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Based on observation, interview, and record review, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements as evidenced by:

1. Failure to provide an appropriate medical screening examination (refer to A2406);

2. Failure to document a medical screening examination (refer A2406);

3. Failure to have the receiving hospital agree to accept the transfers (refer to A2409);

4. Failure to provide medical treatment within its capacity to minimize risk to the patients (refer to A2409);

5. Failure to complete transfer forms and document them accurately (refer to A2409);

6. Failure to report the possible EMTALA violation (refer to A2409);

7. Failure to follow the hospital's policy to have the approval of the second emergency department (ED) physician and the administrator on call (AOC) before initiating the transfer (A2409).

The cumulative effects of these systemic problems resulted in the facility's inability to ensure the provision of quality of emergency services.

Based on observation, interview, and record review, the hospital failed to provide an appropriate medical screening exam [MSE, a process to determine whether a patient has an emergency medical condition or is in labor] for five of 20 patients (Patients 5, 8, 12, 17, and 18) when:

1. There was no emergency department provider note, no obstetrics/gynecology physician consultation (OB/Gyn, a physician specializing in women's health including pregnancy), and no tests performed for Patient 8; and,

2. There was no obstetrics/gynecology physician note (consult [the act of seeking assistance from another physician(s) for diagnostic studies, therapeutic interventions, or other services that may benefit the patient] note) for Patients 5, 12, 17, and 18, despite consultation.

These deficient practices placed the health of pregnant patients and their unborn children at risk.

Findings:

Hospital A is a community hospital with a dedicated emergency department. Hospital B is an academic medical center with a dedicated emergency department.

1. During a concurrent observation and interview on 8/9/22 at 9:29 a.m. with the Emergency Department Director (EDDIR), Registered Nurse 8 (RN8), and the Chief Quality Officer (CQO) in Hospital A's Emergency Department (ED), the EDDIR stated Hospital A did not have a Labor & Delivery floor, a Neonatal Intensive Care Unit [NICU, floor providing intensive care for newborn babies], or a Pediatrics floor. Two tocodynamometer machines [machine to monitor and record uterine contractions before and during labor] were observed in the ED, one in room 21 and one in room T2. Room 21 had a sign on the door noting "Labor and Delivery Room". A hemorrhage [bleeding] cart, NICU cart, delivery cart, patient stretcher, infant warmer, and bassinet were observed in room 21.

During a review of Patient 8's medical records from Hospital A, indicated Patient 8 was triaged [process to categorize patients based on severity of illness in order to determine who needs to be seen first] in Hospital A's emergency department on 7/6/22 at 3:38 a.m. Patient 8 was an 18-year-old pregnant female who presented for cramping and her water breaking. Registered Nurse 5 noted "... ok to redbox pt too [sic] [Hospital B] OB per house sup [house supervisor], ED MD, and county dispatch ...". The ordering providers on Patient 8's orders were ED Physician 5 and ED Physician Assistant 1. All laboratory and radiology orders were cancelled, with a note the patient was discharged. There was no ED provider note and no OB/Gyn physician note.

During a review of the ambulance record for Patient 8, dated 7/6/2022, indicated the ambulance transported Patient 8 from Hospital A to Hospital B.

During a review of Patient 8's Labor and Delivery Triage/Observation Record from Hospital B, dated 7/6/2022, indicated Patient 8 was 39 weeks pregnant and was not in labor. Patient 8 was discharged home.

During an interview on 8/18/22 at 11:32 a.m. with Patient 8, Patient 8 stated she went to Hospital A on 7/6/22 because she was leaking fluid and having contractions. Patient 8 stated, at Hospital A, all they did was weigh her and a physician saw her in a cubicle toward the front. Patient 8 stated no tests were performed, a physician did not examine her, and no monitor was placed on her to check contractions. Patient 8 stated, after seeing the ED physician, she was transferred in an ambulance to another hospital.

During concurrent interview and record review on 8/10/22 at 3:44 p.m. with the Medical Staff Director (MSD), the hospital's Medical Staff Rules and Regulations, approved July 22, 2021, was reviewed. The Medical Staff Rules and Regulations indicated "... The Medical Screening Exam (MSE) must be conducted by physicians or Qualified Medical Personnel (QMP) to determine whether an emergency medical condition exists ... Emergency medicine physician assistants may perform MSE's ...". The MSD stated the QMP included ED nurse practitioners.

During a review of the hospital's policy and procedure titled Care of the Pregnant Patient in the Emergency Department, revised 9/27/21, indicated "... All pregnant patients presenting to the ED [emergency department], including those reporting in active labor, will be evaluated by the Triage RN, receive a medical screening exam (MSE) will be performed by a qualified medical provider (QMP) to determine the presence of an emergency medical condition ..." and "... Pregnant patient (>) greater than 20 weeks gestation ... Upon presentation to the ED, the following will be performed ... Evaluation by the Triage RN [registered nurse] and receive a medical screening exam by a qualified medical provider to determine the presence of an emergency medical condition ... ED provider will consult on call OB/GYN ... a designated ED RN will apply the continuous electronic fetal cardiac [heart] monitoring (EFM) and tocodynamometer (TOCO) ...".

During a review of the hospital's Medical Staff Bylaws, approved 08/24/2020, indicated "... members, and others holding Clinical Privileges shall be governed by all applicable Medical Staff Bylaws, Rules and Regulations, and Medical Staff and Hospital policies and procedures which have been appropriately approved by the Board of Trustees ...".

During an interview on 8/12/22 at 11:46 a.m. with the ED Medical Director (EDMED), the EDMED stated there is always one ED provider sitting in the triage area, either a physician, physician assistant, or nurse practitioner. The EDMED stated, in the triage area, a nurse triages [process of determining the severity of a patient's illness] the patient while the ED provider concurrently begins the Medical Screening Exam. The EDMED stated the ED provider in triage will not write a note in a patient's medical record unless that patient is only treated in the triage area. The EDMED stated, if a patient is sent from the triage area to the main ED or vertical treatment areas, the ED provider in those areas will write a note.

