HospitalInspections.org

Based on interviews, medical record reviews, review of EMTALA (Emergency Medical Treatment and Labor Act) and Obstetrical Policies and Procedures and EMS (Emergency Medical Services/Ambulance) report, Hospital # 1 failed to:

A. Ensure an appropriate Medical Screening Examination (MSE) was conducted for Patient Identifier (PI #1), a 27 week pregnant female who presented to the Emergency Department with lower abdominal pain and vaginal bleeding / spotting on 8/24/14. Refer to findings at A2406.

B. Provide stabilizing treatment on 8/24/14 for PI # 1 by failing to provide ongoing evaluation of:

fetal heart tones,

uterine contractions,

fetal position (refers to whether the fetus is facing rearward (toward the mother's back or forward /face up - www.merckmanuals.com/home/womens health issues/complications of labor and delivery/abnormal position and presentation of the fetus)

station (the relationship between the presenting part of the baby- head, shoulder, buttocks, or feet - and the mother's pelvis
(www.nlm.nih.gov/medlineplus),

cervical dilation (gradual opening of the cervix caused by uterine contractions, www.merckmanuals),

and status of the membranes, i.e. ruptured, leaking, intact.
Refer to findings at A2407.

C. Arrange an appropriate transfer of PI # 1, a patient who required further evaluation and treatment to stabilize her EMC (Emergency Medical Condition) on 8/24/14 via EMS (ground or air) to another facility (Hospital # 3) according to the hospital's policy. Refer to findings at A2409.

This deficient practice effected PI #1, one of 25 ED (Emergency Department) sampled patients and has the potential to effect other patients who present to Hospital #1's Emergency Department with similar obstetrical complaints and symptoms.

Based on review of Patient Identifier # 1's medical record, interviews, hospital policies and procedures, and information obtained from the Internet concerning tests/procedures to diagnose preterm labor, it was determined Hospital # 1 failed to provide an appropriate medical screening examination to include a vaginal examination and/or Nitrazine paper test to PI # 1, a pregnant female, who presented to the Emergency Department (ED) at Hospital # 1 on 8/24/14 with complaints of lower abdominal pain and vaginal bleeding.

This deficient practice affected PI # 1, one of 25 sampled patients and has the potential to affect all pregnant patients who present to Hospital # 1 and request a Medical Screening Examination.



Findings Include:


Medical Record Review - Hospital 1

Nurse's Notes 8/24/14:

19:03: Patient (PI # 1) arrived in ED (Emergency Department)

19:04: Presenting complaint: Patient states, "Started hurting in bottom of stomach after I tried to use the bathroom. I am 7 & 1/2 months pregnant."

Triage Assessment:

19:06: Complains of pain in pelvis. "Pain currently 9 out of 10 on pain a scale." Quality: Described as sharp. Onset: 1 hour ago. Appears uncomfortable. Lower abdominal pain.

OB (Obstetrical) / Gyn (Gynecological): Gravida (the number of times pregnant) 1, Full Term 0, Premature 0, Abortion 0, Living 0.

Vital Signs:
19:08: 123/71, Pulse 72, Respirations 18, Temperature 99.8 (oral). Pulse Oximetry: 98 % (Room Air).

19:41: "Fetal Heart Rate: 146 bpm (beats per minute)."

20:04: UA (Urinalysis) sent.

No medications were administered.

20:06: "Patient is mild amount of bloody mucus noted on toilet paper when patient wiped." (Bloody show: A small discharge of blood mixed with mucus from the vagina is usually a clue that labor is about to start. The bloody show may appear as early as 72 hours before contractions www.merckmanuals.com/home/womens health issues/normal labor and delivery)

20:32: Discharge ordered by MD (Medical Doctor).

20:55: "Discharged to home via wheelchair, with family, patient to go POV (Privately Owned Vehicle) to ... (Hospital # 3) to Labor and Delivery for OB services per (name of on call Obstetrician) at Hospital # 3 as patient is stable."

