Adair County Memorial Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49848 Based on document review, observation, and interviews with staff and patients, the Critical Access Hospital (CAH)’s administrative staff failed to ensure Emergency Department (ED) staff adhered to the hospital’s policies and procedures related to the Emergency Medical Treatment and Labor Act (EMTALA), which resulted in 1 of 20 patients (Patient #12), who presented to the ED between 2/1/25 and 8/1/25 with a request for emergency medical care not receiving an appropriate Medical Screening Examination (MSE), and 4 of 20 sampled patients (Patient #3, #10, #11, and #20) not receiving an appropriate transfer. 1. Failure to provide appropriate transfer resulted in Patient #20, a patient who presented to the ED with complaints of vaginal bleeding, abdominal pain, and contractions during the second trimester of pregnancy, being discharged from the hospital without receiving an appropriate transfer, which resulted in the patient experiencing a precipitous delivery (unusually rapid labor) while traveling to Hospital B via a privately owned vehicle, without monitoring capabilities or qualified medical personnel present. These failures resulted in an increased risk of the patient experiencing adverse health outcomes related to out-of-hospital premature birth, which could include serious infection, hemorrhage (excessive bleeding), or death. Furthermore, these failures could have potentially contributed to the death of the patient’s fetus during said transfer. (see C-2409) 2. Failure to provide appropriate emergency medical care resulted in Patient #12, a patient who presented to the ED with seizure-like activity, a history of epilepsy, and suspected alcohol withdrawal, being discharged from the hospital without receiving an appropriate screening to determine whether an emergency medical condition (EMC) existed. This failure resulted in an elevated risk of the patient experiencing adverse health outcomes related to untreated seizure-like activity, including physical injury from falls, motor vehicle accidents, brain damage or, in severe cases, death. (see C-2406) 3. Failure to provide appropriate transfer resulted in Patient #11, a patient who presented to the ED via ambulance with complaints of right-sided chest pain, lightheadedness, and pericardial effusion (accumulation of fluid around the heart) and a diagnosis of unstable angina (a medical emergency associated with reduced blood flow to the heart) being transferred to Hospital B with an erroneous physician certification of transfer, which indicated the patient did not have an EMC despite the certifying physician identifying the patient as at-risk of cardiac arrest (a sudden loss of all heart activity) or death during transfer. (see C-2409) 4. Failure to provide appropriate transfer resulted in Patient #10, an adolescent patient with a history of self-harm, depression, and suicidal ideations (SI), who presented to the ED with a court-ordered mental health committal due to ongoing mental health concerns, being transferred to Hospital E with an erroneous certification of transfer, which indicated the patient did not have an EMC despite the certifying physician identifying the patient required inpatient hospitalization for safety and stabilization due to the patient being a danger to themselves. 5. Failure to provide appropriate transfer resulted in Patient #3, a patient who presented to the ED with complaints of nausea, vomiting, diarrhea, weakness, and abdominal pain, being transferred to Hospital F with an erroneous certification of transfer, which indicated the patient did not have an EMC despite the certifying physician noting the patient had acute kidney failure (AKF) and identifying the risks of transfer included “shock” and death. The cumulative effect of these deficient practices resulted in the inability of the CAH’s administrative staff to ensure that hospital staff adhered to the hospital’s EMTALA policies and procedures to ensure the safety and efficacy of care delivered to all patients presenting to the ED for emergency care. See C-2406 and C-2409 for additional information.