During an interview on 8/15/22 at 9:27 a.m. with Registered Nurse 5 (RN5), RN5 stated he recalled Patient 8. He stated he did not directly interact with Patient 8 but was the charge nurse on 7/6/22. RN5 stated Patient 8 entered through the triage area, and the triage nurse told him the patient was in active labor, having contractions every three to five minutes, and that her water broke. RN5 stated ED Physician 5 was present and asked if they could transfer Patient 8 so the patient did not deliver at Hospital A. RN5 stated the patient was being moved to ED room T2 when the ambulance staff showed up, so Patient 8 got onto the ambulance stretcher. RN5 stated Patient 8 never made it to ED room T2, was not placed on the tocodynamometer monitor [machine to monitor and record uterine contractions before and during labor], and did not even have an assigned primary nurse. When asked if ED Physician 5 examined Patient 8, RN5 stated he did not know. He stated there was no privacy to perform a pelvic exam in the triage area, only to examine a patient over his or her clothing.

During an interview on 8/16/22 at 7:45 a.m. with ED Physician 5 (EDP5), EDP5 stated he recalled Patient 8. EDP5 stated he was not part of this patient's care past the triage area. He stated he was the ED physician who took in Patient 8 and placed orders in the triage area. He stated ED Physician Assistant 1 was not involved in the patient's care. When asked if he was aware Patient 8 was transferred to Hospital B, EDP5 stated he was not aware. He stated he triaged Patient 8 and sent the patient to the main ED area. EDP5 stated ED Physician 7 then picked up the patient. When asked how ED providers document when a Medical Screening Exam is performed, EDP5 stated there is no formal documentation process. He stated the ED provider puts in orders and a MSE order to note that a MSE was performed.

During an interview on 8/16/22 at 1:18 p.m. with ED Physician 7 (EDP7), EDP7 stated he was not involved in Patient 8's care at all. EDP7 stated he did not know about Patient 8 until after she had been transferred. EDP7 stated he did not receive any communication from the ED provider in triage, triage nurse, or charge nurse about Patient 8. EDP7 stated he informed the ED Medical Director that he heard a pregnant patient in labor was transferred to another hospital and that he saw no Medical Screening Exam was done when he reviewed the patient's medical record. EDP7 stated the other ED provider working on that day was ED Physician 5.

During a concurrent observation and interview on 8/16/22 at 9:00 a.m. with the Director of Clinical Informatics (DCI), the DCI demonstrated how a Medical Screening Exam is documented in the electronic medical record. The DCI stated the ED provider clicks a MSE Statement MD order or MSE Statement PA/NP order that states, "MSE initiated. Patient will be seen by primary provider as soon as possible to complete MSE." The DCI stated the name of the ED provider who entered the MSE order will be documented in the patient's medical record. The DCI stated she could perform an audit trail of orders and notes for Patient 8.

During a concurrent interview and record review on 8/18/22 at 8:53 a.m. with the Accreditation and Regulatory Manager (ARM), the ARM provided a list of all orders for Patient 8. The ARM confirmed there was no MSE Statement MD order or MSE Statement PA/NP order.

During an interview on 8/15/22 at 11:52 a.m. with the Accreditation and Regulatory Manager (ARM), the ARM confirmed there was no ED provider note for Patient 8.

During an interview on 8/17/22 at 2:08 p.m. with the ED Director (EDDIR), ED Medical Director (EDMED), Chief Medical Officer (CMO), and Chief Quality Officer (CQO), the EDMED stated there was no indication an OB/Gyn physician was consulted for Patient 8.

During a review of the hospital's policy and procedure titled EMTALA - California Transfer Policy, approved 01/24/17, indicated "... A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE [medical screening exam] and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer ...".

During a concurrent interview and record review on 8/10/22 at 3:44 p.m. with the Medical Staff Director (MSD), an email from the MSD dated Oct 14, 2021 was reviewed. The email indicated "... Hello ED Providers and OB Physicians ... As a result of the facility's CMS Survey, we have revised the attached Policies and the Physician Section of the EMTALA Memorandum of Transfer Form. Please reply you've received this; read the policies and MOT [Memorandum of Transfer]. We must track physician and PA/NP [physician assistant/nurse practicioner] understanding of the Revised Policies and MOT ...". The MSD showed the revised policies titled Triage in the Emergency Department, and Care of the Obstetric Patient in the Emergency Department. The MSD stated, as a result of a previous EMTALA survey, Hospital A revised several policies. The MSD stated he sent all ED providers and OB/Gyn physicians an email with the updated policies, and the hospital made sure all of the ED providers and OB/Gyn physicians read them. The MSD stated he would provide a list of all providers who responded to his email.

During a concurrent interview and record review on 8/12/22 at 9:00 a.m. with the Medical Staff Director (MSD), the list of all ED and OB/Gyn physicians who responded to his email requesting review of updated EMTALA policies was reviewed. The MSD stated there were probably 40 physicians who did not respond. The MSD then stated it was not required for the ED and OB physicians to respond, that providers were expected to know where to look for policies. When asked if all physicians and midlevel providers [physician assistants and nurse practitioners] are required to complete EMTALA training, the MSD stated no it was not part of Hospital A's medical staff bylaws or online training. The MSD stated the company employing all of the ED providers required EMTALA training. When asked if physicians or midlevel providers from other specialties are part of the same company, the MSD stated only some of the hospitalists [physicians who provide general medical care for hospitalized patients]. When asked how Hospital A knows its providers are familiar with EMTALA if the medical staff department does not require EMTALA training and not all ED and OB providers responded to his email, the MSD stated he does not know.

