Monroe Hospital

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 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: 16405 Based on interviews, medical record review, and policy review, the hospital’s emergency department (ED) failed to provide an appropriate medical screening examination (MSE) for 3 of 24 ED medical records reviewed (Patient [P] 1, P16, and P17). Findings include: 1. Facility policy titled Medical Screening Exam last revised 1/23 indicates on page 3 of 4 under 2. Medical Screening Examination (MSE) 2.1 The hospital will provide a screening examination for every person who comes to the emergency department making a request for examination and treatment. Each patient may be triaged to determine priority for medical screening (see Triage policy and procedure). 2.2 The MSE will be based on the patient’s condition and prior history, and will include at least the following: 2.2.1 Patient chief complaint, age, sex, duration of onset of chief complaint, date and time, level of distress, allergies, current medications, tetanus status (if indicated), Last Menstrual Period (LMP) (as necessary), private physician and any other pertinent medical history. 2.2.2 Vital signs, general observation, and localized examination. 2.2.3 Initiation and documentation of any necessary testing, treatments and/or procedures. 2. Facility policy titled “EMTALA Compliance and Transfer” last reviewed/revised 12/22 indicates under policy: (Facility #1) shall describe and comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) for physicians and staff and its application to (facility #1) define the polices and procedures for compliance. Under Scope of EMTALA, the policy states “The EMTALA requirements are applicable anyone who is on hospital property, including parking lots, sidewalks and driveways.” 3. Facility policy titled “EMTALA- Compliance with the Emergency Medical Treatment and Active Labor Act” last revised 9/21 states under policy “Any individual who “comes to the hospital emergency department” requesting examination or treatment shall be provided with an appropriate Medical Screening Exam (MSE). This MSE will determine whether an individual has an actual Emergency Medical Condition (EMC). This exam should be done in a non-discriminatory way.” Under Scope of EMTALA, the policy states “1. EMTALA is applicable to anyone who presents in any area or department of (facility #1), (including on-campus and off-campus clinics and other departments billed under the Hospital’s Medicare provider number) for primary assessment and treatment, including emergency room, obstetric service, psychiatric service, and other hospital-based clinics. The EMTALA requirements are applicable to anyone who is on hospital property, including parking lots, sidewalks, driveways, or a hospital department within a 250-yard area of the main hospital building.” #5 states “Female in Labor: Any female in labor can go to any hospital for delivery. If the hospital has the capability, EMTALA expects the hospital to deliver the baby. A woman in labor can be transferred if she requests the transfer and if the LIP (licensed independent practitioner) signs a certificate that the benefits outweigh the risks. Any woman in active labor is considered unstable under EMTALA, preventing discharge or transfer unless the transferring hospital has absolutely no capability to deliver the baby safely. Under that circumstance, transfer is permitted when the benefits of transfer outweigh the risks.” Under Procedure, the policy states: “1. Registration: The hospital shall not delay providing a medical screening examination or necessary stabilizing treatment in order to inquire about an individual’s method of payment or insurance status. Basic information such as name, date of birth and address may be obtained prior to triage as long as it does not delay an obvious emergency condition. 2. Triage: Is performed by qualified personnel. Triage does not take the place of an MSE. Triage prioritizes when an individual will be seen by an LIP. 3. MSE: A medical screening examination is offered to any individual who presents for an examination or treatment of a medical condition. The MSE is a continuous process reflection ongoing monitoring in accordance with an individual’s needs.” 4. Review of patient #1 (facility #1 visit) indicated the following: (A) An arrival time of 0730 hours on 10/29/24. The triage clinical notes documented by staff member #7 (Registered Nurse [RN]) listed chief complaint of possible contractions. Additional documentation indicated the patient reported that her water had broke about an hour prior. The note listed the departure time as 0745 hours on 10/29/24. (B) Review of clinical report documentation by staff member #12 indicated time seen was 0731 hours on 10/29/24 and chief complaint listed as pelvic pain that started 1 hour previously and was still present. Document states “The symptoms are described as moderate. Modifying factors. Not worsened by anything. Not relieved by anything. The patient has had pelvic pain.” Review of systems indicated “No nausea, vomiting, diarrhea, black stools or headache. No fever, chills, anorexia, eye discomfort or sore throat. No cough, difficulty breathing, chest pain, skin rash or enlarged lymph nodes. No joint pain. Pt reports her water broke approximately 1 hr pta.” (prior to arrival) Document states “All other systems reviewed and are negative.” The document included past history, medications, surgeries, and allergy sections completed as well. Physical exam section completed for each section including, but not limited to, pharynx normal, bowel sounds normal, neck supple with no lymphadenopathy. Under decision making, the document states “Pertinent clinical findings also include the comorbidities and the history of pregnancy. There was no fever. The exam revealed no vital signs that were significantly abnormal. A serious condition is a possible cause for the patient’s findings. The differential diagnosis includes, but is not limit to, (early labor). The diagnosis appears to be evident. Test(s) not done: labs, imaging. The patient has been stable. The pain, vomiting and exam have not changed. The patient requires specialized care. The patient is to be transferred.” The transfer form indicated report was called to an RN at 0802 hours on 10/29/24 and staff #15 (Doctor of Medicine MD at facility #2) was the receiving physician. The medical record listed a departure time of 0745 hours on 10/29/24. (C) The medical record lacked documentation of timely and appropriate medical screening by a qualified medical practitioner based on patients arrival to facility. 5. Review of patient #1 (facility #2 visit) indicated per EMS run sheet that they arrived at facility #1 at 0731 hours on 10/29/24, departed at 0739 hours on 10/29/24 and arrived at facility #2 at 0750 hours on 10/29/24. The record indicated this was the 4th pregnancy for this patient. The history & physical (H&P) stated “She notes she initially presented to (facility #1) where she reported concerns for labor and SROM (spontaneous rupture of membranes). Was advised they do not have obstetrics service and EMS was called for transport.” The patient delivered infant at 0822 on 10/29/24. The patient signed out AMA (against medical advice) at 1715 hours on 10/29/24. 6. Staff member #4 (Security) indicated in interview beginning at 10:10 a.m. on 12/2/24 that he/she was aware of patient #1 visit to the facility. He/she came in and another security officer was working and there was a homeless lady on the sidewalk. He/she went out and asked patient why they were at facility. The patient said she was having a baby and didn’t want to be there because the facility does not deliver babies. He/she told the patient they can deliver a baby. The patient indicated they were not coming inside and called 911. Explained facility could check her out. He/she went back into facility to get a doctor and told the doctor the patient needed to get in and checked out. An RN got a cart, loaded patient. Fire and police were at the facility and then EMS showed up (transport #1). Unknown how long the patient was on the sidewalk out front. He/she believed the patient called 911 on a security officer’s phone (staff #5). 7. Staff member #5 (Security) indicated in interview beginning at 2:07 p.m. on 12/2/24 he/she was aware of patient #1 and indicated he/she saw that patient was upset in the ED lobby and went to check it out. He/she was told by registration staff that everything was okay. 15-20 minutes later a woman was outside crying sitting on the sidewalk. The patient was there with boyfriend. He/she asked if she wanted to go in and she said that her water broke and that they told her there was nothing they could do for her because they do not do babies here. The patient was trying to call dispatch on their phone and had trouble. He/she called 911 on his/her phone and told them a woman was in labor and needed an ambulance. The police showed up while he/she was there. He/she told staff in case anyone is interested, a woman is outside in labor. No response from staff. Staff member #7 came out with a stretcher and took the patient to a room. 8. Staff member #6 (ED registration staff) indicated in interview beginning at 2:30 p.m. on 12/2/24 he/she was aware of patient #1 and indicated the patient came to registration screaming saying she was in labor, was “hysterical” and crying “it’s coming out”. He/she called back to tell staff about the patient and spoke possibly to the unit clerk at approximately 7:00 a.m.. He/she was told to wait until the patient is registered. 