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49848 Based on medical record review and interviews with patients and staff, the Critical Access Hospital (CAH)’s administrative staff failed to ensure Emergency Department (ED) staff provided a timely and appropriate medical screening examination (MSE), within the capacity and capabilities of the hospital, to 1 of 20 sampled patients (Patient #12) who presented to the ED between 2/1/25 and 8/1/25 with a request for emergency medical care. Failure to provide all patients with an appropriate MSE could result in missed diagnosis and treatment of an emergency medical condition (EMC), thereby increasing patients’ risk of suffering adverse health outcomes, including a deterioration in health, disability, or death. Findings include: 1. Review of the 2024 policy “Provision of Services” revealed in part: “. . . [the CAH] has no available [obstetric] or Women’s Health inpatient services. The hospital has ultrasound available with no stated time for outpatient, ER, Med/Surg . . .” 2. Review of the 10/2024 policy “Emergency Medical Treatment and Labor Act (EMTALA)” revealed in part: a. “Purpose: To establish the procedure by which individuals seeking or requiring emergency care are appropriately screened, examined, stabilized, treated, and/or transferred from or to [the CAH] including emergency obstetrics, pediatrics, medical/surgical and psychiatric services.” b. “Definitions . . . 5. Medical Screening Exam (MSE) is an examination completed by a [qualified medical person (QMP)] to determine if an emergency medical condition exists.” c. “Policy: Basic Responsibilities . . . 1. [The CAH] operates a dedicated emergency department and is subject to the requirements of EMTALA. These requirements include: a. Provide an appropriate MSE to any individual who comes to the Emergency Department . . .” d. “Medical Screening: 1. An EMTALA obligation is triggered when an individual comes by him or herself, with another person, to a hospital’s dedicated emergency department and a request is made by the individual or on the individual’s behalf, or a prudent layperson observer would conclude from the individual’s appearance or behavior a need, for examination or treatment of a medical condition . . .” e. “2. The purpose of the medical screening examination is to determine whether or not an emergency medical condition exists . . .” f. “Any individual with a medical condition that presents to a hospital’s ED must receive an MSE that is appropriate for their medical condition to determine whether or not an emergency medical condition exists.” g. “9. All individuals who present to a hospital and request a MSE for a medical condition must receive that screening. 3. Review of Patient #12 (P12)’s 6/20/25 medical record at Hospital A revealed the following: a. On 6/20/25 at 12:01 PM, P12 presented to the ED with complaints of recent suspected seizures. At 12:35 PM, Staff L (ED Physician) performed an evaluation and documented the following: “[Patient #12 was] brought in by EMS. Currently receiving treatment at [addiction treatment facility] for alcohol detox. Had 2 seizures today . . . [The patient] had full body convulsions, but no incontinence or injury to [their tongue] . . . Of note, [Staff L] did see the patient in the ER just a few days ago, at that point mutual decision through speaking with neurology that no need to start antiepileptics. However, provider at facility did speak with neurology again and they initiated Keppra 500 mg [antiepileptic medication] twice daily, patient took [their] first dose yesterday. Reporting 2 seizure-like activities that were witnessed today . . . [the patient] was feeling lightheaded and had a headache . . . had witnessed seizure-like activity . . . then subsequently reporting that [the patient] was being wheeled out to the elevator . . . [the patient] had another seizure episode . . . Does report some increase stress, reporting headache/fatigue/mid back pain . . . currently in postictal state [a state of altered consciousness following an epileptic seizure] . . . did provide recommendations to make follow-up appointment with neurology, no changes needed to medication today . . . [Staff L does not] believe that [the patient] would benefit from additional images or lab work compared to what [the patient] just had done earlier in the week . . . Patient Discharge Condition: Fair . . . Instructions: Call for follow up appointment. No driving.” b. At 1:53 PM, Staff B (ED Physician) provided the patient with discharge instructions, which included the following: “Please notify the neurology office that helped initiate your Keppra, please follow-up with appointment. Please member [sic] no driving until you are evaluated through neurology. Staff at [addiction treatment facility]: Please help patient coordinate care . . . Please schedule follow-up appointment with [neurology].” c. The medical record did not include evidence the hospital failed to provide an appropriate screening process to provide