During a concurrent interview and record review on 8/16/22 at 11:13 a.m. with the MSD and Chief Quality Officer (CQO), EMTALA training certificates from the ED provider company and the New Provider Orientation slides were reviewed. The MSD stated Hospital A had nothing to do with the EMTALA training certificates from the ED provider company, and that Hospital A does not require EMTALA training. The MSD stated he did not even know about the EMTALA training from the ED provider company until recently. The CQO provided a slide titled, "Welcome to [Hospital A]'s New Provider Orientation" and another slide noting an agenda with "... Ethics and compliance- EMTALA ...". The CQO stated this was a presentation given by the Ethics and Compliance department to new providers when they are onboarded.

During a concurrent interview and record review on 8/16/22 at 12:02 p.m. with the Ethics and Compliance Officer (ECO) and CQO, the Memorandum of Transfer Education - Physician slides were reviewed. The CQO provided the Memorandum of Transfer Education - Physician slides. The ECO stated she puts on an EMTALA presentation to new providers, giving a history of EMTALA and reviewing the EMTALA Memorandum of Transfer (MOT) form. The ECO stated she reviews the top portion of the MOT form since it is the physician portion, and why physicians need to fill out the form. The slides indicated, "... Training Objectives ... At the end of this training you will be able to: Explain the reason for the Memorandum of Transfer (MOT), Accurately complete the required elements, and List resources to where questions may be directed ...". The slides discussed that any transfer of a patient with an Emergency Medical Condition (EMC) must be initiated by a written request from the patient or physician; the definitions of To Stabilize and Stabilized; and that the MOT form is used to document transfer of a patient. The slides also discussed the MOT form sections on Medical Condition, Reason for Transfer, Risks and Benefits for Transfer, and Mode/Support During Transfer as Determined by Physician. When asked if the Medical Screening Exam requirement of EMTALA is covered in the presentation since it was not in the slides, the ECO stated she verbally discusses it. When asked if the Central Log requirement of EMTALA is covered in the presentation since it was not in the slides, the ECO stated she does not discuss it since physicians do not touch the central log per say. The ECO stated she only has five minutes to speak with the new providers.



32999

2a. Review of Patient 5's Emergency Provider Report, dated 5/31/22, indicated the patient stated she was 33 weeks pregnant and presented at the ED with sharp abdominal pain, diarrhea, nausea, spotting bright red blood discharge, and frequent chest pain after eating. The OB ultrasound report, dated 5/31/22 at 9:28 a.m., showed the patient was 35 weeks and five days pregnant. It indicated, at 1:19 p.m., ED Physician 10 (EDP10) spoke to the OBGYN Physician (OBGYN6) and at 2:45 p.m., OBGYN6 performed the pelvic exam. There was no OB/Gyn consult note including the OB/Gyn's assessment, examination, and recommendation for Patient 5 to determine if the patient had an emergency medical condition.

During an interview on 8/15/22 at 3:15 p.m., the ARM confirmed there was no OB/Gyn consult note for Patient 5.

b. Review of Patient 12's Emergency Provider Report, dated 3/6/22 indicated the patient was approximately 40 weeks pregnant and presented with abdominal pain, contractions every three minutes, and high blood pressure. The report indicated on 3/6/22 at 5:52 a.m., OBGYN Physician 1 (OBGYN1) arrived and examined Patient 12. OBGYN1 recommended to transfer Patient 12 emergently to Hospital B. The report indicated on 3/6/22 at 6:06 a.m., OBGYN 1 will accompany patient on the ambulance during transport from Hospital A to Hospital B. There was no OB/Gyn consult note including OBGYN1's assessment, examination, and recommendation for Patient 12.

During an interview on 8/11/22 at 2 p.m., the ARM confirmed there was no OB/Gyn consult note for Patient 12.

c. Review of Patient 17's Emergency Provider Report, dated 6/7/22, indicated Patient 17 was 39 weeks pregnant and presented at the ED for evaluation of active labor.

Review of Patient 17's Emergency Patient Record, dated 6/7/22 at 2:50 p.m., indicated OBGYN Physician 7 (OBGYN7) arrived at the ED and OBGYN7 examined Patient 17. There was no OB/Gyn consult note indicating whether the patient had an emergency medical condition.

During an interview on 8/11/22 2:48 p.m., ED Director (EDDIR) confirmed there was no OB/Gyn consult note for Patient 17.

d. Review of Patient 18's Emergency Provider Report, dated 5/12/11, indicated the patient presented to the ED complaining of moderate vaginal bleeding. The OB ultrasound result, dated 5/23/22 at 11:30 p.m., indicated the patient was 25 weeks and one day pregnant. It indicated, at 11:08 p.m., OBGYN1 was contacted for consultation and on 5/13/11 at 12:16 a.m., OBGYN1 evaluated the patient at bedside. There was no OB/Gyn consult note for Patient 18.

During an interview on 8/15/22 at 3:15 p.m. with the ARM, she confirmed there was no OB/Gyn consult note for Patient 18.

During an interview on 8/16/22 at 10:45 a.m., the regional health information manager (HIM) stated the consult notes should be documented at the time of service. The Chief Quality Officer (CQO) stated manual audits could check whether consult notes were documented timely, but it had not been done in the ED.

Review of Medical Staff Rules and Regulations, "7.2.4 Consultant's Report", dated 7/22/21, approved by Board of Trustees, indicated, "Consultation reports shall be dictated as soon as possible, and in any case, within twenty four (24) hours after the patient is first seen by the consultant, shall reflect a review of the patient's record by the consultant, shall detail pertinent history and patient findings on examination, and shall set forth the consultant's opinion, the reasons therefore, and the consultant's recommendations."


