St Anthony 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: 08621 ************************************************ Based on interviews, review of central log and medical record documentation for 13 of 20 encounters of individuals who presented to the hospital for emergency medical or obstetric services (Patients 2, 3, 5, 7, 11, 13, 14, 15, 16, 17, 18, 19, and 20), review of FBC Daily Floor Census sheets, and review of policies and procedures, it was determined that the hospital failed to fully develop and enforce Emergency Medical Treatment and Labor Act (EMTALA) policies and procedures that ensured it met its EMTALA obligations in the following areas: * For FBC Patients 7, 13, 17, 19, and 20, and all FBC patients, to ensure they were identified on a formal and organized central log that was consistent with the information on the ED central log and tracked the individual’s encounter from the time of arrival through the disposition that resulted from a Medical Screening Examination (MSE). * For ED Patients 2, 3, 11, and 18 to ensure that those individuals were not dissuaded from staying at the hospital to receive MSEs, and to obtain or attempt to obtain written and informed refusal of MSEs in accordance with its policies and procedures.. * For ED and FBC Patients 5, 7, 14, 15, 16, 17, and 19 to affect appropriate transfers to other hospitals for further examination and stabilizing treatment that was not within the hospital’s capability at the time. Findings include: 1.a. On a written EMTALA Investigation Needs List provided to the hospital during the entrance conference on Day 1 of the survey the following request was included: “Copy of all hospital-wide, nursing, ED, OB, and registration policies and procedures that reference EMTALA and are developed to ensure the hospital’s compliance with all EMTALA, Appendix V, requirements in its entirety.” 1.b. There were no hospital-specific or department-specific policies and procedures provided. The only three (3) policies and procedures provided were the following corporate, “CommonSpirit System-Wide” policies and procedure: * The policy titled “Emergency Medical Treatment and Labor Act (EMTALA) Policy” dated as last revised 12/11/2024. * The procedure titled “Emergency Medical Treatment and Labor Act (EMTALA) Procedure” dated as last revised 12/11/2024. * The policy titled “Financial Assistance Policy, Finance” dated as last revised 06/18/2025. 2. Refer to Tag C-2405 for findings regarding policy and procedure development and maintenance of a central log that included Obstetrics/Family Birth Center (FBC). 3. Refer to Tag C-2406 for findings regarding policy and procedure development and informed refusal of MSEs. 4. Refer to Tag C-2409 for findings regarding policy and procedure development and appropriate transfers. ************************************************”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 08621 ************************************************ Based on interviews, review of central log and medical record documentation for 5 of 5 encounters of individuals who presented to the hospital for emergency obstetric (OB) services (Patients 7, 13, 17, 19, and 20), review of OB/Family Birth Center (FBC) Daily Floor Census sheets for April 2025 through the date of this survey, and review of policies and procedures, it was determined the hospital failed to develop and enforce its Emergency Medical Treatment and Labor Act (EMTALA) policies and procedures to ensure maintenance of a central log which contained complete and accurate information about each patient who presented to the hospital for emergency medical or OB services: * The hospital’s policies and procedures regarding the central log were not complete. * A formal, organized central log of individuals who presented to the FBC, unscheduled, with potential Emergency Medical Conditions (EMCs) for possible onset of labor and other pregnancy related concerns had not been developed or maintained. Findings included: 1.a. The “CommonSpirit System-Wide” policy titled “Emergency Medical Treatment and Labor Act (EMTALA) Policy” dated as last revised 12/11/2024 was reviewed. It included the following hospital requirements: “Centralized Log. Hospitals are required to maintain a Central Log. The Central Log includes the patient logs from the [Dedicated Emergency Department (DED)] and, either by direct or indirect reference, patient logs from any other areas of the hospital that may be considered DEDs, or where an individual may present for emergency services or receive an Medical Screening Examination (MSE), such as the Labor and Delivery Department. The Central Log shall be maintained for at least five (5) years. The Central Log should include the following: patient demographics (age/sex/gender/record number); nature of complaint; time of departure/transfer.” 1.b. The “CommonSpirit System-Wide” procedure titled “Emergency Medical Treatment and Labor Act (EMTALA) Procedure” dated as last revised 12/11/2024 was reviewed. The procedure did not include any reference to the central log to ensure that it was maintained to clearly reflect and track each individual’s emergency medical or OB encounter from the time of their arrival through the time of their disposition. 1.c. The policy and the procedure were unclear and did not contain hospital-specific or department-specific procedures, processes, or steps to ensure implementation of the EMTALA Code of Federal Regulation (CFR) requirements: * The policy did not ensure that the central log was maintained to clearly reflect and track each individual’s emergency medical or OB encounter from the time of their arrival through the time of their disposition, to include whether the individual refused treatment, was refused treatment, or whether they were transferred, admitted and treated, stabilized and transferred, or discharged. * The hospital provided no Patient Access/Registration, ED, or FBC policies and procedures that described procedures for maintenance of a complete and accurate central log. 2.a. The FBC central log provided was reviewed. It was found to be a hardbound log that contained information about the newborn deliveries that had occurred in the hospital. It did not include unscheduled patient arrivals, or the discharges and transfers of those unscheduled patients who were undelivered. 2.b. During interview with the Director of Patient Care, Quality and Risk (DPCQ) at the time of the FBC log review on 08/12/2025 at approximately 1645 they reported that the FBC Manager stated the FBC did not have a “log” of patient arrivals to the unit, rather they used “daily [paper] shift sheets” or “assignment sheets” to record arrivals and discharges from the unit. 2.c. During interview with the DPCQ on 08/13/2025 beginning at 0925 they further confirmed there was not an electronic or otherwise formal “log” for the FBC that identified those pregnant individuals who presented unscheduled, for possible onset of labor and other pregnancy related concerns. 2.d. During interview with the FBC Manager on 08/13/2025 beginning at 1415 they stated that FBC “Daily Floor Census sheets” contained information about the pregnant individuals who presented to the FBC. However, they confirmed that the sheets did not differentiate between scheduled and unscheduled visits. 2.e. Review of a FBC Daily Floor Census sheet reflected there was one double-sided sheet for each day/date. On the front of the sheet were the following sections for the entry of patient information: “Admitted ... Discharged ... Outpatient ... Transfers ... Patient Transfers ...” On the back of the sheet were two checklists for day shift and night shift charge nurse responsibilities. * Under the “Outpatient” section were columns titled “[non-stress test (NST)] or OB [check]” and “Patient Name” and “Time In” and “Time Out.” * Under the “Transfers” section were columns for entry of patient movement from one FBC room to another FBC room. * Under the “Patient Transfer” section were columns titled “Name” and “Sending MD” and “Receiving Facility” and “Transfer Per” and “Reason for Transfer.” 2.f. The hospital’s policy specified that “The Central Log should include the following: patient demographics (age/sex/gender/record number); nature of complaint; time of departure/transfer,” while the hospital’s procedure did not reference the log at all. Although the sections on the Daily Floor Census sheet contained some log elements the information was not clear or complete. For example: * The “Outpatient” section reflected individuals who presented to the FBC for both scheduled appointments, and unscheduled visits for evaluation of potential EMCs. There was no distinction in that section or on the sheet to reflect what the case was for each patient. * The reason for the scheduled or unscheduled “Outpatient” encounter was recorded only as either a “NST” or an “OB [check].” There was no documentation to reflect the patient specific “nature of complaint” for those individual’s who presented for unscheduled visits for evaluation of potential EMCs. * The sheet did not contain “patient demographics (age/sex/gender/record number)” for each individual who presented for an unscheduled encounter. * The sheet did not include provisions for recording disposition in cases where the individual refused examination or treatment, left without an exam or treatment, left against medical advice, or was refused exam or treatment. 3.a. The FBC Daily Floor Census sheets for April 2025 through the date of this survey were reviewed. Information about individuals who presented to the FBC was not clear or complete. For example: 3.b. Regarding FBC Patient 7, the Daily Floor Census sheet for 06/12/2025 was reviewed. Patient 7 was entered under the the “Outpatient” section of the sheet with a “Time In” of 2100 and a “Time Out” that was not recorded. The entry was additionally not clear or complete: * It was not evident on the sheet whether the encounter was scheduled or unscheduled. Although the time of day implied was likely unscheduled. * The specific “nature of the complaint” or why the individual presented to the FBC was not evident. Only “OB [check]” was recorded. * Although written in the “Time Out” space was “[transfer] 6/13,” the patient was not entered under the “Transfers” or “Patient Transfers” sections of the sheet. 