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Based on interview, record review, and review of facility's policies, it was determined the facility failed to ensure compliance with CFR 489.24 related to its failure to provide a medical screening exam (MSE) and stabilizing treatment for an emergency medical condition (EMC).

Cross Refer: A2406 The facility failed to provide a medical screening to patient #21.

Cross Refer: A2407The facility failed to provide stabilizing treatment for a patient with an emergency medical condition for patient #21.

Based on interview, record review, and review of facility's policies, it was determined the facility failed to ensure an appropriate medical screening examination (MSE) was provided for one (1) of twenty-two (22) sampled patients who presented to the Emergency Department (ED) with the emergency medical condition (EMC) of active labor with imminent delivery.

The findings include:

Review of the facility's policy titled, "EMTALA Medical Screening Exam," PolicyStat ID: 395635, last revised 03/2013, revealed its purpose was to establish guidelines for providing appropriate MSE's and, if the individual was determined to have an EMC, any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA. The policy further stated an MSE was required when an individual came to an ED and a request was made on his/her behalf for examination or treatment for a medical condition, including when the individual arrived as a transfer from another hospital; when the individual arrived on hospital property other than the ED and a request was made on the individual's behalf for examination or treatment for an EMC; or an individual was in a ground or air ambulance for purposes of examination and treatment for a medical condition at the ED.

Review of the facility's policy titled, "Emergency Childbirth," PolicyStat ID: 758329, last reviewed 02/2014, revealed at the facility, for all pregnant patients sixteen (16) weeks or greater, they would be immediately triaged to labor and delivery (Women's Hospital). If the patient could not be safety transported there prior to delivery, she would be triaged as emergent and the OB/GYN room would be prepared for the delivery. Then, after delivery, the mother and infant would be transported to the Women's Hospital on site.

Review of the medical record of the alleged victim, Patient #21, from the transferring facility, (Facility #1), revealed she was a twenty year old who presented to the labor hall on 08/11/15 at approximately 5:00 AM via ambulance with vaginal bleeding. The patient was a gravida two (2), para one (1) at thirty-two (32) weeks gestation with an expected date of confinement (EDC) of 10/05/15. According to the patient, she had been seeing specialists in the city where Facility #3, the receiving facility was located due to a possible fetal heart defect detected on ultrasound. Prior medical history revealed she was positive for tobacco abuse and a previous spontaneous vaginal delivery (SVD) at term. Upon arrival to Facility #1, she began having severe abdominal pain. Fetal heart monitoring showed no fetal distress with a baseline of one hundred forty (140) beats/minute with moderate variability and intermittent mild variables. The patient was having irregular contractions. The urinalysis showed 5+ blood with negative nitrites. The patient received an intravenous (IV) piggyback of Ampicillin two (2) grams at 6:15 AM because her Group B Streptococcus status was unknown. She also received a bolus of IV fluids of 0.9% Sodium Chloride (NS), started at 6:15 AM; a four (4) gram one (1) time dose of Magnesium Sulfate per IV at fifty (50) milliliter (ml)/hour, started at 6:20 AM; a twelve (12) milligram (mg) intramuscular dose of Celestone Soluspan at 6:45 AM; a continuous IV infusion of Magnesium Sulfate at two (2) grams/hour, started at 6:50 AM; and Fentanyl fifty (50) micrograms (mcg) IV at 7:00 AM and 7:40 AM. The physician's documented plan was to transfer to Facility #3 (a large, teaching, university hospital with many specialties available 24/7 and a sixty-six (66) unit Level III Neonatal Intensive Care Unit (NICU)) if the patient were stable.