36623

Based on observation, interview, and record review, the hospital failed to appropriately transfer six of 13 patients (Patients 1, 8, 10, 12, 17, and 18) when:

1. The receiving hospital's physician did not agree to accept the transfer of five of 13 sampled patients (Patients 1, 8, 12, 17, and 18) and the hospital failed to investigate and report the possible EMTALA violation;

2. The hospital failed to provide medical treatment within its capacity to minimize risk to Patient 8's health and the health of her unborn child;

3. There were no transfer forms for two of 13 sampled patients (Patients 8 and 10) and the hospital provided inaccurate transfer forms for four of 13 sampled patients (Patients 1, 12, 17, and 18); and,

4. The hospital failed to follow its policy requiring a second physician's approval and notification of adminstrator on call (AOC) for patient transfer for six of 13 sampled patients (Patients 1, 5, 8, 10, 17, and 18).

These deficient practices placed the health of pregnant patients and their unborn children at risk.

Findings:

Hospital A is a community hospital with a dedicated emergency department. Hospital B is an academic medical center with a dedicated emergency department.

1. During a concurrent observation and interview on 8/9/22 at 9:29 a.m. with the Emergency Department Director (EDDIR), Registered Nurse 8 (RN8), and the Chief Quality Officer (CQO) in Hospital A's Emergency Department (ED), the EDDIR stated Hospital A did not have a Labor & Delivery floor, a Neonatal Intensive Care Unit [NICU, floor providing intensive care for newborn babies], or a Pediatrics floor. Two tocodynamometer machines [machine to monitor and record uterine contractions before and during labor] were observed in the ED, one in room 21 and one in room T2. Room 21 had a sign on the door noting "Labor and Delivery Room". A hemorrhage [bleeding] cart, NICU cart, delivery cart, patient stretcher, infant warmer, and bassinet were observed in room 21. The EDDIR stated babies could be vaginally delivered in either room 21 or room T2, and that Cesarean sections [c-section, surgical delivery of baby] would be done in the operating room. RN8 stated there were c-section trays in room 21 and room T1. The EDDIR and CQO stated if the baby is not delivered in their ED, Hospital A would request an emergent 911 ambulance transfer from the Emergency Medical Services (EMS) Duty Chief. The EDDIR and CQO stated if the OB/Gyn physician [obstetrician-gynecologist, a physician specializing in women's health including pregnancy] said the patient needs to be transferred now, Hospital A will try to do a courtesy call to the receiving hospital's physician but they are allowed to transfer the patient to the closest hospital. The EDDIR and CQO stated the county EMS Director reviewed this with them and the other hospital cannot deny a 911 ambulance transfer.

During an interview on 8/9/22 at 11:08 a.m. with the Chief Quality Officer (CQO), the CQO stated Hospital A does not need to fill out the EMTALA (Emergency Medical Treatment and Labor Act) Memorandum of Transfer form for patients transferred from Hospital A via 911 ambulance.

During a review of Hospital A's EMTALA Memorandum of Transfer form, undated, indicated sections for Medical Condition, Reason for Transfer, Risks and Benefits for Transfer, Mode/Support During Transfer as Determined by Physician, Receiving Facility and Individual, Accompanying Documentation, and Patient Consent to Medically Indicated Transfer or Patient Request for Transfer. The Receiving Facility and Individual section had space for the receiving facility, person accepting the transfer, and receiving physician. The Patient Consent to Medically Indicated Transfer or Patient Request for Transfer section had space for the patient signature.

During a concurrent interview and record review on 8/10/22 at 2:06 p.m. with the Emergency Department Director (EDDIR), Hospital A's OB [obstetrics, area of medicine related to pregnancy and childbirth] Transfer Report undated was reviewed. The EDDIR stated Hospital A has transferred thirteen pregnant patients who were in labor, as well as two mothers who delivered in the ED since the beginning of 2022.

During an interview on 8/10/22 at 3:31 p.m. with the Accreditation and Regulatory Manager (ARM), the ARM stated there were no c-sections performed at Hospital A in 2022. During a continued interview on 8/15/22 at 12:59 p.m. with the ARM, the ARM stated there were two c-sections performed at Hospital A in 2021.

During an interview on 8/10/22 at 10:09 a.m. with the ARM, the ARM stated the county Emergency Medical Services (EMS) policies #620 and #602 were used to determine that Hospital A can transfer or Redbox patients via 911 ambulance from Hospital A's emergency department to another hospital without going through a transfer center or obtaining an accepting hospital. During a continued interview on 8/10/22 at 11:54 a.m. with the ARM, the ARM stated the county EMS policy #620 is Hospital A's Redbox policy.

During a review of the county EMS policy #620 Interfacility Transfer - Ground Ambulance, effective July 1, 2019, indicated an interfacility call was "... A request for patient transport originating from a health facility for transportation to another health facility ... The sending physician shall prearrange acceptance of the patient by another physician at the receiving facility ... The sending physician or designee shall provide ... transfer documentation to the transporting crew ...". The policy noted "... All requests for interfacility transfers ... shall be made directly to a private ambulance service dispatch center ...". The policy indicated a 911 ambulance may be used to immediately transfer trauma, stroke, or STEMI [heart attack] patients meeting certain criteria to capable hospitals. The policy noted if a physician believes a non-trauma, non-stroke, or non-STEMI patient requires immediate transportation via 911 ambulance, "... the ED Staff shall contact the EMS Duty Chief for authorization. When this occurs the sending facility shall do the following ... The sending physician shall coordinate with the accepting physician prior to sending the patient ...".

During a review of the county EMS policy #620 Schedule B Interfacility Transfer - Ground Ambulance Trauma System Transfer Guidelines, effective January 1, 2021, indicated the trauma transfer procedure was to "... Contact the receiving "Trauma Center" and confirm that the receiving physician will accept the patient ...".

During a review of the county EMS policy #602 911 EMS Patient Destination, effective May 31, 2020, indicated "... The purpose of this policy is to ensure that all patients who require emergency ambulance service are transported to the approved facility most appropriate for their emergency medical condition ... A pregnant patient beyond 20 weeks gestation who meets Major Trauma Victim (MTV) criteria ... shall be transported to ... The closest Labor and Delivery center that is also a Trauma Center ... and ... That is accepting emergency ambulance patients ...".