3.c. Regarding FBC Patient 13, the Daily Floor Census sheet for 07/05/2025 was reviewed. Patient 13 was entered under the “Outpatient” section of the sheet with a “Time In” of 0253 and a “Time Out” of 0347. The entry was not clear or complete: * It was not evident on the sheet whether the encounter was scheduled or unscheduled. * The specific “nature of the complaint” or why the individual presented to the FBC was not evident. Only “OB [check]” was recorded. * There was no documentation as to the individual’s disposition for the “Time Out” of 0347. The patient was not entered under any of the “Admitted” or “Discharged” or “Patient Transfers” sections of the sheet for that disposition time. 3.d. Regarding FBC Patient 17, the Daily Floor Census sheet for 07/31/2025 was reviewed. Patient 17 was entered under the “Outpatient” section of the sheet with a “Time In” of 1106 and a “Time Out” that was not recorded. The entry was additionally not clear or complete: * It was not evident on the sheet whether the encounter was scheduled or unscheduled. * The specific “nature of the complaint” or why the individual presented to the FBC was not evident. Only “OB [check]” was recorded. * Although written in the “Time Out” space was “Transfer,” the “Patient Transfers” section of the sheet was not complete. The “Transfer Per” space was blank. 3.e. Regarding FBC Patient 19, the Daily Floor Census sheet for 08/02/2025 was reviewed. Patient 19 was entered under the “Outpatient” section of the sheet with a “Time In” of 2158 and a “Time Out” of 2325. The entry was not clear or complete: * It was not evident on the sheet whether the encounter was scheduled or unscheduled. * The specific “nature of the complaint” or why the individual presented to the FBC was not evident. Only “OB [check]” was recorded. 3.f. Regarding FBC Patient 20, the Daily Floor Census sheet for 08/03/2025 was reviewed. Patient 20 was entered under the “Outpatient” section of the sheet with a “Time In” of 0446 and a “Time Out” of 0535. The entry was not clear or complete: * It was not evident on the sheet whether the encounter was scheduled or unscheduled. * The specific “nature of the complaint” or why the individual presented to the FBC was not evident. Only “OB [check]” was recorded. * There was no documentation as to the individual’s disposition for the “Time Out” of 0535. The patient was not entered under any of the “Admitted” or “Discharged” or “Patient Transfers” sections of the sheet for that disposition time. 3.g. Similar findings were identified on the Daily Floor Census sheets for numerous patients between April 2025 through the date of this survey. ************************************************”

“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: 08621 ************************************************ Based on interviews, review of central log and medical record documentation for 4 of 7 encounters of individuals who presented to the hospital for emergency medical services and left prior to or during an MSE (Patients 2, 3, 11, and 18), and review of policies and procedures, it was determined that the hospital failed to fully develop and enforce Emergency Medical Treatment and Labor Act (EMTALA) policies and procedures that ensured that individuals who presented to the hospital for emergency medical services were not dissuaded by hospital staff from staying at the hospital to receive Medical Screening Exams (MSEs) within the hospital’s capabilities and capacity: * For Patients 2, 3, 11, and 18 who presented to the emergency department (ED) requesting an MSE and who left prior to the start or completion of the MSE it was not clear whether hospital staff did or said anything to dissuade those individuals from staying. It was not clear whether the individual had been informed of the risks of leaving the hospital without an MSE and whether attempts had been made to obtain informed written refusal for a MSE in accordance with hospital procedures. Findings include: 1.a. The “CommonSpirit System-Wide” policy titled “Emergency Medical Treatment and Labor Act (EMTALA) Policy” dated as last revised 12/11/2024 was reviewed. It included the following: “Except where otherwise permitted by law, Emergency Medical Screening and stabilizing treatment will be provided to all individuals presenting at CommonSpirit Dedicated Emergency Departments (DED) requesting or requiring examination or treatment of a medical condition, and to individuals presenting on hospital property (including parking lots, sidewalks and driveways on all CommonSpirit campuses) within 250 yards of the hospital requesting or requiring examination or treatment of an Emergency Medical Condition (EMC), and if one exists, either to stabilize the emergency condition or to transfer the individual appropriately and in conformity with the legal and regulatory requirements, without regard to their age, race, color, creed, national origin, immigration status, insurance, disability, handicap, diagnosis, sexual orientation, or ability to pay.” 1.b. The “CommonSpirit System-Wide” procedure titled “Emergency Medical Treatment and Labor Act (EMTALA) Procedure” dated as last revised 12/11/2024 was reviewed. It included the following hospital requirements: * That the procedure applied to “... Dedicated Emergency Departments (DED) including free-standing Emergency Departments, Emergency Services, and Labor and Delivery Departments at all CommonSpirit acute care hospitals and outpatient clinics located on Hospital Property.” * Regarding “Medical Screening Examination” the procedure stated that “All individuals who come to the DED and all individuals who present on Hospital Property requesting or requiring examination or treatment of an Emergency Medical Condition (EMC) shall receive an appropriate Medical Screening Examination (MSE). Additionally, the hospital shall not delay in providing the MSE or necessary stabilizing treatment in order to inquire about an individual’s ability to pay or to inquire about eligibility for financial assistance under CommonSpirit Governance Policy, Finance G-003, Financial Assistance Program ...” * Regarding “Registration” the procedure stated that “The hospital shall not delay in providing the MSE or initiate necessary Stabilizing treatment in order to inquire about an individual’s method of payment or insurance status (including inquiries regarding eligibility for financial assistance under the hospital’s Financial Assistance Policy). Requests for any payment or payor authorization are not to be made prior to the MSE and initiation of any stabilizing treatment as clinically indicated. The hospital may follow reasonable registration processes (including asking whether the individual is insured and, if so, a copy of the insurance card) for individuals for whom examination or treatment is required under EMTALA, so long as they do not delay screening or treatment. Requesting prepayment or immediate payment for emergency medical care or permitting debt collection activities that interfere with the provision of emergency medical care are not part of a reasonable registration process and are therefore prohibited as actions that discourage individuals from seeking emergency medical care. The hospital may not seek, nor direct any individual to seek, authorization from the individual’s insurance company or health plan for the MSE or Stabilizing treatment until the hospital has provided the MSE and initiated any further examination and treatment that may be required to stabilize the EMC. If an individual asks whether the hospital accepts their health plan or raises other financial matters, staff may answer the individual’s inquiry. Staff will then reaffirm and document the offer to provide the MSE and take reasonable steps to encourage the individual to remain for the examination. If, after this discussion, the individual is unwilling to proceed with the MSE based upon their own independent contact with the payor, the individual’s refusal to be examined is documented in the medical record.” * Regarding “Refusal to Consent to Examination or Treatment” the procedure stated that “If an individual who has decision making capacity is unwilling to continue with the MSE and Stabilizing treatment (as indicated), the situation must be handled the same as any refusal of care and documented as such. The practitioner informs the individual of the hospital’s EMTALA obligations and offers the individual further medical examination and treatment within the Capability of staff and facilities available to the hospital as may be required to identify and Stabilize an EMC. The practitioner informs the individual of the risks and benefits of such examination and treatment, and of the risks and benefits of withdrawal prior to receiving such examination and treatment and takes reasonable steps to secure the individual’s documented informed refusal of such examination and treatment in the medical record. If an individual does not have decision making capacity then consent can be obtained from the individual’s Designated Representative.” * Regarding “Qualified Medical Person” the procedure stated that meant “those licensed individuals on the Hospital Property with appropriate clinical privileges, or others as may be set forth in the Medical Staff Bylaws or Rules and Regulations. A QMP may, in some states, be a non-physician who: (i) is licensed or certified by the state in which the hospital is located; (ii) practices in a category of health professionals that has been designated by the hospital to perform medical screening exams; (iii) has demonstrated current competence in the performance of MSEs within their health profession; and (iv) as applicable, performs the MSE in accordance with protocols, standardized procedures or other policies as may be required by law or by hospital policy.” * Regarding “Triage” the procedure stated that “means a process to determine the order in which individuals will be provided an MSE. For purposes of EMTALA, Triage is not an MSE and does not determine the presence or absence of an EMC (though Triage may be the first part of a process involving a Medical Screening Examination.” 