9. Staff member #7 (RN) indicated in interview beginning at 2:56 p.m. on 12/2/24 that he/she was aware of event on 10/29/24 with patient #1. He/she indicated they came around the corner and staff member #4 said there was a woman outside and he/she wheeled the OB (Obstetric) bed outside. The patient was on the sidewalk and there was a fire engine out front. The patient was smoking and in pain she said. She refused to get up. The patient said her water broke and she was having a baby. He/she tried multiple times to get her to get on bed. The patient indicated she did not know if she wanted to come into the hospital. He/she finally got her on the bed and told the physician. The patient was taken into a room. Staff member #13 (RN) brought in baby warmer. He/she got the patient in a gown and there was no crowing and pants were not wet. EMS arrived and he/she is unaware of who called them. Care was transferred to EMS. There was no time for vital signs. The physician exposed the genital area to check for crowning. The triage policy requires vital signs, concern, exam, history, medications, allergies, surgeries. For an OB patient, staff would ask about contractions and keep track of time. The facility has a fetal heart monitor and that is part of an exam. The facility has an ultrasound machine both abdominal and vaginal. There were no other staff in hall when security came in about patient #1. 10. Staff member #9 indicated in phone interview at 8:30 p.m. on 12/2/24 that he/she was aware of patient #1 on 10/29/24. He/she indicated they were getting there belongings together to leave and was behind staff member #6 when patient came in frantic saying her water broke while outside. Staff member #6 was trying to get information and the patient did not want checked out or seen and only wanted to wait on husband and wanted to wait inside. He/she went back to back and asked the staff in ED about the patients water breaking and possible need for towels and told them what was going on. They said “okay”. he/she did not speak to anyone in particular. When he/she went back to the registration desk, staff member #6 was still trying to check the patient in and the patient said she was waiting on husband. Spouse arrived and they went outside. 11. Staff member #3 indicated in interview beginning at 12:40 p.m. on 12/3/24 that the physicians utilize a T system to chart and selects 0 if the answer is yes and a slash if the answer is no to questions. Their investigation of events involving patient #1 revealed that staff in the back were not aware of the patient being there until staff member #4 came back to let them know. It is the expectation of licensed staff to go outside to check on a patient if a patient is outside and possibly needing emergency services. The facility can offer ultrasound if ultrasound staff are working and they work 7:00 a.m. to 7:00 p.m. Monday through Friday. Staff can check fetal heart tones (FHTs) on an OB patient. 12. Staff member #12 (Doctor of Medicine [MD]) indicated in phone interview beginning at 1:20 p.m. on 12/3/24 that he/she was aware of patient #1. He/she was working on a cardiac patient when the patient arrived. Patient #1 couldn’t decide if they wanted to check in or not. The nurse went outside and brought the patient in, there was no crowning and no fluid visible. He/she called the labor and delivery department on call and the patient was accepted. “MSE was performed.” He/she verified the elements of a MSE as dictated in the MR. He/she indicated the MSE takes 5-7 minutes to complete. The patient was transferred to labor and delivery at other facility. He/she is unaware of the patient being at the facility prior to being brought back. If there was any delay, he/she had no control of that. The facility has no monitor to check contractions. They do have a hand held doppler. 13. Observation: Review of video footage of a.m. 10/29/24 indicated the following: 0700 patient (identified by staff as patient #1) to the left of door and then came into door 0703 male (identified by staff as boyfriend to pt #1) came in and then both walk out 0721 staff member #5 outside speaking to someone 0722 staff member #5 back in facility 0723 staff member #5 back out carrying a cup 0727 staff member #5 in and out on phone 0729 staff member #5 back outside 0731 staff member #5 back in with male and they along with #4 go back outside 0733 staff member #4 back in 0734 staff member #4 back outside 0735 staff member #7 outside with stretcher 0738 pt #1 on stretcher and brought inside with fire department and staff #7 Camera footage from lobby area: 0700 pt #1 talking to registration and then over to soda machine with phone out 0702 back to registration desk 0704 left registration area 0719 male picked up bags and went outside 0734 staff member #4 outside 0735 staff #7 outside with stretcher Camera footage of inside hall of ED: 0739 (10 seconds) pt #1 to trauma room 0739 (33 seconds) physician to room 0739 (47 seconds) EMS at facility door 0740 staff #7 to room with gown 0740 (37 seconds) physician outside room 0740 (4 seconds) physician outside room 0741 (24 seconds) physician back into room 0741 (39 seconds) EMS to room with stretcher 0742 (01 seconds) physician back out of room 0742 (29 seconds) staff #7 back to room with bag 0743 (31 seconds) pt #1 on stretcher and out of facility. 