Review of the Emergency Medical Services (EMS) "Patient Care Report" for Patient #21, dated 08/11/15, revealed the time of dispatch was 7:36 AM, time at Facility #1 was 7:40 AM, time at the patient was 7:49 AM, time of departure from Facility #1 was 8:11 AM, and time at destination (Facility #3) was 9:59 AM. The report also showed the mileage from Facility #1 to Facility #3 was one hundred thirty-four (134). Further review of the record revealed the patient was receiving IV fluids of NS at one hundred twenty-five (125) ml/hour; Magnesium Sulfate infusion of two (2) gram/hour IV; electrocardiogram (ECG) monitoring which showed normal sinus rhythm; oxygen per nasal cannula at two (2) liters; and vital signs taken (which were unremarkable) every five (5) to fifteen (15) minutes. The record further stated en route to Facility #3, upon entering the county where Facility #2 and Facility #3 were located, the patient's contractions increased dramatically, lasting one (1) minute and being one (1) minute apart, and the patient began crowning with membranes still intact. The patient began pushing, OB supplies were obtained, the Magnesium Sulfate drip was stopped, and EMS diverted to Facility #2 (facility with alleged EMTALA violation), the closest hospital for delivery. Upon arrival at Facility #2, the paramedics stayed in the ambulance, and the EMT (driver) went inside to summon help. The EMT returned and told the paramedics the staff would not take Patient #21 into the ED, and they instructed the EMS to go to the women's center. EMS personnel did not know the location of the women's center, and no staff came to direct them. The record then revealed EMS had contacted Facility #3 previously and preparations were made at Facility #3 ED for Patient #21. The decision was made to continue transport to Facility #3 ED. While en route to Facility #3 ED, the patient had spontaneous rupture of membranes (SROM). At 9:45 AM on the record, the patient's condition was imminent delivery and at 9:58 AM there was a successful delivery of a viable infant with the cord wrapped around its neck which EMS was able to move. The infant had a one (1) minute APGAR score of seven (7). The ambulance arrived at Facility #3 ED where the cord was clamped and cut by labor and delivery staff and the infant was taken away by NICU staff in an incubator. The record then stated the patient was taken by EMS and labor and delivery staff to the labor and delivery area, report was given, and care was turned over to the staff at Facility #3. The last documented assessment by EMS of Patient #21 was at 10:05 AM and was unremarkable.

Review of the medical record of Patient #21 at Facility #3, revealed she delivered a viable infant in an ambulance during transfer from Facility #1. The infant was preterm, around thirty-two (32) weeks. The cord was clamped and cut at Facility #3. The placenta was delivered spontaneously at the facility, and the patient was given ten (10) units of Pitocin after delivery of the placenta. There was a right vaginal sidewall laceration which was repaired. Estimated blood loss was two hundred fifty (250) mls. The History and Physical (H&P) stated at the time of transport from Facility #1, the patient's cervix was five (5) centimeters (cm) dilated, and she was being transferred due to early labor and a fetal heart anomaly. The H&P also revealed the patient was in no acute distress. Further review of the record per Discharge Summary, dated 08/13/15, revealed the patient had a two (2) day length of stay and was stable, meeting all postpartum goals at time of discharge.

Review of the medical record from Facility #3 of the viable infant, Patient #22, born to Patient #21, on 08/11/15, revealed he/she was transported from the ED to NICU and placed on CPAP 30% FiO2 on admission. Patient #22's initial chest x-ray showed diffuse reticulogranular opacities. The infant was transiently intubated and placed back on CPAP; on 08/19 was on room air; on 08/29 placed back on CPAP; on 09/04 on room air again and remained so until discharge on 09/13/15. Patient #22 was also given caffeine from 08/15 to 08/24 for apnea of prematurity; on 08/28, caffeine was restarted and discontinued on 09/08 with monitoring for five (5) days off caffeine with no further problems noted. The possible cardiac anomaly detected on a fetal ultrasound was investigated with an echocardiogram. Patient #22 was to be monitored for this as an outpatient two (2) weeks after discharge. Patient #22's birth weight was 2.42 kilograms, and at discharge it was 3.87 kilograms. Patient #22's newborn screen was positive for a genetic disorder, medium-chain acyl-CoA dehydrogenase deficiency (MCAD). Discharge medication for MCAD was Levocarnitine 100 mg/ml oral solution 1.2 mls orally three (3) times per day. Patient #22 was to follow-up with genetics as an outpatient. The four year old sibling of Patient #22 also had MCAD.

Review of Facility #2's ED log for the date of 08/11/15 revealed no documented evidence of Patient #21's name, date of arrival, departure time, or disposition.