1.c. The “CommonSpirit System-Wide” policy titled “Financial Assistance Policy, Finance” dated as last revised 06/18/2025 was reviewed. It included the following hospital requirements: “Emergency Medical Care, EMTALA - Any patient seeking care for an emergency medical condition within the meaning of Section 1867 of the Social Security Act (42 [United Stated Code (U.S.C.)] 1395dd) at a Hospital Facility shall be treated without discrimination and without regard to a patient’s ability to pay for care. Furthermore, any action that discourages patients from seeking [emergency care], including, but not limited to, demanding payment before treatment or permitting debt collection and recovery activities that interfere with the provision of [emergency care], is prohibited. Hospital Facilities shall also operate in accordance with all federal and state requirements for the provision of care relating to emergency medical conditions, including screening, treatment and transfer requirements under the federal Emergency Medical Treatment and Labor Act (EMTALA) and in accordance with 42 [Code of Federal Regulation (CFR)] 482.55 (or any successor regulation). Hospital Facilities should consult and be guided by any CommonSpirit EMTALA Policy, EMTALA regulations, and applicable Medicare/Medicaid Conditions of Participation in determining what constitutes an emergency medical condition and the processes to be followed with respect to each.” 1.d. The St. Anthony Hospital (SAH) “Medical Staff Rules and Regulations” dated as “Approved by the Board of Trustees” on 10/05/2020 included only the following reference to the EMTALA requirements. Under Section F.6. for “Medical Screening Examination (MSE) per Emergency Medical Treatment and Active Labor Act (EMTALA)” it reflected that “A. All individuals presenting to St. Anthony Hospital’s emergency department for examination or treatment shall be given an appropriate medical screening examination (MSE) by qualified medical personnel (QMP) to determine if an emergency medical condition (EMC) exists according to Federal (EMTALA) and State regulations. B. The St. Anthony Hospital Medical Staff has determined that the following qualified medical personnel may perform a medical screening examination: physicians, physician assistants, advanced registered nurse practitioners, and trained emergency department registered nurses (for emergency severity index (ESI) 4 and 5 patients only). C. The St. Anthony Hospital Medical Staff has determined that the St. Anthony Hospital emergency department may direct pregnant women over 20 weeks gestation with pregnancy related medical conditions to the St. Anthony Hospital labor and delivery department. Furthermore, the St. Anthony Hospital Medical Staff deems registered nurses trained in the care of obstetrical patients as being qualified to conduct an examination on an obstetrical patient with a pregnancy greater than 20 weeks gestation.” 1.e. The policies, procedure, and rules and regulations were unclear and did not contain hospital-specific or department-specific procedures, processes, or steps to ensure implementation of the EMTALA CFR requirements. For example: * The hospital provided no Patient Access/Registration, ED, or Obstetrics/Family Birth Center (FBC) policies and procedures that described procedures for registration, triage, and provision of MSEs, including how or where to document that patients left the hospital without an MSE, or before the MSE was completed or treatment provided. * The medical staff rules and regulations allowed ED Registered Nurses (RNs) to conduct MSEs, and allowed FBC RNs to conduct “examinations” of FBC patients. However, it was unclear whether that information was accurate for both ED and FBC, it was unclear what was meant by “examinations” for FBC and whether that was triage or MSE, and it was not consistent with other information provided during the survey. 1.f. During interview with the Director of Patient Care, Quality and Risk (DPCQ) and the Chief Executive Officer (CEO) on 08/12/2025 beginning at approximately 1515 they provided the following information about MSEs in the ED and the FBC: * ED physicians responsible for MSEs and decision-making are staffed onsite in the ED every shift, twenty four hours a day, 365 days a year. * RNs responsible for triage are staffed in the ED every shift, twenty four hours a day, 365 days a year. * Obstetrics physicians responsible for MSEs and decision-making are staffed onsite, and when not onsite they are on-call, twenty four hours a day, 365 days a year. * FBC RNs responsible for triage are staffed in the FBC every shift, twenty four hours a day, 365 days a year. 2.a. The central log for Patient 2 reflected that they presented to the ED on 05/21/2025 at 1828 with a “Complaint” of “Extremity Pain/Injury.” The “ED Disposition” on the log was both “Patient left without being seen” (LWBS) and “Left Against Medical Advice” (AMA) on 05/21/2025 at 2016. 2.b. The medical record for Patient 2’s 05/21/2025 ED encounter was reviewed and included the following: * At 1846 an RN electronically signed a “Quick Triage Assessment” note that reflected “Patient arrives [PPV] reporting [they were] cleaning garbage off [their] porch and stepped on a sharp object that embedded in [their] heel that [they were] able to pull out. Last tetanus 8-8-21. Arrives with foot wrapped in a diaper. Bleeding controlled.” * At 2016 a second RN electronically signed the next note and wrote “Discharged To/ Against Medical Advice; New Onset Stroke Patient? [No]; [Discharge] Comment: LWBS from lobby.” * A section of the Patient Summary was titled “Departure Information” and reflected that “Primary Impression: Patient left without being seen Secondary Impressions: [blank] Disposition: Left Against Medical Advice Comment: LWBS Condition: [blank]” on 05/21/2025 at 2016. 2.c. The medical record did not clearly describe the ED encounter for Patient 2 and reflected the hospital’s policies and procedures had not been followed. There was no documentation to reflect the circumstances around which the patient left the ED, whether registration or nursing staff had engaged with them, whether “reasonable steps to secure the individual’s documented informed refusal of such examination” had been taken, and whether hospital staff had done or said anything to dissuade the patient from staying. The disposition information indicated the patient left AMA which implied that staff had a conversation with the patient to inform them of the risks of leaving without an MSE. However, there was no AMA form or other informed refusal documentation to reflect that those steps had occurred and who had taken them. 3.a. The central log for Patient 3 reflected that they presented to the ED on 05/23/2025 at 2003 with a “Complaint” of “Laceration.” The “ED Disposition” on the log was both “Patient left without being seen” (LWBS) and “Left Against Medical Advice” (AMA) on 05/23/2025 at 2152. 3.b. The medical record for Patient 3’s 05/21/2025 ED encounter was reviewed and included the following: * At 2028 an RN electronically signed a “Quick Triage Assessment” note that reflected “[Patient (Pt)] presents accompanied by parents with [complaint of] laceration to the [left] lateral pointer finger. [The patient] accidentally cut it with [their] hunting knife. Bleeding is controlled. Subcutaneous tissue is visible and wound edges are well approximated. Pt is alert and oriented and ambulates with a steady gait.” * At 0033 on 05/24/2025 a second RN electronically signed the next note and wrote “Discharged To/ Against Medical Advice.” * A section of the Patient Summary was titled “Departure Information” and reflected that “Primary Impression: Patient left without being seen - Secondary Impressions: [blank] - Disposition: Left Against Medical Advice - Comment: [blank] - Condition: Against Medical Advice” on 05/23/2025 at 2152. 3.c. The medical record did not clearly describe the ED encounter for Patient 3 and reflected the hospital’s policies and procedures had not been followed. There was no documentation to reflect the circumstances around which the patient left the ED, whether registration or nursing staff had engaged with them, whether “reasonable steps to secure the individual’s documented informed refusal of such examination” had been taken, and whether hospital staff had done or said anything to dissuade the patient from staying. The disposition information indicated the patient left AMA which implied that staff had a conversation with the patient to inform them of the risks of leaving without an MSE. However, there was no AMA form or other informed refusal documentation to reflect that those steps had occurred and who had taken them. 4.a. The central log for Patient 11 reflected that they presented to the ED on 06/28/2025 at 1147 with a “Complaint” of “Wound Check.” The “ED Disposition” on the log was both “Patient left without being seen” (LWBS) and “Left Against Medical Advice” (AMA) on 06/28/2025 at 1230. 4.b. The medical record for Patient 11’s 06/28/2025 ED encounter was reviewed and included the following: * At 1209 an RN electronically signed a “Triage Assessment” note that included “Pt has wound on left heel that started as a blister [they think] 3 days ago from wearing a different shoe. Now has increased in size and redness around lateral ankle with pain to bear any weight.” * At 1230 the RN signed a note that reflected “[Discharge] Comment: Pt wandered from room into lobby. Tells this nurse [they’re] going to go. Inquired as to why [they] did not want to wait for doctor or be seen but [they do] not have a reason other then ‘redy [sic] to leave now.’ Wanders out to parking lot and sitting underneath shady tree.” * A section of the Patient Summary was titled “Departure Information” and reflected that “Primary Impression: Patient left without being seen - Secondary Impressions: [blank] - Disposition: Left Against Medical Advice - Comment: [blank] - Condition: Stable” on 06/28/2025 at 1230. 