reasonable clinical confidence as to whether an emergency medical condition existed, based on the individual’s presenting signs and symptoms. Of note, the MSE did not include a basic screening panel, including serum glucose and sodium levels, to rule out common factors that may have contributed to the patient’s suspected seizures, nor did the examination include a serum levetiracetam (Keppra) level to evaluate compliance and therapeutic dosage of the recently started anti-epileptic medication. Additionally, the medical record did not contain evidence of an appropriate evaluation for pregnancy, and the documentation did not include consideration of alcohol withdrawal as a potential etiology of the episodes of seizure-like activity.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification 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 outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49848 Based on medical record review and interviews with patients and staff, the Critical Access Hospital (CAH)’s administrative staff failed to ensure Emergency Department (ED) staff provided an appropriate interfacility transfer for 4 of 20 sampled patients (Patient #3, #10, #11, and #20) who presented to the ED between 2/1/25 and 8/1/25 with a request for emergency medical care. Failure to provide a safe and appropriate transfer to a recipient hospital could result in the delayed provision of emergency medical care and an increased risk of serious harm or injury to the patient and, when applicable, the patient’s unborn fetus. Failure to recognize “A woman experiencing contractions is in true labor unless a physician, certified nurse-midwife, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and State law, certifies that, after a reasonable time of observation, the woman is in false labor.” The hospital documented knowledge of pregnancy and contractions, and the medical record did not contain a certification that, after a reasonable time of observation, she was in false labor.” Findings include: 1. Review of the 10/2024 policy “Emergency Medical Treatment and Labor Act (EMTALA)” revealed in part: a. “Purpose: To establish the procedure by which individuals seeking or requiring emergency care are appropriately screened, examined, stabilized, treated, and/or transferred from or to [the CAH] including emergency obstetrics, pediatrics, medical/surgical and psychiatric services.” b. “Definitions . . . 6. Transfer means the movement (including the discharge) of an individual outside a hospital’s facilities at the direction of any person employed by (or affiliated or associated; directly or indirectly, with) the hospital . . . “ c. “Policy: Basic Responsibilities . . . 1. [The CAH] operates a dedicated emergency department and is subject to the requirements of EMTALA. These requirements include: . . . c. Provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC (or the capability or capacity to admit the individual . . . An EMTALA obligation is triggered when an individual comes by him or herself, with another person, to a hospital’s dedicated emergency department and a request is made by the individual or on the individual’s behalf, or a prudent layperson observer would conclude from the individual’s appearance or behavior a need, for examination or treatment of a medical condition . . . “ d. “If a hospital is unable to stabilize an individual within its capability, an appropriate transfer should be implemented . . . 5. When [the CAH] has exhausted all of its capabilities in attempting to resolve the EMC, it must affect [sic] an appropriate transfer of the individual. “ e. “Restricting Transfer until the Individual is Stabilized: 1. If an individual has an emergency medical condition that has not been stabilized, [the CAH] will not transfer the individual unless: a. The individual requests the transfer and that he or she is aware of the risks and benefits of the transfer . . . b. The expected benefits outweigh the increased risks of the transfer. “ f. “f. In the case of a pregnant woman in labor, the physician must certify that the expected benefits outweigh the risk to both the pregnant woman and the unborn child . . . g. “A woman in labor may be transferred only if she or her representative requests the transfer or if a physician or other qualified medical personnel signs a certification that the benefits outweigh the risks . . . iii. The hospital must still meet the screening, treatment, and transfer requirements... “ h. “2. A transfer to another medical facility will be appropriate only in those cases in which the receiving facility