22198 14. Review of the ED medical record for P16 for the visit on 09/26/24 revealed P16 presented to the ED at 6:10 PM with a chief complaint of “Weakness, Chest Pain, Anxiety.” No triage was performed on P16, and no Emergency Severity Index (ESI) score was given. There was a note written by the Paramedic working for the hospital at 6:30 PM and signed by the nurse at 6:35 PM as follows: “Departure time: 18:30 [6:30 PM] 09/26/24. The patient left the Emergency Department before triage and without being seen by a physician; (Patient asked if he was going to die because he taken 200 mg of caffeine and he said he would rather be home and sleeping if he wasn’t going to die). The patient appears to be alert, oriented x4, coherent and in no acute distress. The patient stated is leaving (Knows he is not going to die right now). He left the Emergency Department ambulatory and via private vehicle.” P16’s ED face sheet for this ED admission dated 09/26/24 had handwritten “LWBS [Left Without Being Seen] 1831 [6:31 PM],” twenty-one minutes after presenting to the ED for weakness, chest pain, anxiety. The medical record lacked documentation of a medical screening exam by a qualified medical practitioner or refusal of such. During an interview and medical record review on 12/03/24 at 12:38 PM for P16’s visit on 09/26/24, the ED Director stated, “yes, the patient [P16] should have been seen right away for the complaint of chest pain, and not waited 21 minutes before leaving without being seen.” The ED Director stated if the staff had time to talk to P16 and obtain the information in the nursing notes, there was no explanation as to why P16 was not triaged. 15. Review of the ED Face Sheet and patient demographics for P17 for the visit on 10/17/24 revealed P17 presented to the ED at 6:25 PM with a chief complaint of “Irregular Heart Beat” [sic].” There was no triage performed on P17, and no ESI score given for this visit. There was a handwritten “LWBS 1905 [7:05 PM]” forty minutes after P17 presented to the ED. A nursing triage was not completed per the ED policy for P17 to determine his/her emergency severity per the ED ESI and there was no note to explain the rationale for not completing the triage for P17. The medical record lacked documentation of a medical screening exam by a qualified medical practitioner or refusal of such. During an interview and medical record review on 12/03/24 at 12:38 PM for P17’s visit on 10/17/24, the ED Director stated, “No, it is not acceptable to have a patient wait 40 minutes with complaint of irregular heartbeat.” 16. Review of the hospital’s ED policy titled “Triage in the Emergency Department” dated 01/23 revealed, “Triage involves a rapid patient evaluation to determine the acuity level for each patient arriving in the Emergency Department. This process also involves identification of patients requiring immediate care, efficient use of resources and space and facilitation of flow in the Emergency Department. The goal is to direct bed and complete intake at the bedside whenever space and/or staffing allow. Acuity levels will be assigned to patients based on the revised Emergency Severity Index (ESI) 5-tier Triage algorithm. The Emergency Department Nurse/Paramedic shall evaluate and determine the priority of care based on the presenting complaint, vital signs, and corresponding appearance of the patient’s condition. The focus is on getting the patient to the right place, at the right time, with the right care provider.” 17. Review of the hospital’s ED policy titled “Care of the Patient in the Emergency Department (Adult and Pediatric)” dated 01/23 revealed, “It is the policy of Monroe Hospital Emergency Department (ED) to establish guidelines for nursing staff in providing quality-nursing care to patients presenting for emergency assessment & treatment. ... EMTALA: the Emergency Medical Treatment and Labor Act mandates all patients presenting to an ED are entitled to receive a medical screening exam (MSE). This includes minors whether accompanied by a parent/legal guardian or not. ... Triage is the process by which a patient is assessed to determine the urgency of the problem and the appropriate health care resource(s) needed to care for the identified problem. ... Vital signs are to include pain score, blood pressure (BP) (when applicable), Heart rate, Temperature, Respiratory Rate, and Pulse Oximetry. (When applicable). ... Reassess vital signs and condition as per ESI triage levels prior to initiation of treatment and stabilizing measures. ESI Level 1: Every 15 minutes or more frequent if patient condition deems necessary. ESI Level 2: Everyone (1) hour for first four hours or more frequent if patient conditions deems (sic) necessary. ESI Level 3: Every four (4) hours or more frequent if patient conditions deems (sic) necessary. ESI Levels 4 & 5: Every four (4) hours. ... Medication Safety: Medication response will be documented within 30-60 minutes after administration. Patients who receive IM/IV sedative/ pain/antibiotics steroids will be held in the ED for thirty (30) minutes after medication has been administered to assess effectiveness, adverse reaction, and to assure that body functions and vital signs are stable before discharge. First time medication will be evaluated in fifteen (15) minutes to assess for effectiveness and no adverse reactions.””