Interview with ED Physician #1, on 09/29/15 at 12:00 PM, revealed the facility was required to do a MSE on all patients. He further revealed, if the patient had an EMC, the facility must provide stabilizing treatment.

Interview with ED Physician #2, on 09/29/15 at 1:01 PM, revealed if a patient came to the ED in active labor, an MSE would be done. He further stated if time allowed, he would call Women's Hospital or the primary care Obstetrician to evaluate the patient, and if there were not enough time, he would deliver the baby in the ED.

Interview with ED Physician Assistant (PA) #1, on 09/29/15 at 1:10 PM, revealed if a pregnant patient sixteen (16) weeks or greater gestation presented to the ED in active labor, a MSE would be done. He further revealed if necessary, preparations would be made for delivery and stabilization of the patient. He then stated if time permitted the OB/GYN hospitalist from the Women's Hospital would be called to help with the delivery.

Interview with EMT #1, on 09/30/15 at 9:10 AM, revealed he was the ambulance driver that stopped at the ED of Facility #2 on 08/11/15 which was transporting Patient #21. He revealed he had gone inside the facility's ambulance entrance and found two (2) people sitting behind the nurses station. He then stated he told the two (2) people there were medics outside with a pregnant lady, and they needed help. He could not recall if he said the patient was ready to deliver. He then stated he was told to go to the Women's Hospital, that it was two (2) buildings down, and one (1) person pointed it its direction. EMT #1 then stated he relayed this information to the two (2) paramedics in the back of the ambulance with Patient #21, and they stated to continue to Facility #3 because the location of the Women's Hospital was not exactly known. He then revealed he did not see anyone running after the ambulance or trying to flag it down as it was leaving Facility #2. EMT #1 then said the baby was delivered en route to Facility #3.

Interview with Registration Clerk #1, on 09/29/15 at 3:15 PM, revealed she was working on 08/11/15 when a man entered through the ambulance bay and said he had a woman in active labor and asked what he needed to do. She further revealed RN #4 told the man the patient needed to go to the Women's Hospital which was one (1) door down. ED Tech #1 then said it was two (2) doors instead of one (1) door down. Registration Clerk #1 then stated the man left immediately. She then revealed RN #4 immediately told ED Tech #1 to go to the ambulance and ride with them to the Women's Hospital; ED Tech #1 ran out the ambulance bay but three (3) to five (5) minutes later she returned, saying the ambulance was gone and that she had run after it and tried to stop it, but it kept going. Registration Clerk #1 then revealed, during this time, RN #4 called Women's Hospital to inform them of the situation and to expect the arrival of the ambulance and then ran to the Women's Hospital. She then stated staff determined where the ambulance was from and contacted the home office to communicate with them, but the home office was unable to do so because EMS was out of range.

Post-survey telephone interview with Paramedic #1, on 10/13/15 at 9:16 AM, revealed he and Paramedic #2 sent EMT #1 into Facility #2 to get a physician and/or nurse to come out to the ambulance because he did not think Patient #21 could be moved inside because of imminent delivery; he stated he actually thought Patient #21 might deliver before EMT #1 would return. He then revealed EMT #1 returned and said he was told to go to the women's center. He then revealed none of the EMS personnel had a clue about what the women's center was or where it was located, so the decision was made to go on to Facility #3 because they were expecting them. Paramedic #1 then stated Patient #21 delivered a short distance from Facility #3 ED, and when EMS arrived at Facility #3, the care of Patient #21 and Patient #22 was assumed by Facility #3 staff. He then revealed EMS did not send a dispatch to Facility #2 about the diversion because they did not have a direct frequency to them; they were too far away from their home base to contact them; and they were busy and did not have time to look up the telephone number of Facility #2.

Post-survey telephone interview with Paramedic #2, on 10/13/15 at 9:30 AM, revealed EMT #1 ran into Facility #2 to ask for help, and he believed he and Paramedic #1 told EMT #1 to tell Facility #2 staff that we had a patient having a baby, ready to deliver. Paramedic #2 then stated EMT #1 came back and stated the facility staff told him to go to the women's center which no one knew anything about. He then stated an executive decision was made by him and Paramedic #1 that it would be better to go to Facility #3 because there was already a NICU team waiting. Paramedic #2 then stated the delivery happened a very short distance from Facility #3, and when EMS arrived, the staff at Facility #3 immediately took over care of Patient #21 and Patient #22. Paramedic #2 then revealed at the time EMS decided to divert to Facility #2, there was no way to contact them by dispatch and no time to look up the telephone number. He then revealed Patient #21 was not off-loaded into Facility #2 because she was so close to delivery, and it would have taken time to disconnect monitors and IV pumps.