During a review of Hospital A's policy and procedure titled Care of the Pregnant Patient in the Emergency Department, revised 9/27/21, indicated "... All pregnant patients presenting to the ED [emergency department], including those reporting in active labor, will be evaluated by the Triage RN, receive a medical screening exam (MSE, a process to determine whether a patient has an emergency medical condition or is in labor) will be performed by a qualified medical provider (QMP) to determine the presence of an emergency medical condition in keeping with the provisions of EMTALA ..." and "... The patient will be stabilized to capacity and capability then as needed, transferred to a higher level of care ... based on the finding of the ED assessment in keeping with the provisions of EMTALA ...".

During a review of the hospital's policy and procedure titled EMTALA - California Transfer Policy, approved 01/24/17, indicated "... If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer ... A transfer will be an appropriate transfer if ... The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer ... The transferring hospital must call the receiving hospital or the Transfer Center ... to verify the receiving hospital has available space and qualified personnel for the treatment of the individual. The receiving hospital must agree to accept the transfer ... The transferring hospital must obtain permission from the receiving hospital to transfer an individual ...".

During a concurrent interview and record review on 8/10/22 at 2:06 p.m. with the Emergency Department Director (EDDIR), the county EMS policy #620 effective July 1, 2019, the county EMS policy #620 Schedule B effective January 1, 2021, the county EMS policy #602 effective May 31, 2020, Hospital A's policy and procedure titled Care of the Pregnant Patient in the Emergency Department revised 9/27/21, and Hospital A's policy and procedure titled EMTALA - California Transfer Policy approved 01/24/17 were reviewed. When asked when Hospital A implemented its Redbox policy, the EDDIR stated at least since 2019. The EDDIR stated Redbox is really a term for trauma patients, but Hospital A was using Redbox to refer to patients immediately transferred from Hospital A by 911 ambulance. The EDDIR stated Hospital A only used the immediate transfer process for OB patients. When asked if Hospital A has a policy related to the immediate transfer out of patients via 911, the EDDIR stated yes it was the EMTALA - California Transfer Policy. Then the EDDIR stated it was actually the Care of the Pregnant Patient in the Emergency Department policy. When asked what section discussed transferring a pregnant patient via 911 ambulance, the EDDIR said it was not clearly stated in that policy.

The EDDIR then showed the county EMS policy #602, saying an ambulance can Redbox pregnant patients to a hospital with a Labor & Delivery unit (L&D) since the county knows Hospital A is not a designated L&D hospital. The EDDIR referred to the section "... A pregnant patient beyond 20 weeks gestation who meets Major Trauma Victim (MTV) criteria ... shall be transported to ... The closest Labor and Delivery center that is also a Trauma Center ... and ... That is accepting emergency ambulance patients ...". When asked if the county EMS policy #602 only referred to pregnant trauma patients, the EDDIR confirmed it did. The EDDIR then showed the county EMS policy #620, saying the section on "... If a physician believes the patient requires immediate transport by 911 ambulance and the patient does not meet the above criteria the ED Staff shall contact the EMS Duty Chief for authorization ..." was where the county EMS agency allows Hospital A to call a 911 ambulance for interfacility transportation. The EDDIR stated Hospital A adopted the county EMS policies #602, #620, and #620 Schedule B.

The EDDIR stated the EMS or ambulance staff is not involved in discussions between Hospital A and the receiving hospital, they are just helping with transportation. When asked if it was still hospital policy for Hospital A to get acceptance from the receiving facility before transferring a patient, the EDDIR stated that was when the county policy takes over since transportation was now via 911 ambulance, and that it was the EMS or ambulance staff who now make the decision to which hospital to take the patient. The EDDIR stated Hospital A still tries their best to call the receiving hospital, but after Hospital A initiates 911 transportation for transfer, it is just like an ambulance picking up a patient from a non-hospital location and bringing them to an emergency department. The EDDIR then confirmed patients being immediately transferred from Hospital A via 911 ambulance were officially patients of Hospital A, that these patients had been logged into the central log and had a medical screening exam. The EDDIR stated Hospital A still completes the EMTALA Memorandum of Transfer form even though it is not required by 911. When asked which policy states the transfer form is not required, the EDDIR said the county EMS policy #620. When asked where the county EMS policy #620 states this, the EDDIR stated it was a county policy so she did not know what was written in it.

During a concurrent interview and record review on 8/17/22 at 2:08 p.m. with the ED Director (EDDIR), ED Medical Director (EDMED), Chief Medical Officer (CMO), and Chief Quality Officer (CQO), the CMO stated, if a patient needs a higher level of care and Hospital A calls for a 911 ambulance, then the 911 ambulance decides where to take the patient. The CMO stated it is up to the 911 ambulance and EMS Duty Chief to make the determination about which hospital has capacity and capability to accept the patient. The CMO stated EMS knows which hospitals have capacity and capability, and EMS calls those hospitals. The CMO asked if, for pregnant patients in labor, the hospital is supposed to hold the patient until there is a physician-to-physician handoff; the CMO stated if the expectation is that any 911 ambulance transfer requires a physician-to-physician handoff, then that delays patient care. The EDMED stated Hospital A had not been operating under the statement that when a Redbox transfer is called, an accepting physician is required.

During an interview on 8/11/12 at 4:14 p.m. with the county EMS Director (EMSDIR), the EMSDIR stated when a hospital needs a 911 ambulance to transfer patients, it calls County Communications and County Communications calls the EMS Duty Chief. The EMSDIR stated the EMS Duty Chief will never say no to a request but does not determine to which hospital the patient goes. The EMSDIR stated the ambulance staff will go where the sending physician says to go. When asked if Hospital A has the county EMS agency's permission to transfer patients without an accepting physician or without completing a transfer form when those patients are transferred via a 911 ambulance, the EMSDIR stated Hospital A did not have permission to do so. The EMSDIR stated this was not allowed in any policy or in writing anywhere. The EMSDIR stated she sent Hospital A a letter reinforcing this last week. The EMSDIR stated EMS and ambulance staff do not check if there is an accepting physician. She stated that is out of EMS purview, that EMS just arranges for transportation. The EMSDIR stated Hospital A is obligated by law to get an accepting physician at the receiving hospital.