Discharge Assessment: Patient awake, alert and oriented x 3...Patient verbalized understanding of disposition instructions... Patient stable and appeared comfortable when she got in...grandmother's car to go to Hospital # 3. Discharge instructions given to patient, family. Instructions to go straight to Hospital # 3 as per (name of Obstetrician on call at Hospital # 3). Demonstrated understanding of instructions.


Physician Documentation:

HPI (History of Present Illness):
8/24/14 20:19: This 16 year old female presents to ED via EMS (Emergency Medical Services) - Ground with complaints of Lower Abdominal Pain with vaginal bleeding, spotting.

Onset: Began just prior to arrival.

Symptoms described as "crampy."

Severity of pain: "At its worst the pain was mild."

The patient has not experienced similar problems in the past. Seen by OB/Gyn (Obstetrician/Gynecologist), patient's primary care physician, one week ago. 28 week. G (Gravida: the number of times a women has been pregnant) 1, P (Para: Number of pregnancies that have resulted in the birth of a viable offspring) 0.

Historical:
19:08: No known drug allergies.
Home Medications: Prenatal vitamin oral tablet once daily.
Medical History: None.
Surgical History: None.
The history from the nurses notes was reviewed: and I agree with what is documented up to this point.

19:16: Patient medically screened.

Review of Systems: 20:21: Negative...

Examination: 20:22
...Respiratory: Lungs have equal breath sounds bilaterally, clear to auscultation...

Cardiovascular: Regular rate and rhythm...

Skin: Warm, dry with normal turgor...

Musculoskeletal/Extremity: ...no edema.

Constitutional: Patient appears alert, "non-toxic," anxious.

Abdomen/Gastrointestinal: Distention...Mild abdominal tenderness in the suprapubic area. Murphy's sign is negative. (a test for gallbladder disease, obtained from medical-dictionary.thefreedictionary.com), Rovsing's sign is negative. (indication of acute appendicitis, medical-dictionary.thefreedictionary.com)...

20:24: ... I had a detailed discussion with the patient regarding...need for an OB/GYN specialist, "Now for NST (Non stress test- also known as fetal heart rate monitoring, Mayo Clinic Website).

Physician consultation: OB (Obstetrician - name not documented) at (Hospital # 3 - has OB services and is approximately 55 miles from Hospital # 1) was called at 20:06 regarding patient's condition...will see patient shortly.

ED Course: No change. OB concurs with POV plan.

20:28: Patient's condition represents a certified medical emergency.

Disposition:
20:32: Discharged to home. Impression: Pelvic Pain. Condition is stable...Proceed to (Hospital # 3) for monitoring now.

There is no documentation in the medical record regarding a vaginal examination or Nitrazine paper test for PI # 1. (A vaginal examination is done to determine whether the membranes have ruptured and how dilated and effaced the cervix is - information obtained at www.merckmanuals.com/home/womens health issues normal labor and delivery).


Interview with Emergency Department Registered Nurse (RN), Employee Identifier (EI) # 1 at 8:32 AM on 9/10/14:

EI # 1 confirmed assignment to PI # 1 in the ED on 8/24/14 and stated she obtained a fetal heart rate of 146. The RN was asked if she felt confident about the fetal heart rate and replied it was, "Obvious. In my limited experience." EI # 1 stated she reported the fetal heart rate to the ED Physician. EI # 1 was asked to describe the bloody mucous documented in the 8/24/14 nurses note. According to the RN, the mucous was "bright red" and stated this finding was also reported to the ED Physician.

EI # 1 stated the ED Physician ordered a discharge for PI # 1 and instructed the patient to go to Hospital # 3 to see her OB physician. The RN was asked if anyone asked her to call an ambulance for PI # 1 and she said, "No."


Interview with EI # 2, Medical Director at Hospital # 1 on 9/10/14 at 1:27 PM and continued at 3:15 PM (due to MD's patient care responsibilities):

The ED Medical Director, EI # 2, stated he was asked to review PI # 1's medical record and found the ED Physician "evaluated" the patient, but did not document a pelvic examination. According to EI # 2, the ED Physician should have done a pelvic examination on PI # 1. EI # 2 stated it would have been appropriate to do a nitrazine test on PI # 1 due to the presence of blood (bloody mucus noted on toilet paper documented in nurses note on 8/24/14 at 20:06) to determine the presence of amniotic fluid that could indicate possible ruptured membranes.