Interview with RN #4, on 09/30/15 at 10:35 AM, revealed she was sitting at the nurses station in the AM of 08/11/15 when a man in street clothes who did not identify himself came into the ED through the ambulance bay. She further revealed he stated he had a lady that was pregnant in active labor, and we were supposed to go to Facility #3, but we came to this facility. RN #4 then stated she told the man to go to labor hall (the Women's Hospital) which was one (1) door down. ED Tech #1 stated it was two (2) doors down. The man immediately left. She then stated she told ED Tech #1 to go find the man to make sure he knew how to get to the Women's Hospital, and she called the Women's Hospital and went there where there were two (2) labor hall/delivery nurses standing outside awaiting Patient #21's arrival, but the ambulance never came. RN #4 stated the man never said he was with an ambulance service. She also revealed the facility policy was if a pregnant patient was over sixteen (16) weeks gestation, an assessment was done, and if the patient were stable, she would be taken to labor hall, or the Women's Hospital, with a nurse via a stretcher or wheel chair using the connecting pedway. She then stated the ambulance left so quickly there was no time to do an assessment, and she was going to go out and see the patient, but the ambulance had already left. RN #4 then revealed if she had had the opportunity to see Patient #21, the staff would have delivered her in the ED or the ambulance.

Interview with the ED Medical Director, on 09/30/15 at 12:30 PM, revealed he was working on 08/11/15 and witnessed some of the event. He further revealed he believed RN #4 made an error when she instructed EMT #1 to go to the Women's Hospital; she realized it, but did not have time to correct because the ambulance left so quickly. The Director stated for patients sixteen (16) weeks or greater gestation they would typically go to the Women's Hospital for pregnancy related issues. They would first be triaged and then sent by stretcher or wheel chair via the pedway that connected Facility #2 to the Women's Hospital. He further revealed this had been a good system, and Facility #2 had never had a precipitous delivery in the pedway. He then stated if delivery were imminent or the situation acute, the pregnant patient would stay in the ED where the physician would deliver. He further revealed he believed this was a "swiss cheese" situation where all the holes lined up for the outcome. First, he stated, the patient traveled a long distance in the ambulance; then, EMT #1 did not identify himself or call ahead with a dispatch or telephone call about the diversion to Facility #2; and EMT #1 left very quickly without giving RN #4 the time to make the right decision. The Director further revealed he believed EMS made the wrong decision to go on to Facility #3, and this decision also contributed to the outcome.

Interview with the President, on 09/30/15 at 2:35 PM, revealed Facility #2 had put together an "Action Plan" because this event was seen as a good opportunity to re-educate and focus on EMTALA requirements. He further revealed he thought it would have helped if EMS had called Facility #2 prior to their arrival. He then said the facility needed to educate EMS personnel around the state about the Women's Hospital when they transport pregnant patients. The President then added he did not feel the ED staff was refusing to treat the patient, but only trying to get the patient to the right location. At the Women's Hospital, there was an OB/GYN hospitalist 24/7 with three thousand (3000) deliveries per year, and a delivery would not be turned away. He then revealed in this situation, there were communication gaps with room for improvement by both Facility #2 staff, RN #4, and EMS personnel.

Interview with the ED Manager, on 09/30/15 at 4:35 PM, revealed she worked on 08/11/15. She further revealed she spoke to one (1) of the Paramedics on 08/11/15 and explained the staff was trying to get the ambulance back but was unsuccessful. She further revealed this Paramedic stated he had instructed EMT #1 to say at Facility #2 that a physician and nurse were needed to come out to the ambulance because the patient was going to deliver. The ED Manager then stated if this had occurred, the staff would have given maximum assistance to the delivery, whether in the ambulance or in the ED. She then stated she thought the staff performed to the best of their ability with the information and time frame involved. She also revealed she wished the staff had asked EMT #1 additional questions, but it was an unusual situation in that EMS did not call or send a dispatch about their arrival.