During a review of the county Emergency Medical Services (EMS) Director's letter to Hospital A, dated August 5, 2022, indicated "... This letter is a reminder to [Hospital A] staff of the process for transferring urgent OB [obstetrics, the branch of medicine specializing in care of women during pregnancy and childbirth] patients utilizing the 911 system. This topic was discussed on July 1, 2020, after [Hospital A] tried to initiate a "Red Box" transfer policy of their own making ... This process had never been discussed with the EMS Agency nor approved. Transfer guidelines are clearly discussed in our policy #620 ... These patients are urgent patient [sic] requiring a higher level of care and not "Red Box" transfers ... Due to the potential seriousness to patient safety, it is imperative that [Hospital A] follow all EMS policies and procedures regarding the transfer of patients to area hospitals ...".

During an interview on 8/12/22 at 2:00 p.m. with OBGYN Physician 5 (OBGYN5), OBGYN5 stated he was a maternal fetal medicine specialist [MFM, a physician specializing in high-risk pregnancies] at Hospital B. OBGYN5 stated the process for obstetric patient transfers [area of medicine related to pregnancy and childbirth] is for a physician to physician discussion with Hospital B's MFM specialist only. OBGYN5 stated hospitals should call Hospital B's transfer center, then the transfer center will contact Hospital B's MFM specialist on call and the charge nurse to check capacity in Labor & Delivery and the Neonatal Intensive Care Unit [NICU, floor providing intensive care for newborn babies]. OBGYN5 stated sometimes hospitals will call the Labor & Delivery floor directly, but the charge nurse will still contact Hospital B's transfer center and the MFM specialist on call.

During an interview on 8/18/22 at 10:00 a.m. with OBGYN5, OBGYN5 stated all patients who are transferred to Hospital B for obstetrical reasons are supposed to go through Hospital B's transfer center and utilization nurse. OBGYN5 stated, for pregnant patients transferred for other issues, those patients can be transferred from ED to ED. OBGYN5 stated if another hospital has an obstetrical reason for transferring a patient, Hospital B's ED is bypassed and not involved in accepting the patient, or evaluating or caring for the patient.

a. During a review of Patient 1's medical records from Hospital A, indicated Patient 1 was seen in Hospital A's emergency department by ED Physician 3 on 7/26/22 at 11:47 p.m. Patient 1 was a 21-year-old 39 week pregnant female who presented in active labor with contractions. At Hospital A, ED Physician 3 consulted OBGYN Physician 1 [obstetrician-gynecologist, a physician specializing in women's health including pregnancy]. Registered Nurse 2 noted "... per [OBGYN Physician 1], imminent delivery, pt [patient] needs to be redboxed ...". In his Consultation Report, dated 07/27/22, OBGYN Physician 1 (OBGYN1) noted Patient 1 "... was in active phase of labor ... We decided to transfer over. Transfer center was contacted, and since she was 8 cm, they would not accept the patient. Any way, I transferred the patient via ambulance to [Hospital B] and I went with the patient in the ambulance ... I am dictating after the incident that she had a baby girl in [Hospital B] Emergency Room at 1:27, as soon as she arrived there ...". In her Emergency Provider Report, dated 07/26/22, ED Physician 3 (EDP3) noted she also requested Patient 1 be transferred to Hospital B, and documented ED Physician 9, the ED physician at Hospital B, accepted the transfer on 7/27/22 at 1:06 a.m.

During a review of the ambulance record for Patient 1, dated 07/27/2022, indicated the ambulance arrived at Hospital A on 07/27/2022 at 12:52 a.m. to pick up Patient 1, and arrived at Hospital B on 07/27/2022 at 1:17 a.m. The ED transfer at Hospital B occurred on 07/27/2022 at 1:23 a.m.

During a review of Patient 1's Obstetrics Admission History & Physical from Hospital B, dated 7/27/2022, indicated Patient 1 "... arrived at [Hospital B] ED, pushing while in the ambulance ...". During a continued review of Patient 1's medical records from Hospital B, indicated Patient 1 delivered her baby on 7/27/2022 at 1:27 a.m. in the emergency department. In his ED Provider Notes, dated 7/27/2022, ED Physician 9 noted he was told prior to Patient 1's arrival that the accepting physician was OBGYN Physician 2. OBGYN Physician 2, a maternal fetal medicine specialist [MFM, a physician specializing in high-risk pregnancies] at Hospital B, documented in her Telephone Notes, dated 7/27/2022, that she spoke with Hospital B's Labor and Delivery (L&D) charge nurse, and that there were only two beds available with three waiting patients. OBGYN Physician 2 noted "... I then clearly explained to [OBGYN Physician 1] that I am not accepting the transport due to safety issues and ... that I am clearly documenting that I did not acceptthe [sic] transport. He verbally agreed and stated that he was still going to proceed with the ambulance transfer ...".

