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Based on record review and audio review, the hospital's "Demand Nursing Station Census Report", ER Call schedule, and interviews, the facility failed to accept the appropriate transfers of 2 sample patients (SP) #11 and #12 of 22 sample patients who required such specialized capabilities (Obstetrics/GYN and Neonatology and Newborn Unit). The decision was based upon the patient's insurance status, and ability to pay. (refer to A-2411).

Based on medical record review and audio recording review, the hospital's "Demand Nursing Station Census Report", Emergency Room Call schedule review, policy and procedure review, Hospital License Review, and Administrative Supervisor Report review, and interviews, the facility refused to accept from a referring facility the appropriate transfers of 2 sample patients (SP) #11 and #12 of 22 sample patients who required such specialized capabilities (Obstetrics/Gynecology and Neonatology and Newborn Nursery Unit). The decision was based upon the patient's insurance status, and ability to pay.

The findings include:


1. Review of sample patient (SP) # 11's ED (Emergency Department) record (medical record from the transferring hospital) showed she delivered a newborn (SP#12) at 37 weeks on 12/2/2018 en route by EMS (Emergency Medical Services) transport to the transferring hospital (Hospital B). As per EMS, cord clamped, cut, placenta delivered within 5 minutes w/out (without) complications and minimal vaginal bleeding or additional complications noted. APGARs 6, and 9 as per EMS.

SP #11 ED Physician Notes also showed she came to the emergency room on 12/2/2018 at 18:18 PM who delivered in her vehicle prior to presenting to the emergency room. She went into labor before that she was attempting to get to the hospital however she delivered a child in the car when EMS (Emergency Medical Services) arrived and/ or to deliver the child the umbilical cord was cut. The placenta was also delivered. Mom states that she had no comp (complications) occasions during her pregnancy she was at 37 weeks only taking prenatal vitamins she was to deliver at this [named] hospital. On arrival to the emergency room the patient is hemolytically (hemodynamically) stable speaking full clear sentences. This patient in (and) the baby to be transferred emergently to facility that has OB/ GYN (Obstetrics/ Gynecology) and pediatric services. We will continue to monitor her status and repeat her vital signs.

SP #11's The ED physician's notes Addendum 2: 12/06/2018 at 11:54 am then showed, This patient was to deliver at (North Shore Medical Center - Hospital A), and upon arrival to our ER requested to be transferred to their facility (Hospital A). I had the transfer center contact Hospital A hospital and was put through to the Nursing Supervisor (Staff D). I informed him that I had a patient that was requesting transfer to his facility. He then asked me if the patient had insurance. I asked the patient and she informed me that she did not. I relayed this information to the Nursing Supervisor (Staff D), and he then informed me that he could not accept this patient for transfer. I asked him several times to provide a reason as to why he would not accept the transfer and he stated "There is no reason I can give you. We cannot accept this patient at this time" he repeatedly asked me to transfer the patient to other nearby hospitals, however the patient refused transfer to those hospitals and vehemently requested to go to [named] hospital He continued to insist that he would not accept the transfer regardless of the patient's wishes and hung up the phone. I then spoke to the patient and explained to her the situation and she agreed to be transferred to another hospital (Hospital C). I spoke to Hospital C hospital ER and NICU team, and they agreed to accept the transfer.

Review of SP #11 EMTALA Memorandum of Transfer" dated 12/2/2018 showed the Emergency Medical Condition identified: Vaginal Delivery. Reason For Transfer: Medically Indicated. Risks And Benefit For Transfer: Obtain level of care/ service unavailable at this facility. Service: OB, Peds (Obstetrics, Pediatrics).

Review of the Transfer Center Pre-Admit Face Sheet for SP# 11 showed at 12/02/2018 at 16:40 pm the mother (SP#11) requested [ Hospital A] since she delivered her last 7 children at this hospital. On 12/02/2018 at 16:55 pm, the case was presented to Hospital A and was declined.

2. SP #12 (the newborn of SP #11) ED physician notes (from the transferring hospital)- Hospital B) showed a male infant is brought to the emergency room was recently delivered vaginally 30 minutes prior to presenting to the emergency room the mom went into labor shortly before that called EMS attempted to get to the hospital however she delivered in the car EMS arrived the child started been delivered they cut the umbilical cord suctioned the patient's mouth and naris. Initial Apgar's were 6 and 9 that patient birth history: full term, vaginal delivery, delivered en route by EMS. 37 weeks EGA (Estimated Gestational Age). Unknown delivery presentation. AGPAR 6, 9. Stable on arrival. Review of SP #12 medical record showed on 12/2/2018 at 16: 52 pm , delivery spontaneous vaginal delivery, term, newborn. The record further showed that patient will be transported with mother to appropriate facility (Hospital C) that has opiate pediatrics.

Review of SP #12 EMTALA Memorandum of Transfer" dated 12/2/2018 showed the Emergency Medical Condition identified: Well Baby. Reason For Transfer: Medically Indicated. Risks And Benefit For Transfer: Obtain level of care/ service unavailable at this facility. Service: Neonatal.