4.c. The medical record reflected the hospital’s policies and procedures for Patient 11 had not been followed. There was no documentation to reflect that “reasonable steps to secure the individual’s documented informed refusal of such examination” had been taken, and whether hospital staff had done or said anything to dissuade the patient from staying. The disposition information indicated the patient left AMA which implied that staff had a conversation with the patient to inform them of the risks of leaving without an MSE. Although the RN documented that they engaged with the patient, there was no indication they advised the patient of the risks of leaving without the MSE. There was no AMA form or other informed refusal documentation to reflect that those steps had occurred. 5.a. The central log for Patient 18, a toddler, reflected that they presented to the ED with their parents on 07/31/2025 at 1233 with a “Complaint” of “Eye Pain/Injury.” The “ED Disposition” on the log was both “Patient left without being seen” (LWBS) and “Left Against Medical Advice” (AMA) on 07/31/2025 at 1401 5.b. The medical record for Patient 18’s 07/31/2025 ED encounter was reviewed and included the following: * At 1251 an RN electronically signed a “Quick Triage Assessment” that reflected “Pt in with an eyelid laceration to [left] upper eyelid. Pt was playing in playpen when parents heard [the patient] suddenly screaming in pain. Parents think that pt was scratched by their cat. Pt acting appropriately per family.” * At 1429 the RN signed a note that reflected “[Discharge] comment: Pt left without being seen at 1401.” * A section of the Patient Summary was titled “Departure Information” and reflected that “Primary Impression: Patient left without being seen - Secondary Impressions: [blank] - Disposition: Left Against Medical Advice - Comment: [blank] - Condition: Against Medical Advice” on 07/31/2025 at 1401 5.c. The medical record did not clearly describe the ED encounter for Patient 18 who was brought in by their parents and reflected the hospital’s policies and procedures had not been followed. There was no documentation to reflect the circumstances around which the parents left the ED with the patient, whether registration or nursing staff had engaged with the parents, whether “reasonable steps to secure the individual’s documented informed refusal of such examination” had been taken, and whether hospital staff had done or said anything to dissuade the parents from staying in the ED with the patient. The disposition information indicated the parents left AMA with the patient which implied that staff had a conversation with the parents to inform them of the risks of leaving without an MSE. However, there was no AMA form or other informed refusal documentation to reflect that those steps had occurred and who had taken them. 6.a. During interviews with the DPCQ, ED Manager, and Informatics Director (ID) at the time of the ED record review on 08/13/2025 beginning at approximately 1000 they confirmed that there was no additional documentation to describe the circumstances under which Patients 2, 3, 11, and 18 left the ED before or prior to completion of an MSE, including evidence that attempts had been made to obtain those patients’ written informed refusal of an MSE. ************************************************”

“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: 08621 ************************************************ Based on interviews, review of central log and medical record documentation for 7 of 7 encounters of individuals who presented to the hospital for emergency medical or obstetric (OB) services and were transferred to other hospitals for further examination or stabilizing treatment not within its capability or capacity at the time (Patients 5, 7, 14, 15, 16, 17, and 19), review of OB/Family Birth Center (FBC) Daily Floor Census sheets, and review of policies and procedures, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that it effected appropriate transfers for patients for whom an Emergency Medical Condition (EMC) had not been ruled out, removed or resolved: * Patient 19 was transferred to another hospital in a personal/private vehicles (PPVs) by family members, contrary to section (2)(iv) of this Code of Federal Regulation (CFR) that requires “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.” Medical transportation with qualified personnel and emergency equipment was not used for transfer to ensure proper monitoring and response to changes in patient condition. It was not clear whether hospital staff or the patients initiated discussions about transport by PPV, and what additional risks secondary to transport by PPV without qualified personnel and emergency equipment had been identified and discussed. * Patients 5, 7, 14, 15, 16, 17, and 19 and other patients were transferred to other hospitals without the required physician certification that included identification of the patient specific and individualized benefits and risks of transfer. * For Patients 5, 14, 15, 16 and 19 it was unclear whether all medical records and transfer documentation had been sent to the receiving facility. Findings include: 1.a. The “CommonSpirit System-Wide” policy titled “Emergency Medical Treatment and Labor Act (EMTALA) Policy” dated as last revised 12/11/2024 was reviewed. It reflected that when an individual who presented to the hospital “requesting or requiring examination or treatment of an Emergency Medical Condition (EMC), and if one exists, [the hospital was obligated] either to stabilize the emergency condition or to transfer the individual appropriately and in conformity with the legal and regulatory requirements, without regard to their age, race, color, creed, national origin, immigration status, insurance, disability, handicap, diagnosis, sexual orientation, or ability to pay.” 1.b. The “CommonSpirit System-Wide” procedure titled “Emergency Medical Treatment and Labor Act (EMTALA) Procedure” dated as last revised 12/11/2024 was reviewed. It included the following hospital requirements: * “Appropriate Transfer” means a Transfer of an individual with an EMC that is implemented in accordance with the following EMTALA standards: · The transferring hospital provides medical treatment within its Capability to minimize the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; · The receiving hospital has available space and qualified personnel for the treatment of the individual, and has agreed to accept the Transfer of the individual and to provide appropriate medical treatment; · The transferring hospital sends to the receiving hospital copies of all medical records available at the time of Transfer related to the EMC for which the individual has presented that are available at the time of Transfer, including the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; and · The sending provider determines the appropriate method of transfer. The transfer may require medical transport, including qualified personnel and equipment.” * Regarding “Treatment or Transfer of Individuals with an Emergency Medical Condition (EMC)” the procedure required that “a. When a physician or QMP determines as a result of the [Medical Screening Exam (MSE)] that an individual has an EMC, the individual will be treated until the condition is Stabilized or when the individual can be appropriately Transferred. b. The hospital will not transfer an individual with an unstabilized EMC unless the individual requests the transfer or a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving hospital outweigh the risks to the individual from the transfer. The hospital must continue to assess and provide ongoing care until the individual leaves the hospital. c. Requirements for an Appropriate Transfer. If the individual’s EMC cannot be Stabilized within the Capability and Capacity of the hospital, the individual shall be transferred in compliance with state and federal law if the hospital complies with the standards defined as an Appropriate Transfer. d. Each DED or other departments of the hospital that transfer individuals with Emergency Medical Conditions shall adopt policies and procedures that describe the procedures for the transfer of individuals and documentation of the transfer, and conduct training of department personnel.” * Regarding “Refusal to Consent to Transfer” the procedure required that “In the event the physician recommends Transfer to another medical facility and after informing the individual of the risks and benefits of such Transfer, the individual (or Designated Representative) refuses transfer, then following must be documented in the EHR: a. The reason for the recommendation of the Transfer. b. The individual was informed of the risks and benefits of the Transfer; and c. The individual’s (or Designated Representative’s) reason(s) for refusing the Transfer. If the individual (or Designated Representative) refuses Transfer via medical transport and insists on using a personal/private vehicle, that is still considered a Transfer and such informed refusal to use medical transport shall be documented in the medical record.” 