Interview with the EI # 3, ED Physician assigned to PI # 1 on 8/24/14, on 9/15/14 at 11:14 AM:

EI # 3 was asked if he performed a vaginal examination on PI # 1 and he said, "No." According to the physician, he knew a vaginal examination and a non stress test were indicated, but felt PI # 1 could travel to (name of city approximately 55 miles from Hospital # 1 where PI # 1's Obstetrician practices) for the vaginal examination because she was not exhibiting substantial cramps and "did not appear to be in labor." PI # 1's "emergency medical condition and evaluation was not complete. She could not go home. She had to go to Hospital # 3." The physician, EI # 3, said PI # 1 needed to go straight to a Labor and Delivery capable suite.

EI # 3 said he spoke with the OB physician on call at Hospital # 3 who was also the patient's obstetrician. Reportedly, the obstetrician agreed that PI # 1 could be transferred in a private vehicle from Hospital # 1 to Hospital # 3, for an evaluation. Hospital # 1 has no obstetricians on staff.

According to EI # 3, the patient (PI # 1) did not appear to be in labor and the physician stated he did not want to deliver a "27 weeker." After PI # 1 was discharged from the ED at Hospital # 1, the physician said he received a telephone call from a physician at Hospital # 2 reporting fetal demise. (Hospital # 2 - facility EMS transported PI # 1 to after responding to call received from PI # 1 during trip in private vehicle to intended destination of Hospital # 3). The physician was unable to recall caller's name and there is no documentation in PI # 1's medical record about this conversation.)

EI # 3 said, "How could we have heard fetal heart tones? I acted on fetal heart tones given to me of 146, but due to lack of tissue tone it appears the baby had been dead for several days. I don't do fetal heart tones." According to EI # 3, the patient was not in active labor when she presented to Hospital # 1's Emergency Department.


Hospital # 1's Emergency Services Policy & Procedure Manual
Policy/Procedure Title: Emergency Medical Treatment and Patient Transfer
Effective date: 4/93 (Annual Review date: 7/14)

Purpose: This 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:
For the purpose of this emergency medical treatment and transfer policy, the following terms shall have the meaning defined in 42 CFR (Code of Federal Regulations) 489.24(b).

... 3. "Emergency medical condition" means (i) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse, active labor) 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...

... D. with respect to a pregnant woman who is having contractions
(i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or
(ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.

4. "Labor" means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor...

C. An emergent patient is considered stable for discharge when, within reasonable clinical confidence the treating physician determines that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions...

I. Medical Screening Examination
A. General
1. Medical Screening. When an individual comes to the Emergency Department of the Hospital, or to any location on Hospital property...and a request is made on the individual's behalf for a medical examination or treatment, an appropriate medical screening examination, within the capabilities of the emergency department (including ancillary services routinely available to the emergency department), shall be provided to determine whether an emergency medical condition exists, or with respect to a pregnant woman having contractions, whether the woman is in labor ...Also, a medical screening exam is not an isolated event, it is an ongoing process. The record must reflect continued monitoring according to the patient's needs and must continued until completion of stabilizing treatment and the patient is discharged, admitted, or appropriately transferred.

Medical screening examinations shall be performed by an Emergency Department physician. An Emergency Department physician on duty shall be responsible for the general care of all patients presenting themselves to the Emergency Department. This responsibility remains with the Emergency Department physician until the patient's private physician or the on-call physician, or an on-call specialist assumes that responsibility, or the patient is appropriately discharged or arrives at the receiving hospital following appropriate transfer...

Policy/Procedure Title: Nitrazine Paper POCT (Point of Care Testing)
Effective date: 3/02 (Review date: 1/15/14)
Policy: Nitrazine Paper will be available in the Emergency Room to be used by nursing personnel when indicated.

Purpose: To assess the status of a patient's membranes, whether intact or ruptured when presenting to the ER (Emergency Room)...