“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: 16405 Based on dcoument review and interview, the hospital’s emergency department (ED) failed to provide an appropriate transfer for 1 of 24 ED medical records reviewed (Patient [P] 1. 1. Facility policy titled “EMTALA- Compliance with the Emergency Medical Treatment and Active Labor Act” last revised 9/21 states under policy: “The EMTALA requirements are applicable to anyone who is on hospital property, including parking lots, sidewalks, driveways, or a hospital department within a 250-yard area of the main hospital building.” #5 states “Female in Labor: Any female in labor can go to any hospital for delivery. If the hospital has the capability, EMTALA expects the hospital to deliver the baby. A woman in labor can be transferred if she requests the transfer and if the LIP (licensed independent practitioner) signs a certificate that the benefits outweigh the risks. Any woman in active labor is considered unstable under EMTALA, preventing discharge or transfer unless the transferring hospital has absolutely no capability to deliver the baby safely. Under that circumstance, transfer is permitted when the benefits of transfer outweigh the risks.” 2. Facility policy titled “EMTALA Compliance and Transfer” last reviewed/revised 12/22 indicates under policy: (Facility #1) shall describe and comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) for physicians and staff and its application to (facility #1) define the polices and procedures for compliance. Under Scope of EMTALA, the policy states “The EMTALA requirements are applicable anyone who is on hospital property, including parking lots, sidewalks and driveways.” 3. Review of patient #1 (facility #1 visit) indicated the following: (A) An arrival time of 0730 hours on 10/29/24. The triage clinical notes documented by staff member #7 (Registered Nurse [RN]) listed chief complaint of possible contractions. Additional documentation indicated the patient reported that her water had broke about an hour prior. The note listed the departure time as 0745 hours on 10/29/24. (B) Review of clinical report documentation by staff member #12 indicated time seen was 0731 hours on 10/29/24 and chief complaint listed as pelvic pain that started 1 hour previously and was still present. Document states “The symptoms are described as moderate. Modifying factors. Not worsened by anything. Not relieved by anything. The patient has had pelvic pain.” Review of systems indicated “No nausea, vomiting, diarrhea, black stools or headache. No fever, chills, anorexia, eye discomfort or sore throat. No cough, difficulty breathing, chest pain, skin rash or enlarged lymph nodes. No joint pain. Pt reports her water broke approximately 1 hr pta.” (prior to arrival) Document states “All other systems reviewed and are negative.” The document included past history, medications, surgeries, and allergy sections completed as well. Physical exam section completed for each section including, but not limited to, pharynx normal, bowel sounds normal, neck supple with no lymphadenopathy. Under decision making, the document states “Pertinent clinical findings also include the comorbidities and the history of pregnancy. There was no fever. The exam revealed no vital signs that were significantly abnormal. A serious condition is a possible cause for the patient’s findings. The differential diagnosis includes, but is not limit to, (early labor). The diagnosis appears to be evident. Test(s) not done: labs, imaging. The patient has been stable. The pain, vomiting and exam have not changed. The patient requires specialized care. The patient is to be transferred.” The transfer form indicated report was called to an RN at 0802 hours on 10/29/24 and staff #15 (Doctor of Medicine MD at facility #2) was the receiving physician. The medical record listed a departure time of 0745 hours on 10/29/24. (C) The medical record lacked documentation of risk and benefits of a transfer. 4. Review of patient #1 (facility #2 visit) indicated per EMS run sheet that they arrived at facility #1 at 0731 hours on 10/29/24, departed at 0739 hours on 10/29/24 and arrived at facility #2 at 0750 hours on 10/29/24. The record indicated this was the 4th pregnancy for this patient. The history & physical (H&P) stated “She notes she initially presented to (facility #1) where she reported concerns for labor and SROM (spontaneous rupture of membranes). Was advised they do not have obstetrics service and EMS was called for transport.” The patient delivered infant at 0822 on 10/29/24. The patient signed out AMA (against medical advice) at 1715 hours on 10/29/24.”