1.c. The procedure was unclear and did not contain hospital-specific or department-specific procedures, processes, or steps to ensure implementation of the EMTALA CFR appropriate transfer requirements: * It was not clear what “state and federal law” was referred to in the following statement: “... the individual shall be transferred in compliance with state and federal law if the hospital complies with the standards defined as an Appropriate Transfer.” * The hospital provided no Emergency Department (ED) or FBC “policies and procedures that described the procedures for the transfer of individuals and documentation of the transfer.” * Where the procedure stated that “When a physician or QMP determines as a result of the MSE that an individual has an EMC ...” it was not clear that appropriate transfer must be effected for patients for whom EMCs had not been ruled out, removed, or resolved, as required by section (2)(iv) of this CFR. The procedure provided no assurance that staff would not offer a personal/private vehicle (PPV) transport as an option. Further, it did not clearly recognize the additional risks of transfer that exist in the stress-filled scenario where a lay-person, caregiver, family member, or the patient themselves for whom an EMC has not been ruled out, removed, or resolved, drives to another hospital. There was no evident consideration that the drive may be to another distant town/city, on rural roads and highways, during the night, or during inclement weather. * There were no references to how or where staff were to document the implementation of the appropriate transfer requirements in the medical record. 1.d. The St. Anthony Hospital (SAH) “Medical Staff Rules and Regulations” dated as “Approved by the Board of Trustees” on 10/05/2020 included no references to the responsibilities of the ED and FBC medical staff to effect appropriate transfers of patients for whom the hospital did not have capability or capacity for further examination or stabilizing treatment necessary to rule out, remove, or resolve an EMC. Including, but not limited to, the physician certification that the patient specific benefits of transfer outweigh the patient specific risks, and informed consent for patient refusal of transfer or refusal of transfer by medical transport with qualified medical personnel and emergency equipment. 2.a. During interview with the Director of Patient Care, Quality and Risk (DPCQ) on 08/12/2025 beginning at 1520 they stated that Doctor of Medicine (MD) G came into the hospital to evaluate Patient 19, who was approximately 34 weeks gestation and who presented to the FBC on 08/02/2025 with premature rupture of membranes (PROM). The DPCQ provided the following information: * The patient “needed to go to a higher level of care.” * Patient 19 was 0.5 centimeters (cm) dilated. * MD G determined the patient was “not in active labor,” and “wanted to transfer the patient to Kadlec Regional Medical Center (Kadlec).” * “The patient did not want to go by ambulance and because the patient was “’stable’ [they were] discharged.” * The patient went to Kadlec by PPV. * An EMTALA transfer form was not sent with the patient to Kadlec. 2.b. Regarding Patient 19, the FBC Daily Floor Census sheet for 08/02/2025 was reviewed. It included an entry under the “Outpatient” section of the sheet that Patient 19’s “Time In” for an unspecified “[OB check]” was 2158, and their “Time Out” was 2325. Under the “Patient Transfers” section of the sheet it reflected for Patient 19 that the “Receiving Facility” was “Kadlec [Labor & Delivery (L&D)],” the transportation was “Transfer Per Personal Vehicle,” and the “Reason for Transfer” was “[Preterm premature rupture of membranes (PPROM) at 34 weeks].” 2.c. The medical record for Patient 19’s 08/02/2025 FBC encounter was reviewed. It included the following information: * At 2200 the FBC RN recorded the first entry on the FBC Flowsheet (flowsheet) as “Nitrazine Equivocal.” There was no other information recorded at that time. * At 2205 and 2207 the RN recorded on the flowsheet that external monitors for evaluation of uterine activity and fetal assessment were applied and adjusted. * At 2212 the RN recorded “Triage” entries on the flowsheet that included that abdomen pain was “Intermittent” and “Cramping” and “Observed Coping Behavior - Rhythmic Activity During Contraction ... Able to relax Between Contractions ...” * At 2213 an Amnisure ROM test was conducted with a “Positive” result. * At 2217 the RN recorded on the flowsheet “Vaginal Exam Dilation (cm) 0.5 - Effacement [percent] 30 - Station [minus] 3.” * At 2241 the RN recorded the next entry on the flowsheet as “RN Reviewed Strip; Call/Page Placed to Provider ... [MD G] updated to pt [chief complaint], positive amnisure, [sterile vaginal exam], fetal status and uterine activity. MD will come to bedside to discuss [transfer] to another hospital ... Membranes Ruptured Date/Time 08/02/25 [2140].” * At 2247 the RN wrote on the flowsheet “[MD G] at nurse’s station, reveiws [sic] chart. Verbal order received for betamethasone 12 [milligrams (mg) intramuscular (IM)].” * At 2255 the RN wrote on the flowsheet “[MD G] in room to see pt, comfirms [sic] cephalic position by bedside ultrasound, discusses [plan of care] to transfer still pregnant.” * At 2258 the physician Order Summary reflected that MD G ordered the corticosteroid medication: “Betamethasone [sodium phosphate]/Acetate (Celestone-Soluspan), 6 mg/[milliliter (ml)], 12 mg, IM, every 24 hours.” * At 2306 the RN recorded medication administration on the flowsheet for “Celestone [betamethasone]12 mg IM right thigh.” * At 2307 the RN recorded on the flowsheet that “RN reviewed Strip” and for ’”Uterine Activity” wrote “Frequency [3-23 minutes] - Quality Mild - Duration [50-90 seconds] - Pattern Normal: [less than or equal to] 5 Contractions in 10 Minutes ... Contraction Comments [occasional contraction], some irritability seen.” For “Fetal Assessment” the RN wrote “[Fetal heart rate] baseline rate 145 - Variability Moderate ... Decelerations None - Category 1 - Comments break in tracing, unable to [rule out decelerations] with low suspicions.” The RN also recorded “Provider Reviewed Strip Yes.” * At 2308 the RN wrote on the flowsheet “After conversations with [MD G] pt elects to go to Kadlec L&D by personal vehicle. [MD G] contacts charge nurse there and updates them to plan of care. [External fetal monitor] off for transfer.” * At 2314 MD G electronically signed the OB Provider Admission Physical and Note that reflected that Patient 19 “presnted [sic] to [FBC with complaint of] PROM clear fluid at 2140. Amnisure confirms rupture ... per RN, [fetal heart tracing] reassuring, [vertex fetal position] by [ultrasound], Pt has [history of cesarean section] and declines [vaginal birth after cesarean]. Plan: [Transfer] to Kadlec, [betamethasone first dose given at 2300], [Intravenous (IV) antibiotics] per protocol. Pt declines ambulance transfer, will head to Kadlec [immediately] by private vehicle. Instructed to remain [nothing by mouth (NPO)].” * At 2318 Patient 19 signed a Discharge Instructions form. The form included the following information: - “Discharge Date/Time: 08/02/2025 [2325]” - “Condition: Guarded” - “Accompanied by: [significant other (S.O.)]” - “Discharged to:” was blank - “Diet Restrictions: DO NOT EAT UNTIL TOLD OTHERWISE” - “Comments: Transfer by personal vehicle to Kadlec [L&D] for preterm rupture of membranes. Please drive directly to Kadlec L&D and do not eat anything on the way until they tell you otherwise.” * At 2319 the RN wrote on the flowsheet “[Discharge] instructions given including directions for NPO and to drive directly up to Kadlec L&D, pt expresses understanding.” * At 2325 the RN recorded on the flowsheet that the patient was “[discharged] off unit for [transfer] to Kadlec L&D by personal vehicle. Stable and undelivered with PPROM.” * At 2342 the Order Summary included an order from MD G that the patient be discharged. * At 2350 MD G dated an untitled one-page form that reflected NST results were “Reactive.” The “Comments” were “PPROM [34 weeks and four/seven days - Transfer].” 2.d. A Patient Transfer Order form in Patient 19’s medical record was signed by MD G at 2303 and contained more information related to the transfer: * The form stated “I direct that this patient be transferred consistent with these instructions:” * “Destination hospital: Kadlec” * The space for “Accepting physician (full name):” was blank. * Section 1 of the form contained spaces for “Name of person accepting for the hospital” and “Date” and “Time” and “Phone [number] for report” and “Available space confirmed” and “Available personnel confirmed” and “Confirmed by.” All of the spaces were blank. * Section 2, “Equipment,” reflected that the spaces next to the following three choices were checked: “Monitor” and “[Advanced Life Support (ALS)]” and “Other [privately owned/operated vehicle].” However, the “Monitor” and “ALS” selections had been crossed out and initialed by the HS. Pre-printed language under that section stated that “Patient’s condition indicating ‘medically necessary’ for ambulance transportation (i.e. cannot be transported by taxi, wheel chair, car, private vehicle.” * Section 3, “Copies sent with patient: (check each record that applies)” reflected that the following documents were sent with the patient: Laboratory reports, Physician’s orders, Face sheet, History and Physical, Complete FBC record. * Section 4, the space for “Required life support” had “[not applicable]” written in it. * Section 5, the space for “Required personnel to accompany patient” was blank. * Section 6, the space for “Medical orders” was blank. * Under “Mode of transfer” the “Private vehicle” selection was checked. * Section 7 contained pre-printed language that stated “When possible, radio contact is to be maintained during transfer. Physician orders and appropriate protocols will be followed until arrival at the receiving facility.” * Section 8 contained spaces for “Report called to” and “By” and “[Time].” Those spaces were blank. * At 2305 the HS signed the form. * At 2322 the FBC RN signed the form. 2.e. A Physician Initiated Transfer Certificate of Transfer form in Patient 19’s medical record was signed by MD G at 2305 and contained “Risks versus Benefits” information: * Under “Benefits:” MD G wrote “[Appropriate] care higher level.” * Under “Risks:” MD G wrote “Transfer baby.” * Pre-printed language under “Risks” stated “All transfers have the inherent risks of traffic delays, accidents during transport, inclement weather, rough terrain or turbulence, and the limitations of equipment and personnel in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient.” 2.f. The medical record did not contain clear and complete information about Patient 19’s encounter and the communications regarding transfer and mode of transportation