has: a. Available space and qualified personnel for the treatment of the individual. b. Agreed to accept transfer of the individual and to provide appropriate medical treatment . . . i. “The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of transfer . . . The transfer is affected through qualified personnel and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer... “ 2. Review of Patient #20 (P20)’s 7/29/25 medical record at Hospital A revealed the following: a. On 7/29/25 at 3:43 AM, P20 presented to the ED with complaints of vaginal bleeding, abdominal pain, and contractions during the second trimester of pregnancy b. On 7/29/25 at 3:43 AM, Staff A (ED Registered Nurse (RN)) performed a triage assessment of the patient and collected vital signs, which revealed an elevated heart rate (109 beats per minute), and did not appear confused/lethargic/disoriented, or in severe pain/distress. c. On 7/29/25 at 3:50 AM, Staff A (ED RN) noted the patient screened positive for contractions. An evaluation of fetal heart tones (FHT) revealed a measurement of 161 beats per minute (bpm) at this time, indicating fetal viability (ability of a fetus to survive outside of the uterus). d. On 7/29/25 at 3:51 AM, staff collected blood samples to perform a complete blood count (CBC) with automated differential and a qualitative human chorionic gonadotropin (hCG) serum pregnancy test. The CBC results revealed an elevated white blood cell (WBC) count (associated with infection, injury, or stress). e. On 7/29/25 at 3:56 AM, Staff B (ED Physician) documented the following history of present illness (HPI) notes: “[P20] presenting today with mother, reporting concerns for vaginal bleeding/positive home pregnancy test . . . [The patient] does smoke cigarettes/vape and has been doing so. No alcohol. Unsure how far along [the patient] is. Reporting that [the patient] did need RhoGAM as [their] blood type is B-. [The patient] did receive it at the birth of [their] last child. Reporting that [the patient] saw some blood in the toilet bowl today with abdominal cramping and came to the ER for further evaluation. No active vaginal bleeding in the sense of menstrual flow.” Staff B noted the patient exhibited mild acute distress upon physical examination. f. On 7/29/25 at 4:04 AM, Staff A (ED RN) documented, “[P20 reported] contractions 1-2 mins apart starting at [10:00 PM]. [The patient] reported having yellow discharge, and then it turned into blood. [The patient] stated that [they] just found out a few days ago that [the patient] was pregnant. [The patient] doesn’t have any prenatal care. “ g. On 7/29/25 at 4:34 AM, Staff B (ED Physician) completed an EMTALA Transfer Consent form, which documented that the patient required a higher level of care and consented to transfer to another healthcare facility at 4:48 AM. Staff B erroneously certified that the patient was not in labor and documented the patient’s condition upon transfer as “Stable Patient within reasonable medical probability, no significant deterioration of the patient’s condition is likely to result from or during the transfer.” However, the form included a statement specifying “Patient in Unstable Emergency Medical Condition includes OB patients in active labor.” The transfer form did not include documentation of a discussion with the patient regarding the benefits of transfer via emergency medical services (EMS), nor the risk of delivery during transfer via a privately owned vehicle (POV), and the provider failed to establish whether Hospital A had adequate time to safely effect transfer of the patient during labor. h. On 7/29/25 at 4:48 AM, Staff B (ED Physician) documented the following medical decision-making (MDM) notes: “[Patient #20] presenting today for concerns of vaginal bleeding/spotting/pregnancy-completely unsure of how far along [the patient] is . . . Unfortunately, we do not have in-house ultrasound, [and] we do not have the reagent to get a beta-hCG quantitative level, given [the patient’s] need for RhoGAM with [their] last pregnancy, concerns for vaginal bleeding, no prenatal care, no estimation of gestational age due to unreliable menstrual periods, will be transferring patient via private vehicle to [Hospital B] . . . [Staff B] did speak with on-call ER Physician . . . Accepted patient for further cares . . . [The patient’s husband] will be driving [the patient] . . . [Vital signs (VS)] stable for transfer. 