During an interview on 8/9/22 at 1:40 p.m. with OBGYN Physician 1 (OBGYN1), OBGYN1 stated he recalled Patient 1. He stated he has been an OB/Gyn physician for 40 years. He stated Patient 1 was eight centimeters dilated but he knew he had time to transfer her. He stated it only takes ten minutes to transfer a patient from Hospital A to Hospital B, and that Patient 1 was not going to have a baby in ten minutes. He stated Hospital B's OB/Gyn physician said Patient 1 was not stable for transfer. He stated he is the physician who decides if a patient is stable, not Hospital B's physician. When asked if there was a way to monitor the fetus [unborn baby] in the ambulance, he stated there was no fetal monitoring in the ambulance but he was trying to listen to the fetal heartbeat with a stethoscope. When asked if he was aware Patient 1 delivered four minutes after arriving at Hospital B, OBGYN1 stated, "Good, is something wrong?" When asked if he considered the risks of transferring Patient 1, OBGYN1 stated yes he considered that the patient might deliver the baby on the way. He stated if the patient is expected to deliver in the ambulance then the patient should stay at Hospital A, that Hospital A is better than an ambulance but that Hospital B is better than Hospital A. OBGYN1 stated on his exam, he knew Patient 1 would make it to Hospital B before delivering but since there was a chance of that he went with the patient. When asked if he contacted other hospitals after Hospital B's physician said Patient 1 was not stable for transfer, OBGYN1 did not answer. OBGYN1 stated he does not believe he did anything wrong.

During a second interview on 8/16/22 at 2:00 p.m. with OBGYN1, OBGYN1 stated OBGYN Physician 2 (OBGYN2) did not refuse to accept Patient 1. OBGYN1 stated OBGYN2 said the patient was not stable enough for transfer. OBGYN1 stated Hospital B cannot refuse a patient transfer. OBGYN1 then stated OBGYN2 said she was not going to accept the transfer since Patient 1 was not stable. When asked why the EMTALA Memorandum of Transfer form lists OBGYN2 as the accepting physician when OBGYN2 did not accept the transfer, OBGYN1 stated he did not see the discrepancy. OBGYN1 stated OBGYN2 never mentioned there were not enough staff or beds for the patient. OBGYN1 stated they did not have enough time to look at other hospitals to transfer Patient 1 to.

During an interview on 8/10/22 at 9:30 a.m. with OBGYN Physician 2 (OBGYN2), OBGYN2 stated she is an MFM specialist at Hospital B. OBGYN2 stated, on 7/27/22 shortly after midnight, she was contacted by Hospital B's transfer center about Patient 1. OBGYN2 stated she knew beds were full and staffing was an issue from earlier so she called Hospital B's Labor & Delivery, and the charge nurse said there were two beds available but three patients who were in active labor awaiting those beds. OBGYN2 stated there were only two nurses available, and one nurse was required for each active labor patient. OBGYN2 stated the charge nurse was aware of Patient 1 because OBGYN1 had called, but the charge nurse did not accept Patient 1 and asked OBGYN1 to go through Hospital B's transfer center. OBGYN2 stated she then called OBGYN1, who told her Patient 1 was 39 weeks pregnant, eight centimeters dilated, and had a history of a prior c-section. OBGYN2 stated she felt it was not safe to transfer Patient 1 to Hospital B because the patient was attempting vaginal birth after cesarean (VBAC) and she was eight centimeters dilated. OBGYN2 stated Patient 1 could have uterine rupture or could deliver the baby in the ambulance. OBGYN2 stated uterine rupture is a catastrophic outcome requiring immediate surgery. OBGYN2 stated she did not feel it was safe to transfer the patient and Hospital B did not have the capacity to accept the patient due to bed and staffing issues. OBGYN2 stated OBGYN1 said he would still transfer the patient over. OBGYN2 stated she checked how long it takes to travel from Hospital A to Hospital B, and it was 20 minutes. OBGYN2 stated 20 minutes is a long time in a multiparous patient [woman who has given birth to a child previously].

During a second interview on 8/17/22 at 10:00 a.m. with OBGYN2, OBGYN2 stated she declined the transfer of Patient 1 since it was not safe to transfer the patient, and also because there was no bed availability and a shortage of nursing staff. OBGYN2 stated she was pretty sure she told OBGYN1 that there was no bed available, but she cannot be 100% sure. OBGYN2 stated she believes OBGYN1 would have been aware of the lack of beds because he had called Hospital B's Labor & Delivery himself. OBGYN2 stated she recommended to OBGYN1 that Patient 1 deliver at Hospital A, because Hospital A had capability to take the patient to the operating room for an emergency c-section if she had a uterine rupture, and then transfer the patient and baby to Hospital B.

During an interview on 8/12/22 at 10:26 a.m. with Unit Clerk 1 (UC1), UC1 stated he recalled Patient 1. UC1 stated, for Redbox transfers, he contacts Hospital A's transfer center, the transfer center calls the receiving hospital's transfer center, Hospital A's ED physician will speak with the receiving hospital's physician, the ED physician fills out the EMTALA Memorandum of Transfer form if the patient is accepted, and he facilitates transportation. UC1 stated, for Patient 1, he attempted to go through Hospital A's transfer center but he was on hold for about 20 minutes. He stated OBGYN Physician 1 (OBGYN1) said they could not wait that long and asked him to call Hospital B simultaneously. UC1 stated OBGYN1 spoke with Hospital B's OB/Gyn physician, and OBGYN1 said Hospital B's OB/Gyn physician accepted Patient 1. UC1 stated ED Physician 3 spoke with Hospital B's ED physician after OBGYN1 spoke with Hospital B's OB/Gyn physician. UC1 stated Hospital B's ED physician asked ED Physician 3 for the name of Hospital B's accepting OB/Gyn physician, so he was asked to confirm that name with OBGYN1.