SP #11 and SP#12 was transferred on 12/2/2018 at 19:02 pm to the receiving hospital- Hospital C.

Audio recording review from the transferring hospital Transfer Center (TC) revealed a call regarding SP #11 and SP #12. During the call the staff identified by name from this hospital asked the ED Physician of the transferring hospital if the patient has any insurance. He also stated that the patient should go to Hospital A because it is a government hospital. He was made aware that the patient requested this hospital.


Review of hospital's license show emergency services: Obstetrics, Neonatal Intensive Care Units - level 2 and level 3 services.


Review of the hospital's Administrative Supervisor Report on 12/02/2018 showed at 07:30 am newborn census of 4.

Review of the hospital's Demand Nursing Station Census Report dated 12/02/2018 at 21:45 pm showed 5 neonatal unit beds were occupied and 27 available beds.

Review of the hospital's Demand Nursing Station Census Report dated 12/02/2018 21:45 pm showed 3 Nursery occupied beds and 36 available.

Review of the hospital's Demand Nursing Station Census Report dated 12/02/2018 21:45 pm showed 4 Obstetrics occupied beds and 31 available.

Review of Facility A's Nursery census for 12/2/2018, issue time 21:45: 59 showed 3 occupied beds, 36 available beds, 39 total beds.

Interview with the Nursing Supervisor (Staff D) on 1/29/2019 at 12:15 PM revealed that as a supervisor when a patient wants to transfer to this hospital, supervisors facilitate transfers. Depending on situations- ED calls us to facilitate the transfer. Supervisors gather the information such as the patient's status to see the level of service that the patient will need. Then, supervisors give the information to the ED, so that the ED can call back the ED physician from the hospital who is requesting the transfer. He continued to state that the Supervisor log will not document conversations with the ED Physician or with any requests for transfer from another facility. He stated: If I spoke to the ED Physician from another facility, supervisors don't log requests for admission. ED Physicians are the ones who decide whether to transfer or not. We get all the documents from the facility to get a brief idea why the patient is coming. For a patient who just had a baby, we ask if something is wrong with the mom or the baby so we can accommodate the level of service of care, for example if the infant needs to go to the Neonatal ICU (NICU) for level 2 or level 3 of care. Information about insurance is through the case management. The registration will ask for the insurance. They pre -register the patient. If a patient has no insurance they still have to go through admission, and the same information are asked. We do not dictate if a patient can or cannot be transferred in, just because a patient has no insurance. That is an EMTALA violation." When asked if he ever received a call from another ED facility where the ED Physician requesting to admit a mother who just gave birth, specifically on December 2, 2018 a Sunday, and he denied transfer. His response was: He does not recall. It does not sound true that a patient will be denied because the patient do not have an insurance. That is not accurate. Majority of our patients are uninsured.

In another interview with the Nursing Supervisor (Staff D) on 1/30/2019 at 1:33 PM, he was asked if he remembered any conversation with an ED Physician from another ED asking to transfer a patient who just had a baby on December 2, 2018 a Sunday. He stated: "I know the process. I know that we would be in violation if we decline the patient without insurance.

Interview with ED Physician A on 1/30/19 at 12:00 PM revealed that he cannot refuse or deny any admission if a mother who just delivered a baby outside of the hospital would like to be transferred here. He added that they have a neonatologist 24 hours a day.



Review of Facility A ER Call schedule from December 1st through December 31, 2018 showed there was a Pediatrician on call on 12/2/2018 Sunday. Review of Facility A ER Call schedule from December 1st through December 31, 2018 showed there was an OB/GYN on call on 12/2/2018 Sunday. Record review of Neo (Neonatologist) Schedule for December 2, 2018 there was a neonatologist on call.


Review of the Policy Section: "Patient Rights and Organizational Ethics, Subject: EMTALA"
(review 09/2017) states the hospital will not base the provision of emergency services and care upon an individual's race, ethnicity, religion, national origin, citizenship, culture, language, age, sex, pre-existing medical condition, physical or mental disability, insurance status, sexual orientation, gender identity or expression, economic status or ability to pay for medical services, except to the extent that a circumstance is relevant to the provision of appropriate medical care. I. Obligation to Accept Transfers- 1. To the extent that the hospital has specialized capabilities (including capabilities available through the Hospital's on-call roster) or facilities, such as a burn unit, a shock- trauma unit or a neonatal intensive care unit, that are not available at the transferring facility, the Hospital must accept appropriate transfers of an individual needing such specialized capabilities or facilities if the Hospital has the capacity to treat the individual.

2. The following personnel or categories of personnel are authorized to accept or reject transfers from another hospital on behalf of the Hospital: Administrator On Call, via Nursing Supervisor. Personnel who accept or reject another facility's request for transfer must record the request, the response to the request, and the basis for any denial of such a request, in a patient transfer request log which should be maintained in the Emergency Department in order to document the appropriateness of any transfer that were refused by the Emergency Department. This policy was not enforced.

The facility's refusal to accept from a referring facility SP#11 and SP#12 based on insurance status resulted in a delay for the completion of the medical screening examinations for these individuals on December 2, 2018.