155 FHT prior to d/c.” i. Of note, the MDM notes did not include documentation of a discussion with the patient regarding the risks of transfer, despite staff identifying multiple high-risk factors related to the patient’s pregnancy, including the following: smoking during pregnancy; no prior prenatal care until well into the second trimester; and Rh-negative blood type without receiving RhoGAM, a medication administered to Rh-negative patients during pregnancy to reduce the risk of ABO incompatibility. j. On 7/29/25 at 4:56 AM, Staff B (ED Physician) discharged the patient with instructions to follow up with their primary care provider (PCP) in two to four weeks. At 5:12 AM, Staff A (ED RN) documented the following disposition notes: “Other: Transferred to [Hospital B ED] via private vehicle. “ At 5:58 AM, Staff B documented the following addendum notes: “Spoke with [ED Physician at Hospital B] . . . Patient delivered a nonviable fetus in the vehicle. We discussed the case prior to [discharge (d/c)], normal vital signs, not active bleeding here, FHT present. No continuous fetal monitoring available . . . [the patient] just found out about pregnancy a few days ago and previously smoking/vaping usage. Husband/patient were okay with private transfer/not requesting EMS transfer prior to d/c. “ k. Furthermore, review of the medical record did not include evidence of appropriate discussion with and acceptance by a physician at the recipient hospital (Hospital B), nor did the medical record include evidence of Hospital A staff providing Hospital B with all medical records (or copies thereof) related to the patient’s EMC prior to or during transfer of the patient. 3. Review of P20’s 7/29/25 medical record at Hospital B revealed the following: a. On 7/29/25 at 4:29 AM, Staff J (ED Physician) received a phone call from Staff B (Hospital A ED Physician) and documented the following ED notes: “[Staff J] took a phone call from [Hospital A] at [4:29 AM] providing me a courtesy notification that a pregnant patient would be arriving at our ER for further testing . . . [Staff J] asked if this was an official request to transfer because the OB provider on call at [Hospital B] would need to be involved to make transfer arrangements and to accept the transfer if applicable. No official transfer request was made to my knowledge. At [5:39 AM, Staff J] was notified that the patient had delivered a fetus in [the patient’s] vehicle and would be arriving imminently. “ b. On 7/29/25 at 4:30 AM, Staff I (ED RN) received a phone call from Staff A (Hospital A ED RN) and documented the following telephone encounter notes: “[On 7/29/25 at 4:30 AM, Hospital A] called with “report” in regards to [P20] coming to our ER for a serum quant [pregnancy test]. [Staff A (Hospital A ED RN)] called to talk to a [Hospital B] ER nurse about this patient coming to [Hospital B] . . . due to [Hospital A] “not having a hCG quant serum.” Staff A stated, “[The patient] was having yellow discharge and then vaginal bleeding . . . [the patient] thought she was having contractions. [Staff I] asks if [the patient] is clinically stable, and [Staff A states] “yes, [the patient] is stable” . . . Staff I asked Staff A for any additional information on the patient’s condition, and Staff A replied, “[Staff B (Hospital A ED Physician)] did a fundal check . . . [the patient] has been having complaints of cramping . . . [the patient] also stated she has been vaping and using tobacco.” Staff I documented, “When [the patient] arrived at [Hospital B], [Staff I] received no paperwork. “ c. On 7/29/25 at 5:40 AM, P20 presented to the hospital via POV with complaints of preterm labor with cramping, spotting, and unplanned out-of-hospital delivery (spontaneous vaginal delivery at approximately 5:30 AM) and history of previous pregnancy complications and miscarriage. Staff K (Hospital B Paramedic) documented the following ED notes: “[P20] presented to ER receiving door via car with husband and had already delivered. Fetus was wrapped in a towel and moved with [the patient] to wheelchair due to cord still being attached. [The patient] and fetus were briskly moved through the hospital to the OB floor where care for both was fully initiated. “ d. On 7/29/25 at 5:52 AM, staff collected vital sign (VS) measurements, which revealed hypertension (elevated blood pressure (BP)), with a BP measurement of 147/94 mmHg. At 5:59 AM, staff collected blood samples to perform a CBC, which revealed an elevated WBC count (associated with infection, injury, or stress). At 10:56 AM, Staff N (OB RN) administered an intramuscular (IM) RhoGAM injection. e. On 7/29/25 at 1:50 PM, Staff L (Hospital B OB Physician) discharged the patient home and documented the following Hospital Course