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An unannounced on-site Emergency Medical Treatment and Labor Act (EMTALA) complaint investigation was conducted November 11-14, 2014. The findings were forwarded to the Centers for Medicare and Medicaid Services (CMS) Regional Office (Region IV) in Atlanta, Georgia for final determination of compliance.

Investigative findings identified concerns with noncompliance with A2409 regarding the lack of an appropriate transfer by failing to: complete a written physician certification for transfer for individuals having an Emergency Medical Condition (EMC) that were transferred to another hospital

As a result of the lack of non compliance, the administrator was notified by overnight mail on April 29, 2015 that the facility is on a 90 day termination track with a projected date for the agreement terminating of July 28, 2015.

Based on policy and procedure reviews, closed medical record reviews, staff and physician interviews the hospital's Obstetrical (OB) Physician failed to ensure an appropriate transfer by failing to complete a written physician certification for transfer for 1 of 2 OB patients having an Emergency Medical Condition (EMC) that were transferred to another hospital (Patient #19) .

The findings include:

Review of current hospital policy 13.0 "Emergency Medical Treatment and Active Labor Act (EMTALA)" revealed "(Name of Hospital) will assure compliance with EMTALA regarding patient transfers to other facilities...1. Medically indicated - A physician certifies that based up[on the information available at the time of transfer, the benefits of the transfer outweigh any increased risks of the transfer and an appropriate transfer is arranged with transfer forms completed...An appropriate transfer is defined as: 1. Name of Hospital has provided medical treatment, within its capacity, that minimizes the risk to the patient's health and in case of a woman in labor, the unborn child... Certificate of Transfer - means a certification signed or countersigned by a physician that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility (receiving facility) outweigh the increased risks to the individual and in the case of a women in labor, to the unborn child, from effecting the transfer".

1. Medical record review of Patient #19 revealed a 32 year old presenting to the Labor and Delivery department (L&D) from the physician's office on 10/21/2014 at 0955 with a chief complaint of Rupture of Membranes (ROM)greater than 48 hours. Record review revealed the patient was a gravida 2 para 1 (second pregnancy and 1 living child) and was 30.2 weeks gestation. Record review revealed documentation by nursing staff at 1005 the vaginal exam was deferred due to the patient having an exam in the physician's office prior to arrival at the hospital. Further review revealed per the physician "ROM greater than 48 hours, 1 cm dilated". Record review revealed documentation by the physician "1. 30 weeks intrauterine pregnancy. 2. Spontaneous rupture of membranes, 48 hours ago." Further review of the physician documentation revealed "Physical exam:...Speculum exam demonstrated a pool of clear fluid in the vaginal vault with some trickling from the os. Nitrazine was positive. The cervix was fingertip dilated 50 % effaced at -1 to -2 station...Impression : 30 weeks intrauterine pregnancy. EDC (estimated date of confinement) of 12/28 by seven week ultrasound. Oligohydramnious with clinical; findings of spontaneous rupture of membranes preterm. Plan: Will send the patient directly to labor and delivery and arrange immediate transfer to a tertiary care center for further observation and probable preterm delivery". record review revealed the patient was transferred by ambulance at 1156. Record review revealed a "physician certification of Transfer form. Review of the form did not reveal any documentation by the physician certifying the transfer. Review of the section"(10) Transferring Physician Certification" revealed the section was blank. Further record review did not reveal documentation of written physician certification for transfer.

Interview with the OB nurse Manage on 11/13/2014 at 1545 revealed there was no written physician documentation available for patient #19. The interview revealed the physician should complete and sign the form to document written physician certification.

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