in this case where the patient went by a PPV and was instructed to go “immediately” to Kadlec and to remain NPO. For example: * There was no documentation to reflect that Kadlec had been contacted, had the necessary capability and capacity, and had accepted Patient 19 in transfer. * On the Physician Initiated Transfer Certificate form the meaning of “Benefits: [Appropriate] care higher level” was not clear and specific to Patient 19 and their unborn infant. It did not describe what capability or capacity Kadlec had to benefit Patient 19 and their unborn infant that was not available at SAH, nor was that documented elsewhere in the medical record. * On the Physician Initiated Transfer Certificate form the meaning of “Risks: Transfer baby” was not clear and specific to Patient 19 and their unborn infant. There was no documentation on the transfer form or elsewhere in the medical record to reflect what the individualized and specific risks of transfer were for Patient 19 and their unborn infant. The pre-printed language on the form about the inherent risks of transport does not constitute patient specific risks. * The PPV mode of transport decision for this EMTALA transfer was not clear, and it was not evident whether hospital staff or Patient 19 had initiated the idea of transfer by PPV. There was no documentation on the Patient Transfer Order, the Physician Initiated Transfer Certification, and elsewhere in the medical record to reflect that MD G had informed Patient 19 of the specific additional risks of transfer to themselves and their unborn infant secondary to transport by PPV without qualified personnel and emergency equipment on rural roads and highways to the other hospital during dark, nighttime hours. 2.g. During interview with MD G on 08/13/2025 beginning at approximately 1300 they provided the following information about their encounter with Patient 19: * They assessed the patient, confirmed the PROM, checked for uterine activity, did an ultrasound to check presentation, and determined the patient “was not too far along.” * Although they stated they did not check the patient’s cervix for dilation, the FBC RN had done so. * MD G determined to send the patient to a facility with a Neo-natal Intensive Care Unit (NICU). * They stated that SAH does not have a NICU and therefore does not deliver infants who are less than 35 weeks gestation. * Patients who are less than 35 weeks gestation are transferred to a hospital with a NICU, generally to Kadlec or to a hospital in Portland. * Patient 19 agreed to go to Kadlec. * The MD stated the patient asked “’do I have to go by ambulance?’” * The MD stated they told the patient they couldn’t “force” them to go by ambulance.” * The MD stated, “it was not unreasonable or dangerous” to go by PPV as the patient “was not in active labor.” MD G stated they didn’t think it was “unsafe.” * MD G called Kadlec L&D and talked to the charge nurse to inform them that Patient 19 was going to be arriving at Kadlec. They “explained the situation” to the charge nurse that they had a patient who was “here with PROM, not contracting, not in active labor, and declined to go by ambulance.” They told the charge nurse that “if the [Kadlec] on-call physician has questions have them call me.” * MD G stated the charge nurse’s response was “’Okay, we’ll keep an eye out for [them].’” * The Kadlec charge nurse did not tell MD G that Kadlec could not, or would not, accept Patient 19. * MD G did not have the name of the Kadlec L&D charge nurse. * MD G stated the “risks of delivering the baby by the side of the road” on the way to Kadlec was “unlikely.” 2.h. During interview with the House Supervisor (HS) on 08/14/2025 beginning at approximately 1300 they confirmed they were on duty at the time of Patient 19’s encounter on 08/02/2025 and provided the following information: * The HS received a call from the FBC that a 34-week OB patient needed transfer to Kadlec. As part of their HS duties they proceeded to the FBC to assist unit staff with the transfer arrangements and paperwork. * When they arrived to the FBC the transfer to Kadlec was already in motion, “like a fast moving train,” and the patient and their S.O. were getting ready to leave the FBC. * The HS heard MD G on the phone speaking about Patient 19 and thought the MD was talking to a Kadlec physician about the transfer. * After the MD got off the phone to Kadlec they informed the HS that they had not called the Kadlec physician, but had made a “courtesy call” to the Kadlec L&D and spoke to the charge nurse to let them know Patient 19 was coming. * MD G told the HS that the Kadlec L&D charge nurse said “’We’ll be expecting [Patient 19].’” * MD G reported to SAH FBC staff that the patient refused ambulance transport and was telling the patient they needed to go. * The FBC RN reported that the patient was being discharged, and they were completing the discharge paperwork, including the discharge instructions to give to the patient so they could leave for Kadlec. * The HS questioned why “discharge documentation and instructions” were being completed when the situation was a “transfer” and not a “discharge” and was told it was because the patient was driving a PPV. * The HS called the Kadlec Transfer Center themselves to inform transfer center staff that Patient 19 was leaving SAH to drive to Kadlec L&D in a PPV. They also requested the name of a Kadlec physician to record on the SAH transfer form. The Kadlec staff person stated that because SAH called the Kadlec L&D directly versus the transfer center, there was no MD to MD call, and there was a concern about what would happen if Kadlec did not have capacity. The Kadlec transfer center staff did confirm with the HS that in fact Kadlec did have capacity for Patient 19 at that time. * By the time the HS got off the phone with the Kadlec Transfer Center the patient and their S.O. had left the SAH FBC. * The HS stated the Transfer Form was “partially completed.” * They stated that they were hurriedly working with the FBC RN to copy the medical record documents and put them in the envelope before Patient 19 left. Those documents were a “full patient summary that included prenatal information, the discharge instructions, and a face sheet.” They thought the Transfer Form had been included. * The HS believed they heard the patient or S.O. say that before they would leave town to drive to Kadlec, they had to stop and drop their other child off to be cared for while they went to Kadlec. 2.i. Internet/GPS distance calculators reflected that Kadlec in Kennewick, Washington is approximately 75 miles, and approximately 1 hour and 15 minutes drive-time from rural SAH Hospital in Pendleton, Oregon. 3.a. The central log for Patient 5 reflected that they presented by ambulance to the ED on 05/30/2025 at 0000 with a “Complaint” of “Hip Pain/Injury.” The disposition on the log was “[Discharge/Transfer] Acute Care Hospital” on 05/30/2025 at 0803. 3.b. The medical record for Patient 5’s 05/30/2025 ED encounter was reviewed, reflected that an MSE was conducted by Doctor of Osteopathic Medicine (DO) B, and included the following information: * At 0304 DO B electronically signed the ED note that included the following information: “Patient ... presents [ED] complaint of ground-level fall at home EMS brought [them] in tripped over something on the floor fell and landed on [their] right buttock/side ... side pain to palpation with hip rock at the right hip patient endorses it radiating into the groin and with palpation of that area you can see spasm down into the thigh patient refuses any movement of the right lower extremity particularly at the hip pulses are positive distal and palpation of the thigh or femur area and knee and [tibia-fibula] are negative patient winces in pain at palpation of the groin. no abnormalities on the left side no upper extremity chest wall or back abnormalities ... X-ray Hip ... Impression: Displaced right intertrochanteric fracture ... ED Course: ... patient seen and examined differential right hip dislocation, fracture, contusion. Patient sent for [laboratory testing] [IV route] was established and x-ray of the right hip. As well patient had been treated with 100 of fentanyl and 50 of ketamine in the ambulance which did not resolve [their] pain but did make [them] altered and associated and panicking. Patient was given 2 and half diazepam and half milligram of Dilaudid [they] still had pain so another half was given at that point because we then had to put oxygen on the patient secondary to all the medications [they] gotten we went ahead and called anesthesia for a block for pain relief. Patient seemed to settle somewhat after that and will wean oxygen off likely as the narcotics wear off. l did go ahead and call [Good Shepherd Medical Center (GSMC)] we do not have orthopedics on we have sent pictures of the x-rays as well as push the images and nursing staff is not [sic] going to forward the chart. Patient’s labs do show elevated creatinine which is not entirely abnormal normally the patient runs about 1.7-1.9 [they are] at 2.3 today with a elevated BUN as well likely dehydration related patient is also diabetic and has a history of high blood pressure and hypothyroid despite [their] history of smoking and the wheezing that I hear on examination I do not see a diagnosis history of [Chronic Obstructive Pulmonary Disease] on [their] chart nor any medications for it. The only other abnormality that is pertinent is a potassium of 5.2 however it is 0.1 above the normal and [they are] dehydrated likely with fluids this will go down as a result patient was given a bolus of fluids and then started on maintenance will forward the chart to [GSMC] for their evaluation and await possible transport. Patient was accepted for transport to [GSMC] ... [They] will admit to the hospitalist service.” * At 0311 an RN wrote: “0308 - called Hermiston fire [department] to attempt to arrange transfer. states they are unable to [due to] staffing. 