Information obtained from mayoclinic.org/diseases-conditions/preterm-labor:
"... To help diagnose preterm labor, your health care provider will document your signs and symptoms...
Tests and procedures to diagnose preterm labor include:

Pelvic exam. Your health care provider might evaluate the firmness and tenderness of your uterus and the baby's size and position. He or she might also do a pelvic exam to determine if your cervix has begun to open - if your water hasn't broken and the placenta isn't covering your cervix (placenta previa)..."

Based on review of Patient Identifier (PI) # 1's medical records (Hospital # 1 and Hospital # 2), EMS (Emergency Medical Services) / Ambulance report, EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures and interviews, it was determined Hospital # 1 failed to provide stabilizing treatment for PI # 1, a 7 and 1/2 month pregnant female who presented to the Emergency Department (ED) on 8/24/14 with complaints of lower abdominal pain and vaginal bleeding / spotting. These actions resulted in a delay in treatment of PI # 1, who required intervention by EMS (Emergency Medical Services) personnel prior to arrival at Hospital # 2 after having been discharged from Hospital # 1 with instructions to proceed via private vehicle to Hospital # 3, a facility located 55 miles from Hospital # 1.

This deficient practice affected PI # 1, one of 25 sampled ED patients, but has the potential to negatively impact all pregnant patients who present to Hospital # 1 who are determined to have an Emergency Medical Condition and require stabilizing treatment.


Findings include:

Medical Record Review - Hospital # 1

Physician Documentation:

HPI (History of Present Illness):
8/24/14 20:19: This 16 year old female presents to ED via EMS - Ground with complaints of Lower Abdominal Pain with vaginal bleeding, spotting.

Onset: Began just prior to arrival.

Symptoms described as "crampy."

Severity of pain: "At its worst the pain was mild."

The patient has not experienced similar problems in the past. Seen by OB/Gyn (Obstetrician/Gynecologist), patient's primary care physician, one week ago. 28 week. G (Gravida: the number of times a women has been pregnant) 1, P (Para: Number of pregnancies that have resulted in the birth of a viable offspring) 0...


19:16: Patient medically screened...

20:24: ... I had a detailed discussion with the patient regarding...need for an OB/GYN specialist, "Now for NST (Non stress test- also known as fetal heart rate monitoring, a baby's heart rate is monitored to see how it responds to the baby's movements. Recommended for women at increased risk of fetal death and is usually done after week 26 of pregnancy, Mayo Clinic Website).

Physician consultation: OB (Obstetrician - name not documented) at (Hospital # 3 - has OB services and is approximately 51 miles from Hospital) was called at 20:06 regarding patient's condition...will see patient shortly.

ED Course: No change. OB concurs with POV plan.

20:28: Patient's condition represents a certified medical emergency.

Disposition:
20:32: Discharged to home. Impression: Pelvic Pain. Condition is stable...Proceed to (Hospital # 3) for monitoring now.

There was no documentation PI # 1 received stabilizing treatment of her Emergency Medical Condition, as the patient was discharged home with instructions to go by privately owned vehicle (POV) to Hospital # 3.

Summary of EMS Ambulance Report: 8/24/14

Dispatch Notified: 21:37

Arrive Scene: 21:50

Dispatch Complaint: Pregnancy/Childbirth

Arrive Destination: 22:16 ED at Hospital # 2

Narrative: Dispatched to scene for possible labor...patient (PI # 1) laying on the ground outside her car. A/O (alert, oriented) x 3. Severe abdominal pain lower right and left quadrant and vaginal pain. Patient states she is 7.5 months pregnant, first pregnancy, pain and some bleeding earlier this date, states she does not feel the baby moving...Lower left and right suprapubic area tender to touch, "patient in obvious severe pain," her shorts are wet - patient unsure if she urinated or her membrane ruptured, constant pain, although unable to palpate contractions...no crowning present throughout contact, very light bleeding is present...

Vital signs:
22:04: 114/71, 77, 22. Cardiac Rhythm: regular.
22:14: 125/83, 86, 22. Cardiac Rhythm: regular.

...Transfer to Hospital # 2 (patient choice and closest facility)....Labor and Delivery team took patient care from ED up to Labor and Delivery...


