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Based on document review and interview, it was determined that in 1 of 23 (patient #1) Medical Records (MR) reviewed, the facility failed to ensure compliance with 489.24, in that the facility failed to provide an appropriate transfer and failed to stabilize the patient.

Findings included:

1. See findings cited at 42 CFR 489.24 (d) (1-3) C 2407 and 42 CFR 489.24(e)(1)-(2) C 2409.

Based on document review, the facility failed to provide stabilizing treatment to 1 of 23 patients (patient #1).


Findings include;

1. Review of patient #1's MR, Admission Note, written by QMP #1, Obstetrician, dated 6/23/2018, indicated patient came to facility #1's OB triage at 0120 hours for a labor check. Patient #1 had a medical screening exam. Maternal assessment: Contractions: every 3 to 4 minutes, no fluid or bleeding. OB history: 3 pregnancies, 2 deliveries, no prenatal care, no plans to deliver at hospital, regular contractions. Impression and Plan: 41 weeks, latent labor. Patient was advised to be admitted to facility #2 due to no prenatal care, no labs, no provider, no insurance. No urgent care required at this time. Discharge Clinician Summary, written by QMP #1, indicated: Patient #1 released from facility #1 stable. Plans to go to facility #2 for delivery. Will head to receiving outside hospital (OSH) ED (facility #2) via private car. The medical record lacked evidence that the patient was stabilized prior to release.

2. Review of patient #1's MRs were obtained from facility #2 indicated QMP #4's (Obstetrician at facility #2) on 6/23/2018 at 0342 hours documented: admitted at 9 centimeters (dilation) status post spontaneous vaginal delivery, shortly after admission, no problems.

Based on document review and interview, the facility failed to follow Policy and Procedure regarding a transfer and failed to appropriately transfer 1 of 23 patients (patient #1).

1. Review of Policy, Version 4, Non-Emergent Transfer of Patients to another Facility, effective 10/20/2015, indicated transfers require completing transfer paperwork and informing and giving report to receiving Outside Hospital (OSH) (facility #2) accepting physician, for all patients who are transferred for care.

2. Review of patient #1's entire Obstetrics (OB) Triage Medical Record (MR) documentation on 6/23/2018, lacked evidence that transfer paperwork had been completed, or that facility #2, receiving outside hospital, had been contacted to accept transfer. The record indicated that the patient was sent via private auto and not EMS/ALS and was in active labor and delivered shortly after arrival at facility #2.

3. Review of receiving OSH's medical record for patient #1 for 6/23/2018 indicated that no information or report was sent when patient #1 was transferred to it.

4. On 7/10/2018 at 0830 hours, Staff #2, Director of Quality, confirmed in interview that patient #1's transfer had not complied with EMTALA regulations or facility Policy and Procedures.