0310 - Boardman fire [department] called for transport. they are also short staffed and unable to provide transport until shift change.” * At 0804 the RN recorded that the patient was transferred by ambulance after “bedside report” with ambulance staff. 3.c. A Patient Transfer Order form in Patient 5’s medical record was signed by DO B at 0304 and contained more information related to the transfer: * “Destination hospital: “Good Shepherd Medical Center.” * The section for “Equipment Needed” reflected “ALS. * The “Mode of transfer” was recorded as “Ambulance.” * The section for “Copies sent with patient (check all that apply):” reflected that a number of documents and diagnostic imaging reports were sent with the ambulance. 3.d. A Physician Initiated Transfer Certificate of Transfer form in Patient 5’s medical record was signed by DO B at 0304 and contained “Risks versus Benefits” information: * Under “Benefits:” DO B wrote “Higher level care.” * Under “Risks:” DO B wrote “[Motor Vehicle Accident (MVA)] deterioration in transport.” * Pre-printed language under “Risks” stated “All transfers have the inherent risks of traffic delays, accidents during transport, inclement weather, rough terrain or turbulence, and the limitations of equipment and personnel in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient.” 3.e The medical record for Patient 5 did not contain clear and complete information about the patient’s transfer. * On the Physician Initiated Transfer Certificate form the meaning of “Benefits: Higher level care” was not clear and specific to Patient 5. It did not describe what capability or capacity GSMC had to benefit Patient 5 that was not available at SAH. * On the Physician Initiated Transfer Certificate form the meaning of “MVA deterioration in transport” was not clear and specific to Patient 5. There was no documentation on the transfer form or elsewhere in the medical record to reflect what “deterioration” meant for Patient 5, and what the individualized and specific risks of transfer were. In addition, the “MVA” risk was duplicative to the pre-printed language on the form about the inherent risks of transport and was not patient specific. * It was unclear whether all records available, specifically the Transfer Order and the Transfer Certificate, had been sent with the patient to GSMC. 3.f. Internet/GPS distance calculators reflected that GSMC in rural Hermiston, Oregon is approximately 29 miles and approximately 33 minutes drive-time from rural SAH Hospital in Pendleton, Oregon. 4.a. Regarding Patient 7, the FBC Daily Floor Census sheet for 06/12/2025 was reviewed. It included an entry under the “Outpatient” section of the sheet that Patient 7’s “Time In” for an unspecified “[OB check]” was 2100, and their “Time Out” was “[transfer 6/13].” Patient 7 was not entered under the “Patient Transfers” section of the sheet. 4.b. The medical record for Patient 7’s 06/12/2025 FBC encounter was reviewed, reflected that an MSE was conducted by DO C , and included the following information: * At 0013 on 06/13/2025 DO C electronically signed a progress note that reflected “Chief Complaint: [Spontaneous rupture of membranes (SROM)], Cerclage ... Impression: [Intra-uterine pregnancy at 31 weeks and 6 days] PPROM [history of] cervical insufficiency cerclage in place. Plan: Reviewed case [with physicians at LEMC] who kindly accepted transfer for PPROM. Reviewed [with] pt who again denies any pain with uterine irritability. Discussed risks and benefits of transfer with risks including but not limited to infection, bleeding, delivery en route, maternal/fetal death. Pt understands and agrees. Reviewed cephalic position. Will check [cervix] prior to transfer and if cervical change noted or painful contractions would not transfer and would coordinated NICU team here. Consents and orders completed. Reviewed Betamethasone given at 22:45 ... maternal tachycardia noted, afebrile ... Dilatation: 4.0 Effacement: 90 Contraction Comments: [every] 4-5 minutes ... Amniotic Fluid Color: Clear ... [Fetal heart rate] Baseline: 150 Variability: Minimal ... Deceleration: None ... Category: II ... Comments: No evidence of fetal metabolic acidosis ... Presentation: Vertex.” * At 0111 DO C signed a progress note that reflected “Plan: Pt doing well. Denies painful contractions or increased pelvic pressure. [Fetal heart tones] reassuring [Cervix] unchanged again on exam now _3.5 [hours status post] PPROM. Afebrile. Air transportation landed and en route to hospital. Pt and I both feel comfortable moving forward with transfer. All questions answered ... “ . 4.c. A Patient Transfer Order form in Patient 7’s medical record was signed by DO C at 2355 and contained more information related to the transfer: * “Destination hospital: “[Legacy Emanuel Medical Center (LEMC)].” * The section for “Equipment” reflected “ALS.” * “Mode of transfer” was recorded as “Fixed wing” airplane. 4.d. A Physician Initiated Transfer Certificate of Transfer form in Patient 7’s medical record was signed by DO C at 2356 and contained “Risks versus Benefits” information: * Under “Benefits:” DO C wrote “Higher level care.” 4.e The medical record for Patient 7 did not contain clear and complete information about the patient’s transfer. * On the Physician Initiated Transfer Certificate form the meaning of “Benefits: Higher level care” was not clear and specific to Patient 7. It did not describe what capability or capacity LEMC had to benefit Patient 7 and their unborn infant that was not available at SAH. 4.f. Internet/GPS distance calculators reflected that LEMC in Portland, Oregon is approximately 189 air miles and approximately 22 minutes flight time from rural SAH Hospital in Pendleton, Oregon. That does not include the ambulance drive time to the hospital in Portland from the airfield. 5.a. The central log for Patient 14 reflected that they presented to the ED on 07/10/2025 at 2157 with a “Complaint” of “Bite.” The disposition on the log was “[Discharge/Transfer] Acute Care Hospital” on 07/10/2025 at 2330. 5.b. The medical record for Patient 14’s 07/10/2025 ED encounter was reviewed, reflected that an MSE was conducted by DO B, and included the following information: * At 2312 DO B electronically signed the ED note that reflected the patient presented to the ED with a “complaint of rattlesnake bite patient stopped go to the bathroom on the side of the road [their] phone fell down and [they] went to grab it and was bitten [they] did not see the snake was indeed a rattlesnake bite was on the left second digit at the metatarsal interphalangeal joint. area is already swollen bite happened approximately 50 minutes prior to [their] arrival at the [ED] patient has no medical conditions is diaphoretic nauseated actually bradycardic and mildly hypotensive feeling dizzy lips and tongue are numb and [they] starting to feel very thirsty ... ED course: patient seen and examined no large differential here patient has been bitten by a rattlesnake [they] did see it was definitely not a bull snake or any other manner of nonvenomous snake that sometimes bites [they are] familiar and certain. patient is an [ED] tech I am confident in [their] assessment that it was indeed a rattlesnake. Patient had IV [times] 2 established fluids running as [they were] mildly hypotenslve after the first blood pressure 88/50 heart rate started to drop lowest we got was 36 then [they] settled into rates in the high 50s. patient continued to appear pale diaphoretic have numbness and tingling in the lips and tongue and throat area. [they are] not up-to-date on tetanus so we did update that. [Their] left upper extremity was measured and marked and times circumferentially from the area of the bite all the way up to the shoulder in inches. [They are] eligible for 6-10 vials per our protocol given [their] smaller size I am going to give [them] 6 vials assess [their] symptoms and go from there. We definitely do not have enough to continue any maintenance dosing after that as we only have 12 vials total. So transfer is likely, labs were written for CBC, CMP, fibrinogen, PTT, PT pregnancy test. Everything was within normal limits except for creatinine mildly elevated at 1.12. EKG showed normal sinus rhythm rate of 61 with sinus arrhythmia. Patient was given small amount of pain medication and nausea meds, has NS running and was discussed with [physician] at Kadlec in the [ED] and was accepted for transport [ED] to [ED] I suspect that the finger may need attension [sic] or hand if it swells much more ... Impressions: Toxic effect of rattlesnake venom ... Condition: Critical.” * At 2358 an RN recorded that the patient was transferred by helicopter after “bedside report” with helicopter staff. 5.c. A Patient Transfer Order form in Patient 14’s medical record was signed by DO B at 2311 and contained more information related to the transfer: * “Destination hospital: “Kadlec” * The section for “Equipment Needed” reflected “ALS. * “Mode of transfer” was recorded as “Helicopter.” * The section for “Copies sent with patient (check all that apply):” reflected that a number of documents and diagnostic imaging reports were sent with the ambulance. 5.d. A Physician Initiated Transfer Certificate of Transfer form in Patient 14’s medical record was signed by DO B at 2310 and contained “Risks versus Benefits” information: * Under “Benefits:” DO B wrote “Higher level care.” * Under “Risks:” DO B wrote “MVA deterioration in transport.” * Pre-printed language under “Risks” stated “All transfers have the inherent risks of traffic delays, accidents during transport, inclement weather, rough terrain or turbulence, and the limitations of equipment and personnel in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient.” 5.e The medical record for Patient 14 did not contain clear and complete information about the patient’s transfer. * On the Physician Initiated Transfer Certificate form the meaning of “Benefits: Higher level care” was not clear and specific to Patient 14. It did not describe what capability or capacity Kadlec had to benefit Patient 14 that was not available at SAH. * On the Physician Initiated Transfer Certificate form the meaning of “MVA deterioration in transport” was not clear and specific to Patient 14. There was no documentation on the transfer form or elsewhere in the medical record to reflect what “deterioration” meant for Patient 14, and what the individualized and specific risks of transfer were. In addition, the “MVA” risk was duplicative to the pre-printed language on the form about the inherent risks of transport and was not patient specific. * It was unclear whether all records available, specifically the Transfer Order and the Transfer Certificate, had been sent with the patient to GSMC. 5.f. Internet/GPS distance calculators reflected that Kadlec Regional Medical Center in Kennewick, Washington is approximately 41 air miles and approximately five minutes flight time from rural SAH Hospital in Pendleton, Oregon. 