During a concurrent interview and record review on 8/11/22 at 7:28 a.m. with ED Physician 3 (EDP3), Patient 1's EMTALA Memorandum of Transfer form dated 7/27/22 was reviewed. The Memorandum of Transfer form indicated [OBGYN2] was the accepting physician. EDP3 confirmed she retains primary responsibility for a patient even if an OBGYN physician is consulted. EDP3 stated she recalled caring for Patient 1, that Patient 1 was a Redbox transfer. EDP3 stated OBGYN Physician 1 evaluated the patient in person, noted the patient was dilated to eight centimeters and decided they needed to transfer the patient. EDP3 stated she was calling Hospital B's ED physician while OBGYN1 was calling Hospital B's OB/Gyn physician. EDP3 stated she spoke with ED Physician 9 at Hospital B, relaying that Patient 1 was 39 weeks pregnant, that OBGYN1 was speaking with Hospital B's OB/Gyn, and that OBGYN1 would accompany the patient in the ambulance. EDP3 confirmed it was her signature on Patient 1's EMTALA Memorandum of Transfer form. When asked which physician was listed as the accepting physician, EDP3 confirmed it was not ED Physician 9 and that she believed it was Hospital B's OB/Gyn physician. When asked what OBGYN1 said about his conversation with Hospital B's OB/Gyn physician, EDP3 stated from what she can recall, Hospital B's OB/Gyn physician was aware of and would accept Patient 1. EDP3 stated, despite the Redbox categorization, Hospital A is still required to obtain an accepting facility and fill out the EMTALA Memorandum of Transfer form.

During a second concurrent interview and record review on 8/15/22 at 4:18 p.m. with EDP3, Patient 1's medical record was reviewed. EDP3 stated she spoke with ED Physician 9 after OBGYN1 had already spoken with Hospital B's OB/Gyn physician. When asked if she was getting acceptance from ED Physician 9 to transfer Patient 1 to Hospital B, EDP3 stated she could not recall what he said, something like "sounds good" and not like don't send the patient over. When asked if she was aware Hospital B's MFM specialist did not accept Patient 1, EDP3 stated her understanding was Patient 1 was accepted, that she did not know Hospital B's MFM specialist said no.

During an interview on 8/17/22 at 7:30 a.m. with ED Physician 9 (EDP9), EDP9 stated he did not accept Patient 1. He stated he was told by a unit clerk in Hospital B's emergency department that there was a physician on the phone waiting to speak with him. EDP9 stated that was how he came into contact with Hospital A's ED physician. He stated Hospital A's ED physician told him Patient 1 was in acute distress, in active labor, that OBGYN1 was accompanying the patient, and that OBGYN2 was the physician at Hospital B who discussed the patient with OBGYN1. EDP9 stated Hospital A's ED physician told him Patient 1 was already in the ambulance and on the way to Hospital B. EDP9 stated, to him, this was just a "heads up" conversation; he stated it was not a formal are you accepting this patient type conversation and that Hospital A's ED physician did not ask him to pronounce or spell his name. EDP9 stated there was no language such as are you the accepting physician. EDP9 stated he was told OBGYN2 has accepted Patient 1. EDP9 stated there was no indication from the sending physician that OBGYN2 had refused the transfer. EDP9 stated he was not aware OBGYN2 had refused the transfer and, in his mind, if he did not have OB/Gyn physician backup then he would not be able to provide a service Hospital A already had. EDP9 stated, if he did not have an OB/Gyn physician, then Hospital A has the higher level of care because OBGYN1 was onsite. EDP9 stated he did not want to risk a delivery in the ambulance. EDP9 stated any pregnant patient greater than 20 weeks bypasses Hospital B's ED and goes straight to Labor & Delivery. He stated the first time he heard there was no accepting physician was after Patient 1 had already arrived at Hospital B's ED.

b. During a review of Patient 8's medical records from Hospital A, indicated Patient 8 was triaged [process to categorize patients based on severity of illness in order to determine who needs to be seen first] in Hospital A's emergency department on 07/06/22 at 3:38 a.m. Patient 8 was an 18-year-old pregnant female who presented for cramping and her water breaking. Registered Nurse 5 noted "... ok to redbox pt too [sic] [Hospital B] OB per house sup [house supervisor], ED MD, and county dispatch ...". The ordering providers for Patient 8's orders were ED Physician 5 and ED Physician Assistant 1. All laboratory and radiology orders were cancelled, with a note the patient was discharged. There was no ED provider note, OB/Gyn physician note, EMTALA Memorandum of Transfer form, or documentation of a physician accepting transfer for Patient 8.

During a review of the ambulance record for Patient 8, dated 07/06/2022, indicated the ambulance transported Patient 8 from Hospital A to Hospital B.

During a review of Patient 8's Labor and Delivery Triage/Observation Record from Hospital B, dated 7/6/2022, indicated Patient 8 was 39 weeks pregnant and was not in labor. Patient 8 was discharged home.

During an interview on 8/15/22 at 11:52 a.m. with the Accreditation and Regulatory Manager (ARM), the ARM confirmed there was no ED provider note or EMTALA Memorandum of Transfer form for Patient 8.

During a review of Hospital A's emergency medicine physician schedule for July 2022, undated, indicated ED Physician 5 was scheduled to work from 7/5/22 7:00 p.m. to 7/6/22 5:00 a.m. and ED Physician 7 was scheduled to work from 7/5/22 9:00 p.m. to 7/6/22 7:00 a.m.

During an interview on 8/15/22 at 9:27 a.m. with Registered Nurse 5 (RN5), RN5 stated Redbox was Hospital A's process for emergent patient transfers, and that they did not understand it was only for trauma patients. RN5 stated, to his understanding, the Redbox process bypassed getting an accepting physician at the receiving hospital, that it was like a 911 call from the street. RN5 stated they do not contact their transfer center for Redbox patients. RN5 stated he recalled Patient 8, he did not directly interact with Patient 8 but he was the charge nurse on 7/6/22. RN5 stated Patient 8 entered through the triage area, and the triage nurse told him the patient was in active labor, having contractions every three to five minutes, and that her water broke. RN5 stated ED Physician 5 was present and asked if they could Redbox Patient 8 to Hospital B so the patient did not deliver at Hospital A. RN5 stated the patient was being moved to ED room T2 when the ambulance staff showed up, so Patient 8 got onto the ambulance stretcher. RN5 stated it was a mutual agreement between himself, ED Physician 5, and the triage nurse to transfer Patient 8 out of Hospital A. He stated he spoke with the house superviso