Medical Record review - Hospital # 2:

Nursing Notes:

8/24/14 22:32: " Pt. (PI # 1) to LDR (Labor and Delivery Room) via stretcher...Pt. breathing with "UC (uterine contractions)." Upon viewing perineum fetal legs were noted to be presenting from vagina...

22:33: ...Vag. (vaginal) exam performed. Attempt to deliver fetus. Vaginal bleeding noted...

22:35: Fetus remains undelivered. Attempting to deliver head of baby. Pt. encouraged to push. Peeling skin of fetal legs noted.

22:38: Fetal umbilical cord palpated. No FHR (fetal heart rate) palpated. Skin peeling. Twisting of umbilical cord noted...Head of fetus remains undelivered...encouraged to keep pushing. Vag. exam completed...

22:45: Delivery of fetus. Fetal demise noted. Skin peeling, head soft... "


Discharge Summary O.B. - Hospital # 2:

Physician Documentation: 8/24/14: 16 year old female (PI # 1) presented to Labor and Delivery via ambulance with fetal feet hanging out of vagina. Patient seen at Hospital 1 and told to go to Hospital # 3... States traveling by car until they reached (area 8 miles from Hospital # 2) and an ambulance was called and proceeded to bring patient to Hospital # 2. EDD (Expected Date of delivery / due date): 12/2/14.

Impression:
Vaginal Delivery: Patient delivered a non viable female infant in the breech position on 8/24/14 at 22:45. Baby appeared to have been demised for several days. (Breech occurs when the baby's buttocks, feet, or both may be in place to come out first during birth - requires special planning for how the baby will be born- American Congress of Obstetricians and Gynecologists website- article dated 8/2011)


Hospital # 1: Policy/Procedure: Emergency Medical Treatment and Patient Transfer
Date: 4-93 (Annual Review date 7-14)

B. Stabilizing Treatment for Emergency Medical Conditions and Women in Labor

If it is determined through a medical screening examination that an emergency medical condition exists or that a woman is in labor, emergency department personnel shall: (1) provide such further medical examination and treatment as may be required to stabilize the medical condition or provide treatment to the woman in labor, within the capabilities of the staff and facilities available at the Hospital (including if a woman is labor is having a normal delivery without complications and the Hospital has the capacity to handle a normal delivery, despite the fact that it does not have an obstetrical department, the Hospital required to provide the necessary stabilizing treatment, that is to deliver the baby and placenta), or (2) transfer the individual to another facility provided the conditions in sections II and III herein are fulfilled.

5. "To stabilize" means:
... A. with respect to an emergency medical condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or with respect to a pregnant woman in labor, that the woman has delivered the child and the placenta ...

C. An emergent patient is considered stable for discharge when, within reasonable clinical confidence the treating physician determines that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient...

Interview with the EI # 3, ED Physician assigned to PI # 1 on 8/24/14, on 9/15/14 at 11:14 AM:

EI # 3 was asked if he performed a vaginal examination on PI # 1 and he said, "No." According to the physician, he knew a vaginal examination and a non stress test were indicated, but felt PI # 1 could travel to (name of city where PI # 1's Obstetrician practices) for the vaginal examination because she was not exhibiting substantial cramps and "did not appear to be in labor." PI # 1's "emergency medical condition and evaluation was not complete. She could not go home. She had to go to (Hospital # 3)." The physician, EI # 3, said PI # 1 needed to go straight to a Labor and Delivery capable suite.

Based on review of medical records, EMS (Emergency Medical Services) / Ambulance Report, Hospital # 1's Policy and Procedure and interviews, it was determined Hospital # 1 failed to arrange an appropriate transfer via ambulance or medical helicopter with Qualified Medical Personnel from Hospital # 1 to Hospital # 3 for Patient Identifier (PI) # 1, a 7 and 1/2 month pregnant female who presented to Hospital # 1's Emergency Department on 8/24/14 with complaints of lower abdominal pain and vaginal bleeding / spotting. As a result, PI # 1's treatment was delayed. PI # 1 delivered a non-viable fetus at 20:45 on 8/24/14 at Hospital # 2.