Based on interview, record review, and review of facility's policies, it was determined the facility failed to provide stabilizing treatment for a patient with an emergency medical condition (EMC) for one (1) of twenty-two (22) sampled patients, Patient #21.

The findings include:

Review of the facility's policy titled, "Treatment and Transfer of Individuals in Need of Emergency Medical Services," PolicyStat ID: 408532, last reviewed 03/2013, revealed the facility must provide to any individual who requested medical care within the ED, any individual who requested care outside the ED but on hospital property, or when a layperson would recognize that an individual on hospital property required emergency treatment or examination, though no request for treatment was made, a MSE. The policy then stated, if there were an EMC or the patient was in labor, the facility must provide either any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer to another medical facility The policy then defined an EMC as a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in 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. With respect to a pregnant woman who was having contractions, there was inadequate time to effect a safe transfer to another hospital before delivery or the transfer may pose a threat to the health or safety of the woman or unborn child.

Review of the facility's policy titled, "Emergency Childbirth," PolicyStat ID: 758329, last reviewed 02/2014, revealed at the facility, for all pregnant patients sixteen (16) weeks or greater, they would be immediately triaged to labor and delivery (Women's Hospital). If the patient could not be safety transported there prior to delivery, she would be triaged as emergent and the OB/GYN room would be prepared for the delivery. Then, after delivery, the mother and infant would be transported to the Women's Hospital on site.

Review of the medical record of the alleged victim, Patient #21, from the transferring facility, (Facility #1), revealed she was a twenty year old who presented to the labor hall on 08/11/15 at approximately 5:00 AM via ambulance with vaginal bleeding. The patient was a gravida two (2), para one (1) at thirty-two (32) weeks gestation with an expected date of confinement (EDC) of 10/05/15. According to the patient, she had been seeing specialists in the city where Facility #3, the receiving facility was located due to a possible fetal heart defect detected on ultrasound. Prior medical history revealed she was positive for tobacco abuse and a previous spontaneous vaginal delivery (SVD) at term. Upon arrival to Facility #1, she began having severe abdominal pain. Fetal heart monitoring showed no fetal distress with a baseline of one hundred forty (140) beats/minute with moderate variability and intermittent mild variables. The patient was having irregular contractions. The urinalysis showed 5+ blood with negative nitrites. The patient received an intravenous (IV) piggyback of Ampicillin two (2) grams at 6:15 AM because her Group B Streptococcus status was unknown. She also received a bolus of IV fluids of 0.9% Sodium Chloride (NS), started at 6:15 AM; a four (4) gram one (1) time dose of Magnesium Sulfate per IV at 50 milliliter (ml)/hour, started at 6:20 AM; a twelve (12) milligram (mg) intramuscular dose of Celestone Soluspan at 6:45 AM; a continuous IV infusion of Magnesium Sulfate at two (2) grams/hour, started at 6:50 AM; and Fentanyl fifty (50) micrograms (mcg) IV at 7:00 AM and 7:40 AM. The physician's documented plan was to transfer to Facility #3 (a large, teaching, university hospital with many specialties available 24/7 and a sixty-six (66) unit Level III Neonatal Intensive Care Unit (NICU)) if the patient were stable.

