potential to affect all emergency patients seeking care at this facility.

Based on record review and interview, the facility failed to document the risks and benefits of driving in a private vehicle to another facility for a higher level of care, failed to contact the receiving facility prior to sending the patient and failed to complete a transfer form in 1 of 20 medical records reviewed of patients who presented with an emergent obstetrical condition (Patient #1).

Findings include:

The facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy-NW WI (Northwest Wisconsin) Region," dated 10/19/2017, was reviewed on 2/4/2019 at 1:40 PM. The policy revealed in part, "Transfer out: b. Transfer for Unstable Patients: If the patient's medical needs for stabilization and further medical treatment exceed the capabilities of a (hospital system) Hospital and the transfer is in the medical interest of the patient (i.e.., the expected benefits of the transfer outweigh the risks of the transfer),...the patient will be transferred to an appropriate facility in accordance with the procedures outlined below..." The policy goes on to describe the provider's responsibilities: explain risks and benefits, arrange transfer to a receiving facility, provide treatment within its capabilities, contact the receiving facility prior to arranging for transfer and verify acceptance, arrange for medical information to be sent to receiving facility, arrange for mode of transportation matching patient's clinical needs, complete the "Physician Certification of Need for Transfer Medical Necessity Information" form"

A review of Patient #1's medical record was conducted on 2/4/2019 at 2:00 PM accompanied by Nursing Supervisor D who confirmed the following findings per interview:

A progress note dated 1/20/2019 at 3:36 AM written by Registered Nurse E revealed that Patient #1 called the OB (obstetric) department on 1/20/2019 around 3:00 AM stating that #1 lost the mucous plug and shortly after that heard a pop followed by quite a bit of leaking fluids and has continued to leak fluids. "Given pt's (patient's) EDC (estimated date of confinement-due date), explanation given on the possibility of having to transfer to (receiving hospital) for delivery. Pt verbalized understanding."

Patient #1 arrived to the OB unit (all emergent OB conditions are sent directly to the OB unit vs. the Emergency Department at this facility) on 1/20/2019 at 4:49 AM. Registered Nurse E initiated the medical screening exam at 4:56 AM. The following was completed: vital signs, hypertension assessment, cervical exam, amnisure test (test to check for amniotic fluid), external fetal monitor, and uterine activity assessment.

On 1/20/2019 at 5:50 AM Patient #1 was discharged from the sending facility with the instruction from Registered Nurse E to go straight to (the receiving hospital). Patient #1 left with a family member via private vehicle.

On 1/20/2019 at 5:54 AM Nurse E called report to a nurse in the OB unit at the receiving hospital.

An interview with Nursing Supervisor D was conducted on 2/4/2019 at 2:10 PM. Supervisor D stated, "There is no transfer form. There was a verbal ok with the plan of care...(Patient #1) was an outpatient. There is no order to discharge. (Patient #1) was considered an outpatient and as an outpatient (#1) was just given instructions after the MD (Medical Doctor) told the RN (Registered Nurse) what to do. (Patient #1) was sent to (receiving hospital) because (sending hospital) doesn't keep patients less than 36 weeks (due to no neonatal intensive care unit for the care of pre-term babies). (Patient #1) was discharged by private vehicle. Because the nurse and provider did not feel patient was in danger of giving birth imminently, a private vehicle was considered an appropriate mode of transportation."

An interview with Doctor F was conducted on 2/5/2019 at 9:35 AM. Doctor F stated, "The patient came in for leaking fluids and felt a pop. (Registered Nurse E) did the triage. Ordered an amnisure. The results were not back yet when (Nurse E) called. (Nurse E) had put the patient on the tocometer (fetal monitor) and (Patient #1) was having some contractions but not feeling them. I recommended delivery in (receiving hospital). (Patient #1) was 2 centimeters and not feeling contractions. We figured the amnisure was positive and decided to send (Patient #1) to (receiving hospital) for an assessment and possible induction."

Patient #1 was "discharged" from this facility and sent directly to the receiving hospital via private vehicle. There was no documentation that a provider discussed risks and benefits of this decision. There was no documentation that the receiving facility was contacted prior to Patient #1 being discharged from the transferring facility. A Physician Certification of Need for Transfer form was not completed.