notes: “Patient presented at unknown [gestational age (GA)] having delivered fetus in private car en route to hospital. Fetal resuscitation was unsuccessful.” Subsequently, at 8:08 PM, Staff L documented the following resuscitation notes: “At [5:48 AM, the patient] arrived to nursery via wheelchair, accompanied by paramedics. Newborn held in [the patient’s] hands with cord still attached to placenta. Placenta not delivered, cord clamped and cut, newborn taken to radiant warmer . . . unknown gestational age . . . [the patient was] seen in [Hospital A] ER for abdominal cramping. Newborn delivered en route in vehicle prior to arrival to [Hospital B] . . . Intubation successful . . . chest compression initiated . . . chest compressions and [positive pressure ventilation (PPV)] discontinued . . . time of death pronounced at [6:56 AM] by [Staff L (OB Physician)]. 4. During an interview on 8/6/25 at 11:00 AM, P20 reported presenting to Hospital A on 7/29/25 with complaints of abdominal pain, vaginal bleeding with yellow discharge, and suspected contractions, with two positive at-home urine pregnancy tests. The patient reported informing staff of the positive pregnancy tests, kicking sensations in their abdomen (which prompted the initial pregnancy test), vaginal bleeding and discharge (similar in appearance to amniotic fluid), and suspected contractions (which the patient reported occurred approximately 3 to 7 minutes apart and 30 to 35 seconds in duration). The patient informed staff of their concern that they were experiencing active labor, similar to their experience during two previous births. The patient recalled Staff B (ED Physician) palpated their abdomen, which intensified the abdominal pain, but the ED staff indicated they did not have an ultrasound available and could not perform a serum pregnancy test because “the machine was broken.” The patient vocalized their desire to transfer to a nearby hospital with obstetric (OB) capabilities due to their concern for imminent labor, but per the patient, staff determined the patient could drive with their spouse to Hospital B (approximately 20 miles away), so staff did not offer to provide a transfer via ground ambulance. Upon discharging from the ED, the patient recalled their “water breaking” approximately halfway to the recipient hospital. Despite efforts to delay the delivery until arriving at Hospital B, the patient then delivered a live but unstable fetus in their POV. Upon the patient’s arrival at Hospital B, staff-initiated resuscitation efforts for the fetus, but to no avail. 5. During an interview on 8/6/25 at 9:30 PM, Staff J (ED Physician at Hospital B) reported receiving a call from Hospital A on 7/29/25 at approximately 4:30 AM regarding P20. Staff J reported the caller provided a “heads-up” notice that an OB patient (P20) from Hospital A, whom the caller identified as stable, would soon arrive at Hospital B. Staff J reported the caller did not state they were requesting a transfer, nor did the caller follow the appropriate steps to effectuate said transfer. 6. During an interview on 8/6/25 at 10:30 AM, Staff I (ED RN at Hospital B) reported receiving a phone call from Staff A (ED RN at Hospital A) on 7/29/25, indicating that an OB patient (P20) had left Hospital A and would soon arrive at Hospital B. Staff I reported Staff A characterized the patient as “clinically stable” with “some vaginal bleeding.” Staff I reported Hospital A failed to provide Hospital B with appropriate paperwork for the transfer, which would include the complete medical record pertaining to the patient’s EMC. 7. During an interview on 8/5/25 at 11:26 AM, Staff F (Paramedic at Hospital A) acknowledged that, per EMTALA requirements, staff must obtain confirmation of acceptance from an accepting facility prior to initiating an interfacility transfer of a patient. 8. During an interview on 8/5/25 at 9:54 AM, Staff B (ED Physician at Hospital A) reported performing a physical examination of P20 on 7/29/25 but denied performing a vaginal exam. Staff B reported that if they had performed a vaginal exam and observed premature opening of the patient’s cervical os (an indication of premature birth or miscarriage), this would have warranted transfer of the patient to a higher level of care by ambulance. Staff B reported they planned for the patient to transfer to Hospital B via POV to obtain an ultrasound, which would allow for an evaluation of fetal viability and identification of any malformations of the fetus. Staff B reported they provided notice via phone call to Hospital B about the patient’s pending