Review of the Emergency Medical Services (EMS) "Patient Care Report" for Patient #21, dated 08/11/15, revealed the time of dispatch was 7:36 AM, time at Facility #1 was 7:40 AM, time at the patient was 7:49 AM, time of departure from Facility #1 was 8:11 AM, and time at destination (Facility #3) was 9:59 AM. The report also showed the mileage from Facility #1 to Facility #3 was one hundred thirty-four (134). Further review of the record revealed the patient was receiving IV fluids of NS at one hundred twenty-five (125) ml/hour; Magnesium Sulfate infusion of two (2) gram/hour IV; electrocardiogram (ECG) monitoring which showed normal sinus rhythm; oxygen per nasal cannula at two (2) liters; and vital signs taken (which were unremarkable) every five (5) to fifteen (15) minutes. The record further stated en route to Facility #3, upon entering the county where Facility #2 (facility with the alleged EMTALA violation) and Facility #3 were located, the patient's contractions increased dramatically, lasting one (1) minute and being one (1) minute apart, and the patient began crowning with membranes still intact. The patient began pushing, OB supplies were obtained, the Magnesium Sulfate drip was stopped, and EMS diverted to Facility #2, the closest hospital for delivery. Upon arrival at Facility #2, the paramedics stayed in the ambulance, and the EMT (driver) went inside to summon help. The EMT returned and told the paramedics the staff would not take Patient #21 into the ED and they instructed the EMS to go to the women's center. EMS personnel did not know the location of the women's center, and no staff came to direct them. The record then revealed EMS had contacted Facility #3 previously and preparations were made at Facility #3 ED for Patient #21. The decision was made to continue transport to Facility #3 ED. While en route to Facility #3 ED, the patient had spontaneous rupture of membranes (SROM). At 9:45 AM on the record, the patient's condition was imminent delivery and at 9:58 AM there was a successful delivery of a viable infant with the cord wrapped around its neck which EMS was able to move. The infant had a one (1) minute APGAR score of seven (7). The ambulance arrived at Facility #3 ED where the cord was clamped and cut by labor and delivery staff and the infant was taken away by NICU staff in an incubator. The record then stated the patient was taken by EMS and labor and delivery staff to the labor and delivery area, report was given, and care was turned over to the staff at Facility #3. The last documented assessment by EMS of Patient #21 was at 10:05 AM and was unremarkable.

Review of the medical record of Patient #21 at Facility #3, revealed she delivered a viable infant in an ambulance during transfer from Facility #1. The infant was preterm, around thirty-two (32) weeks. The cord was clamped and cut at Facility #3. The placenta was delivered spontaneously at the facility, and the patient was given ten (10) units of Pitocin after delivery of the placenta. There was a right vaginal sidewall laceration which was repaired. Estimated blood loss was two hundred fifty (250) mls. The History and Physical (H&P) stated at the time of transport from Facility #1, the patient's cervix was five (5) centimeters (cm) dilated, and she was being transferred due to early labor and a fetal heart anomaly. The H&P also revealed the patient was in no acute distress. Further review of the record per Discharge Summary, dated 08/13/15, revealed the patient had a two (2) day length of stay and was stable, meeting all postpartum goals at time of discharge.

Review of the medical record from Facility #3 of the viable infant, Patient #22, born to Patient #21, on 08/11/15, revealed he/she was transported from the ED to NICU and placed on CPAP 30% FiO2 on admission. Patient #22's initial chest x-ray showed diffuse reticulogranular opacities. The infant was transiently intubated and placed back on CPAP; on 08/19 was on room air; on 08/29 placed back on CPAP; on 09/04 on room air again and remained so until discharge on 09/13/15. Patient #22 was also given caffeine from 08/15 to 08/24 for apnea of prematurity; on 08/28, caffeine was restarted and discontinued on 09/08 with monitoring for five (5) days off caffeine with no further problems noted. The possible cardiac anomaly detected on a fetal ultrasound was investigated with an echocardiogram. Patient #22 was to be monitored for this as an outpatient two (2) weeks after discharge. Patient #22's birth weight was 2.42 kilograms and at discharge it was 3.87 kilograms. Patient #22's newborn screen was positive for a genetic disorder, medium-chain acyl-CoA dehydrogenase deficiency (MCAD). Discharge medication for MCAD was Levocarnitine 100 mg/ml oral solution 1.2 mls orally three (3) times per day. Patient #22 was to follow-up with genetics as an outpatient. The four year old sibling of Patient #22 also had MCAD.

Review of Facility #2's ED log for the date of 08/11/15 revealed no documented evidence of Patient #21's name, date of arrival, departure time, or disposition.

Interview with ED Physician #1, on 09/29/15 at 12:00 PM, revealed the facility was required to do a MSE on all patients. He further revealed, if the patient had an EMC, the facility must provide stabilizing treatment.

