HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the receiving hospital and receiving physician consented to the transfer of an individual for one of 20 medical records reviewed (MR1).

Findings include:

Review on August 4, 2025, of facility policy, "EMTALA" reviewed February 2025, revealed "Purpose: The purpose of this policy is to ensure that the emergency medical treatment and patient transfer policy is based on federal law relating to the emergency medical treatment and medically appropriate transfer of individuals between hospitals. ...Definitions: Appropriate Transfer occurs when ...2) the receiving facility has the appropriate space and the qualified personnel for the treatment of the individual and has agreed to accept Transfer of the individual and to provide appropriate medical treatment; ...Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. 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. With respect to a pregnant woman who is having contractions; a. There is inadequate time to effect a safe Transfer to another Hospital before delivery; or b. The Transfer may pose a threat to the health or safety of the woman or the unborn child. ...Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. ...D. Transfer Procedures After determining that an individual with an unstabilized emergency medical condition will be transferred from the emergency department (or in the case of the patient in labor this may be the OB Department), the individual will be transferred in accordance with the following procedures: 1. Acceptance by Receiving Hospital and Receiving Physician. Prior to transfer, the receiving hospital and receiving physician must consent to the transfer of the individual and agree to provide appropriate medical treatment and hospital care. ..."

Review on August 4, 2025, of MR1, revealed the patient presented to the Emergency Department (ED) on July 21, 2025, at 2131, via private vehicle. The patient reported being 34 weeks pregnant and was experiencing contractions six to eight minutes apart which started approximately 10 hours prior to coming to the ED. The patient was gravida four, para three; all pregnancies were delivered via cesarean section and were complicated by pre-eclampsia.

Continued review of MR1 revealed physician documentation that at approximately 2138, [Name of local ambulance company] was notified via telephone of the emergent/911 transfer. The Transfer center was called at 2140 to notify of the emergent transfer in place. The call was placed on hold. While awaiting connection with the Obstetric attending via phone, [Name of local ambulance company] arrived to the ED at 2146 to transport the patient to [Name of local hospital] which is the nearest obstetric facility. The patient left the ED at 2148. At 2151, the Transfer center returned to the line with OTH1. When sharing the story with OTH1 regarding the urgency for sending the patient, OTH1 stated that their neonatal intensive care unit (NICU) was full and they could not accept the patient. OTH1 recommended [Name of another facility in this health system] be contacted. At 2157, CF2 spoke with OTH2, who stated the patient should be transferred to [Name of local hospital] for urgent evaluation as this was the closest facility with full capabilities for evaluating the patient. The Transfer center proceeded to contact OTH1, where OTH1 and OTH2 discussed the proper disposition for the patient. OTH2 continued to support the need for the patient to present to [Name of local hospital] for evaluation. After continued discussion, the conversation ended with OTH1 being made aware that an emergent transfer was already underway, and CF2 wanted to give notification of the patient's pending arrival.

Continued review on August 4, 2025, of MR1 revealed the facility, "Patient Transfer Form - EMTALA" revealed no documentation of an accepting physician.

Interview on August 4, 2025, with EMP1 and EMP3 confirmed the above findings.

Review on August 4, 2025, of the facility provided audio recording from the Transfer center dated July 21, 2025, revealed the conversation between CF2 and OTH1. OTH1 stated the facility could not accept the patient, as the NICU was level red. CF2 informed OTH1 the patient was already enroute to the facility. OTH1 repeated they could not accept the patient. The Transfer center then connected CF2 to OTH2, which was another network provider affiliated with the local network provider that refused the transfer. OTH2 stated the patient should go to the nearest labor and delivery unit given the status of the patient. OTH1 was then brought back on the call, and once again stated the NICU is level red. The call ended with OTH1 being notified the patient was underway and coming to the nearby facility.

Interview on August 4, 2025, with EMP1 confirmed the above findings.