arrival. Staff B indicated they informed Hospital B of the patient’s complaints of abdominal pain and vaginal spotting at home, and noted the patient required a serum pregnancy test and ultrasound. Staff B alleged Hospital B staff accepted the patient’s transfer but reported uncertainty as to whether Hospital A staff sent the appropriate paperwork to Hospital B. Staff B denied having knowledge of Hospital A’s protocols for the transfer of pregnant patients but acknowledged the transferring hospital must provide the patient’s medical records to the recipient hospital, and the transferring provider must confer with an accepting provider prior to the transfer. Staff B reported they typically transfer OB patients to another facility if not in active labor; however, they would not transfer a patient in active labor if the following applied: the patient was experiencing contractions at 10-minute intervals; the patient had a positive fern test; or the patient’s “water broke.” Staff B indicated they would attempt to deter these patients from transferring via POV, as effectuating said transfer would place the lives of both the patient and fetus at risk. Staff B reported that patients at 17 weeks of gestation and above face a higher risk of heavy bleeding and infection; therefore, they would typically monitor these patients in-house, assessing their hemoglobin and hematocrit levels to evaluate for blood loss, until staff could safely transfer the patient to a higher level of care with more OB capabilities. 9. During a subsequent interview on 8/6/25 at 8:45 AM, Staff B (ED Physician at Hospital A) denied awareness that P20 complained of white or yellow discharge and noted they would have identified this as a “serious situation,” would have performed further testing and examination to determine whether the patient was in labor, and if so, would have transferred the patient to a higher level of care via ambulance. Staff B denied having knowledge of Hospital A’s routine process for determining whether staff have sufficient time to effect a safe transfer of a pregnant patient experiencing contractions to another hospital before delivery. Similarly, Staff B denied knowledge of Hospital A’s process for determining whether a transfer may pose a threat to the health and safety of the patient or fetus. Staff B acknowledged that the risks of transferring a pregnant patient could include worsening of the patient’s condition, worsening of the patient’s pain, and an elevated risk of experiencing a motor vehicle accident (MVA). 10. Review of Patient #11 (P11)’s 5/18/25 medical record revealed the following: a. On 5/18/25, P11 presented to the ED via ambulance with complaints of right-sided chest pain (reported as constant, sharp, and radiating pain) rated 10 out of 10 (with 10 being the highest), lightheadedness, and pericardial effusion (an accumulation of fluid around the heart) and a history of hypertension (high blood pressure), obstructive sleep apnea (OSA) (a condition involving repeated interruptions of breathing during sleep), and right bundle branch block (RBBB) (an abnormal electrical signal in the heart). b. Nursing staff administered an intravenous (IV) bolus of normal saline (NS) and heparin (a blood thinner), sublingual morphine (a pain medication), and chewable aspirin (a blood thinner), and collected blood samples for laboratory analysis, including repeated cardiac enzymes (a test to identify damage of the heart muscle) and D-dimer (a test used to detect blood clots). Additionally, staff performed an electrocardiogram (ECG), chest x-ray (CXR), and computed tomography angiogram (CTA) of the chest. c. Staff O (ED Physician), in consultation with a cardiology specialist, determined inpatient admission was indicated for further evaluation. Due to a lack of available beds at Hospital A, Staff O decided to transfer the patient to Hospital B via ground ambulance. d. Review of the Transfer Form, dated 5/18/25, revealed Staff O diagnosed the patient with unstable angina (a medical emergency associated with reduced blood flow to the heart). Staff O documented the Risks of Transfer Specific to Patient Diagnosis at Transfer included a risk of cardiac arrest (a sudden loss of all heart activity) and death; however, prior to transferring the patient to Hospital B, the provider erroneously certified that the patient did not have an EMC despite knowledge of the serious risks to the patient’s life and well-being. 