Interview with ED Physician #2, on 09/29/15 at 1:01 PM, revealed if a patient came to the ED in active labor, an MSE would be done. He further stated if time allowed, he would call Women's Hospital or the primary care Obstetrician to evaluate the patient, and if there were not enough time, he would deliver the baby in the ED.

Interview with ED Physician Assistant (PA) #1, on 09/29/15 at 1:10 PM, revealed if a pregnant patient sixteen (16) weeks or greater gestation presented to the ED in active labor, a MSE would be done. He further revealed if necessary, preparations would be made for delivery and stabilization of the patient. He then stated if time permitted the OB/GYN hospitalist from the Women's Hospital would be called to help with the delivery.

Interview with EMT #1, on 09/30/15 at 9:10 AM, revealed he was the ambulance driver that stopped at the ED of Facility #2 on 08/11/15 which was transporting Patient #21. He revealed he had gone inside the facility's ambulance entrance and found two (2) people sitting behind the nurses station. He then stated he told the two (2) people there were medics outside with a pregnant lady, and they needed help. He could not recall if he said the patient was ready to deliver. He then stated he was told to go to the Women's Hospital, that it was two (2) buildings down, and one (1) person pointed it its direction. EMT #1 then stated he relayed this information to the two (2) paramedics in the back of the ambulance with Patient #21, and they stated to continue to Facility #3 because the location of the Women's Hospital was not exactly known. He then revealed he did not see anyone running after the ambulance or trying to flag it down as it was leaving Facility #2. EMT #1 then said the baby was delivered en route to Facility #3.

Post-survey telephone interview with Paramedic #1, on 10/13/15 at 9:16 AM, revealed he and Paramedic #2 sent EMT #1 into Facility #2 to get a physician and/or nurse to come out to the ambulance because he did not think Patient #21 could be moved inside because of imminent delivery; he stated he actually thought Patient #21 might deliver before EMT #1 would return. He then revealed EMT #1 returned and said he was told to go to the women's center. He then revealed none of the EMS personnel had a clue about what the women's center was or where it was located, so the decision was made to go on to Facility #3 because they were expecting them. Paramedic #1 then stated Patient #21 delivered a short distance from Facility #3 ED, and when EMS arrived at Facility #3, the care of Patient #21 and Patient #22 was assumed by Facility #3 staff. He then revealed EMS did not send a dispatch to Facility #2 about the diversion because they did not have a direct frequency to them; they were too far away from their home base to contact them; and they were busy and did not have time to look up the telephone number of Facility #2.

Post-survey telephone interview with Paramedic #2, on 10/13/15 at 9:30 AM, revealed EMT #1 ran into Facility #2 to ask for help, and he believed he and Paramedic #1 told EMT #1 to tell Facility #2 staff that we had a patient having a baby, ready to deliver. Paramedic #2 then stated EMT #1 came back and stated the facility staff told him to go to the women's center which no one knew anything about. He then stated an executive decision was made by him and Paramedic #1 that it would be better to go to Facility #3 because there was already a NICU team waiting. Paramedic #2 then stated the delivery happened a very short distance from Facility #3, and when EMS arrived, the staff at Facility #3 immediately took over care of Patient #21 and Patient #22. Paramedic #2 then revealed at the time EMS decided to divert to Facility #2, there was no way to contact them by dispatch and no time to look up the telephone number. He then revealed Patient #21 was not off-loaded into Facility #2 because she was so close to delivery, and it would have taken time to disconnect monitors and IV pumps.

Interview with Registration Clerk #1, on 09/29/15 at 3:15 PM, revealed she was working on 08/11/15 when a man entered through the ambulance bay and said he had a woman in active labor and what did he need to do. She further revealed RN #4 told the man the patient needed to go to the Women's Hospital which was one (1) door down. ED Tech #1 then said it was two (2) doors instead of one (1) door down. Registration Clerk #1 then stated the man left immediately. She then revealed RN #4 immediately told ED Tech #1 to go to the ambulance and ride with them to the Women's Hospital; ED Tech #1 ran out the ambulance bay but three (3) to five (5) minutes later she returned, saying the ambulance was gone and that she had run after it and tried to stop it, but it kept going. Registration Clerk #1 then revealed, during this time, RN #4 called Women's Hospital to inform them of the situation and to expect the arrival of the ambulance and then ran to the Women's Hospital. She then stated staff determined where the ambulance was from and contacted the home office to communicate with them, but the home office was unable to do because EMS was out of range.