This deficient practice affected PI # 1, one of 25 sampled ED patients and has the potential to negatively affect all pregnant patients who present to Hospital # 1 who require transfer to another facility for stabilizing treatment of their Emergency Medical Condition.


Findings include:

Policies and Procedures Hospital # 1: Emergency Medical Treatment and Patient Transfer

Effective date: 4-93 (Annual Review date: 7-14)

II. Transfer of Individuals
... B. Transfer Prior to Stabilization an Individual with an Emergency Medical condition or a Woman in Labor.
An individual with an emergency medical condition, or a woman in labor, must be stabilized prior to transfer, unless

... 2. A licensed physician evaluates the individual and signs a certification, which includes a summary of the risks and benefits, that, based upon the information available at the time of the transfer, the medical benefits reasonably expected from the provision of the appropriate medical treatment at another medical facility outweigh the risks to the individual's medical condition from effecting the transfer, or in the case of labor, to the unborn child from effecting the transfer. The physician will sign a certification form ...

Policy Title: EMTALA Medical Treatment and Patient Transfer Policy
Introduction: the purpose of this policy is to define the relevant terms and provide an overview of the Emergency Medical Treatment and Labor Act (EMTALA)....

... Appropriate Transfer occurs when 1) the transferring Hospital provides medical treatment within its Capacity and Capability that minimizes the risks to the individual's health and in the case of a woman in labor, the health of the unborn child; 2) the receiving facility has the appropriate space and qualified personnel for the treatment of the individual and has agreed to accept Transfer of the individual and to provide appropriate medical treatment ... 4) the Transfer is effected through Qualified Medical Personnel and appropriate transportation and equipment...

Interviews:

During an interview with Employee Identifier (EI ) # 2, Emergency Department (ED) Medical Director at Hospital # 1, on 9/10/14 at 1:27 PM and 3:15 PM (due to patient care responsibilities), the ED Medical Director said if a patient requires a transfer out of the ED, it must be via ambulance. If a patient refuses transfer via ambulance, they must be discharged against medical advice.

During an interview with EI # 3, ED Physician on 9/15/14 at 11:14 AM, the ED Physician stated Hospital # 1 requires EMS transport for all transfers out of the ED, but there are a limited number of ambulances available.

EI # 3 stated PI # 1's grandmother presented to the ED at Hospital 1 "demanding EMS transport" for the patient. According to the physician he said, "I don't have an ambulance. It's not for that." EI # 3 said he felt PI # 1 was stable enough to go by car to (Hospital # 3). According to the physician, PI # 1 was not in active labor.

PI # 1 presented to Hospital # 1 on 8/24/14 with complaints of Lower Abdominal Pain with vaginal bleeding / spotting and was evaluated by Employee Identifier (EI # 3), Emergency Department (ED) Physician, who determined PI # 1 required an OB/GYN (Obstetric/Gynecology) specialist for an evaluation and a non stress test. EI # 3 documented having consulted the OB/GYN at Hospital # 3. However, PI # 1 was discharged with instructions to proceed by private vehicle to Hospital # 3, (a hospital located 55 miles from Hospital # 1). PI # 1's condition was documented as stable at the time of discharge form Hospital # 1.

Hospital # 1 failed to effect a transfer through qualified personnel and emergency equipment, as required, including the use of necessary and medically appropriate life support measures as evidenced by instructing and allowing PI #1, to travel to Hospital # 3, located 55 miles from Hospital # 1 via a private vehicle for obstetrical care.

Enroute, PI # 1 required Emergency Medical Services intervention and transportation due to possible membrane rupture and severe pain related to pregnancy. PI # 1 arrived at Hospital # 2 at 22:16 and was taken to Labor and Delivery, where she vaginally delivered a non-viable female infant in the breech position at 22:45.

Hospital # 1 failed to follow it's own policies for Emergency Medical Treatment and Patient Transfer and EMTALA Medical Treatment and Patient Transfer by failing to provide and effect an appropriate transfer of PI #1 on 8/24/2014. This failure posed an immediate and serious threat to the patient and the unborn child's health and safety and resulted in a delay in treatment and stabilization for this patient.