11. Review of Patient #10 (P10)’s 5/19/25 medical record revealed the following: a. On 5/19/25, P10, an adolescent patient accompanied by law enforcement with a court-ordered mental health committal, presented to the ED with a history of self-harm, generalized anxiety disorder (GAD), major depressive disorder (MDD), suicidal ideations (SI), and ongoing mental health concerns. b. On 5/19/25 at 10:53 PM, Staff Q (Psychiatric Mental Health Nurse Practitioner (PMHNP)) documented a psychiatric evaluation of the patient and identified suicidal risk factors, which included “history of depression and other mental illness” and “impulsive or aggressive tendencies.” Staff Q identified the patient’s MDD as “inadequately controlled” and documented, “Patient is in need of inpatient hospitalization due to being a danger to [themself] . . . [P10] left numerous suicide notes to different members of [the patient’s] family . . . [the patient] is putting [themself] in dangerous situations and is very manipulative in order to get [their] way in situations . . . [P10] admitted to the provider that [the patient] had a plan to overdose on medications. [The patient’s Legal Guardian (LG)] feels [the patient] is very impulsive, and due to the recent events, does not feel safe returning home with [the patient] at this time, in [the patient’s] current mental state. Upon discharging from inpatient services, [the patient] should follow up with medication provider and outpatient therapy as soon as possible. Overall recommended disposition is inpatient hospitalization for safety and mood stabilization.” c. On 5/20/25 at 3:59 PM, Staff B (ED Physician) performed an evaluation and documented the following: “Admission Information: court-ordered behavioral hold. Hospital Course: Court-ordered for behavioral [health concerns] . . . [the patient] has been excepted [sic] at [Hospital E] . . . Updated court order was obtained, local sheriff office to help with transfer.” d. Review of the P10’s Transfer Form, dated 5/20/25, revealed Staff R (ED Nurse Practitioner) documented the patient’s diagnoses as Suicidal ideations and Mental Health, listed the Risks of Transfer Specific to Patient Diagnosis at Transfer as Death and [Motor Vehicle Accident (MVA)], and identified the transfer modality as Secure Car with Suicide Precautions; however, the provider erroneously certified that the patient did not have an EMC. 12. Review of Patient #3 (P3)’s 3/8/25 medical record revealed the following: a. On 3/8/25 at 10:28 AM, P3 presented to the ED with complaints of nausea, vomiting, diarrhea, weakness, and abdominal pain, and a history of acute kidney failure (AKF), hypothyroidism (abnormally low activity of the thyroid gland), hypertension (elevated blood pressure), dyslipidemia (an abnormal level of fats in the blood), and metabolic syndrome (a group of conditions that increases the risk of heart disease, stroke, and type 2 diabetes). b. On 3/8/25 at 2:21 PM, Staff O (ED Physician) documented performing a physical examination and documented, “I discussed finding [sic] with the patient . . . and recommended [the patient] be transferred for further evaluation and management . . . Patient is stable at the time of transfer. Patient will be transferred via ambulance.” Discharge diagnoses included the following: acute kidney injury (AKI) (a sudden loss of kidney function), nausea, leukocytosis (an increase in white blood cells associated with infection), and metabolic acidosis (a serious condition in which acid builds up in the body). c. Review of the patient’s Transfer form, dated 3/8/25, revealed Staff O documented the Risks of Transfer Specific to Patient Diagnosis at Transfer included a risk of “shock” and death; however, Staff O erroneously certified the patient’s condition as “Stable Patient within reasonable medical probability.” d. On 3/8/25 at 3:29 PM, P3 transferred to Hospital F via ground ambulance. Failure by the CAH’s administrative staff to ensure ED staff provided a transfer with appropriate certification of the risks and benefits for P3, P10, and P11 could have increased the patient’s risks of adverse health events during said transfers. Additionally, failure to provide P20 with a safe and appropriate transfer may have resulted in the delayed provision of necessary care for the patient and their fetus, the latter of whom expired shortly thereafter. Furthermore, the alleged failures resulted in an unsafe transfer in which P20’s family (including the patient, the patient’s unborn fetus, the patient’s infant child, and the patient’s spouse) drove at a high rate of speed in an attempt to receive life-saving intervention for the fetus, which further endangered the health and safety of the patient and fetus.”