Interview with RN #4, on 09/30/15 at 10:35 AM, revealed she was sitting at the nurses station in the AM of 08/11/15 when a man in street clothes who did not identify himself came into the ED through the ambulance bay. She further revealed he stated he had a lady that's pregnant in active labor, and we were supposed to go to Facility #3, but we came to this facility. RN #4 then stated she told the man to go to labor hall (the Women's Hospital) which was one (1) door down. ED Tech #1 stated it was two (2) doors down. The man immediately left. She then stated she told ED Tech #1 to go find the man and make sure he knew how to get to the Women's Hospital, and she called the Women's Hospital and went there where there were two (2) labor hall/delivery nurses standing outside awaiting Patient #21's arrival, but the ambulance never came. RN #4 stated the man never said he was with an ambulance service. She also revealed the facility policy was if a pregnant patient was over sixteen (16) weeks gestation, an assessment was done, and if the patient were stable, she would be taken to labor hall, or the Women's Hospital, with a nurse via a stretcher or wheel chair using the connecting pedway. She then stated the ambulance left so quickly there was no time to do an assessment, and she was going to go out and see the patient, but the ambulance had already left. RN #4 then revealed if she had had the opportunity to see Patient #21, the staff would have delivered her in the ED or the ambulance.

Interview with the ED Medical Director, on 09/30/15 at 12:30 PM, revealed he was working on 08/11/15 and witnessed some of the event. He further revealed he believed RN #4 made an error when she instructed EMT #1 to go to the Women's Hospital; she realized it, but did not have time to correct because the ambulance left so quickly. The Director stated for patients sixteen (16) weeks or greater gestation they would typically go to the Women's Hospital for pregnancy related issues. They would first be triaged and then sent by stretcher or wheel chair via the pedway that connected Facility #2 to the Women's Hospital. He further revealed this process had been a good, and Facility #2 had never had a precipitous delivery in the pedway. He then stated if delivery were imminent or the situation acute, the pregnant patient would stay in the ED where the physician would deliver. He further revealed he believed this was a "swiss cheese" situation where all the holes lined up for the outcome. First, he stated, the patient traveled a long distance in the ambulance; then, EMT #1 did not identify himself or call ahead with a dispatch or telephone call about the diversion to Facility #2; and EMT #1 left very quickly without giving RN #4 the time to make the right decision. The Director further revealed he believed EMS made the wrong decision to go on to Facility #3, and this decision also contributed to the outcome.

Interview with the President, on 09/30/15 at 2:35 PM, revealed Facility #2 had put together an "Action Plan" because this event was seen as a good opportunity to re-educate and focus on EMTALA requirements. He further revealed he thought it would have helped if EMS had called Facility #2 prior to their arrival. He then said the facility needed to educate EMS personnel around the state about the Women's Hospital when they transport pregnant patients. The President then added he did not feel the ED staff was refusing to treat the patient, but only trying to get the patient to the right location. At the Women's Hospital, there was an OB/GYN hospitalist 24/7 with three thousand (3000) deliveries per year, and a delivery would not be turned away. He then revealed in this situation, there were communication gaps with room for improvement by both Facility #2 staff, RN #4, and EMS personnel.

Interview with the ED Manager, on 09/30/15 at 4:35 PM, revealed she worked on 08/11/15. She further revealed she spoke to one (1) of the Paramedics on 08/11/15 and explained the staff was trying to get the ambulance back but was unsuccessful. She further revealed this Paramedic stated he had instructed EMT #1 to say at Facility #2 that a physician and nurse were needed to come out to the ambulance because the patient was going to deliver. The ED Manager then stated if this had occurred, the staff would have given maximum assistance to the delivery, whether in the ambulance or in the ED. She then stated she thought the staff performed to the best of their ability with the information and time frame involved. She also revealed she wished the staff had asked EMT #1 additional questions, but it was an unusual situation in that EMS did not call or send a dispatch about their arrival.