6.a. The central log for Patient 15 reflected that they presented to the ED on 07/20/2025 at 1351 with a “Complaint” of “Medical Clearance/[Psychiatric].” The disposition on the log was “[Discharge/Transfer] Psychiatric Hospital” on 07/21/2025 at 1207. 6.b. The medical record for Patient 15’s 07/20/2025 ED encounter was reviewed, reflected that an MSE was conducted by two MDs, and included the following information: * At 1911 and 2319 MD D and MD E, respectively, electronically signed the ED note that reflected Patient 15 presented to the ED “for evaluation of suicidal ideation ... Pt reports feeling anxiety and depression that has increased in the last few days, the day before yesterday the pt reports suicidial [sic] ideation. Pt had a plan to step in front of traffic on the freeway but never attempted and came straight to the hospital ... ED course: Medical Decision Making [Patient 15], otherwise healthy, presents to the [ED] voluntarily complaining of suicidal ideation with a plan. On my evaluation [they are] calm and cooperative and articulate. [They do] not appear intoxicated Standard battery of labs have been ordered as well as consultation with the medical team. CBC shows mild microcytic anemia. Chemistry panel is unremarkable. TSH is within normal limits. Urinalysis is unremarkable. Urine drug screen is positive for amphetamines and MOMA. Negative for salicylates and acetaminophen and alcohol. The patient is medically cleared for psychiatric disposition. The patient was evaluated by the crisis team. [Patient] is voluntary. They are seeking placement for [the patient]. Differential diagnosis: Depression, suicidal ideation, substance use disorder ... Impression: Suicidal ideation.” * At 1207 on 07/21/2025 an RN recorded that the patient was transferred to a hospital with a psychiatric unit by County Sheriff’s officers after “bedside report.” 6.c. A Patient Transfer Order form in Patient 15’s medical record was signed by MD F at 1104 on 07/21/2025 and contained more information related to the transfer: * “Destination hospital: “Mercy Medical Roseburg” * “Mode of transfer” was recorded as “Secure Transport.” * “Copies sent with patient (check all that apply):” reflected that a number of documents and diagnostic imaging reports were sent with the ambulance. 6.d. A Physician Initiated Transfer Certificate of Transfer form in Patient 15’s medical record was signed by MD F at 1104 and contained “Risks versus Benefits” information: * Under “Risks:” MD F wrote “Travel.” * Pre-printed language under “Risks” stated “All transfers have the inherent risks of traffic delays, accidents during transport, inclement weather, rough terrain or turbulence, and the limitations of equipment and personnel in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient.” 6.e The medical record for Patient 15 did not contain clear and complete information about the patient’s transfer: * On the Physician Initiated Transfer Certificate form the meaning of “Travel” was not clear and specific to Patient 15. There was no documentation on the transfer form or elsewhere in the medical record to reflect what the individualized and specific risks of transfer were for Patient 15. In addition, the “Travel” risk was duplicative to the pre-printed language on the form about the inherent risks of transport and was not patient specific. * It was unclear whether all records available, specifically the Transfer Order and the Transfer Certificate, had been sent with the patient to GSMC. 6.f. Internet/GPS distance calculators reflected that Mercy Medical Center in Roseburg, Oregon is up to approximately 386 miles and approximately six hours and 13 minutes drive-time from rural SAH Hospital in Pendleton, Oregon, depending on the route taken. 7.a. The central log for Patient 16 reflected that they presented by ambulance to the ED on 07/24/2025 at 1713 with a “Complaint” of “Hip Pain/Injury.” The disposition on the log was “[Discharge/Transfer] Acute Care Hospital” on 07/25/2025 at 0133. 7.b. The medical record for Patient 16’s 07/24/2025 ED encounter was reviewed, reflected that an MSE was conducted by a DO and MD, and included the following information: * At 2358 on 07/24/225, and on 0801 on 07/25/2025, DO B and MD F, respectively, electronically signed the ED note that reflected the patient presented to the ED “complaining of shortness of breath. The patient was seen here for shortness of breath last night, and had workup that was consistent with congestive heart failure. [They were] started on Lasix and potassium, however when [they] got home [they] stayed in [their] recliner most of the night, felt short of breath throughout the night, and was having difficulty getting up and going to the bathroom due to [their] hip pain. Family feels like [the patient] probably needs a Foley catheter, especially in light of the fact that [they are] on Lasix, now has increasing urine output, and at the same time has worsening hip pain ... had an x-ray of [their] hip last night that showed degenerative change, but no new fracture ... has not had any recent falls ... pt with continued hip and shoulder pain. pt states that [their] current hip pain is unbearable. [they] rec’vd 2 doses of dilaudid in the ambulance ... ED course: [Patient] seen here yesterday for hip pain and shortness of breath. Found to have signs of congestive heart failure, started on Lasix but then had worsening shortness of breath last night, due to [their] hip pain not able to get up and ambulate to the bathroom making diuresis more difficult. I think [they need] to come in for diuresis. [Their] chest x-ray shows a pleural effusion on the right. Discussed with [hospitalist, they have] requested CT to further evaluate. Signed out to DO B ... patient was turned over at change of shift pending results of a CT scan for possible admission here. Results returned and patient has a moderate size right-sided loculated effusion I spoke to ... hospitalist on today [they are] concerned that the patient will need treatment by CT surgery and is not appropriate for here and so regrettably cannot take the patient ... called Legacy and got a return call from [physician]. And [sic] patient was accepted for transfer to a med telemetry bed and we are currently awaiting bed assignment. [Physician] did request that we give another dose of Lasix [they were] plus or minus on the antibiotics and would prefer that we let them do the thoracentesis versus small bore chest tube there so that the samples are there and they do not have to recollect. Also it does not look like when the patient first got here [they were] checked in as a sepsis but [they are] persistently tachycardic ... has got a white count of 17 and ... is tachypneic no [sic] granted some of that might be from work of breathing etc. however I do think we should collect cultures and lactic secondary to that and I did after that was done give [the patient] a dose of antibiotics. and [sic] discussed the transfer previously and again with the family they are on board ... Primary Impression: Loculated pleural effusion Secondary Impressions: Acute exacerbation of CHF (congestive heart failure), Diabetes, Elevated troponin level not due myocardial infarction, Lytle bone lesions on xray, Mass of soft tissue of chest, Obesity, Osteoarthritis of right hip.” * At 0104 on 07/25/2025 an RN recorded that the patient was transferred by Life Flight after “bedside report.” 7.c. A Patient Transfer Order form in Patient 16’s medical record was signed by DO B at 2351 on 07/24/2025 and contained more information related to the transfer: * “Destination hospital: “[Legacy Good Samaritan (LGSMC)].” * “Equipment Needed” reflected “ALS.” * “Mode of transfer” was recorded as “Helicopter.” * “Copies sent with patient (check all that apply)” reflected that a number of documents and diagnostic imaging reports were sent with the ambulance. 7.d. A Physician Initiated Transfer Certificate of Transfer form in Patient 16’s medical record was signed by DO B at 2351 on 07/24/2025 and contained “Risks versus Benefits” information: * Under “Benefits:” DO B wrote “Higher level care.” * Under “Risks:” DO B wrote “MVA deterioration in transport.” * Pre-printed language under “Risks” stated “All transfers have the inherent risks of traffic delays, accidents during transport, inclement weather, rough terrain or turbulence, and the limitations of equipment and personnel in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient.” 7.e The medical record for Patient 16 did not contain clear and complete information about the patient’s transfer. * On the Physician Initiated Transfer Certificate form the meaning of “Benefits: Higher level care” was not clear and specific to Patient 16. It did not describe what capability or capacity LGSMC had to benefit Patient 16 that was not available at SAH. * On the Physician Initiated Transfer Certificate form the meaning of “MVA deterioration in transport” was not clear and specific to Patient 16. There was no documentation on the transfer form or elsewhere in the medical record to reflect what “deterioration” meant for Patient 16, and what the individualized and specific risks of transfer were. In addition, the “MVA” risk was duplicative to the pre-printed language on the form about the inherent risks of transport and was not patient specific. * It was unclear whether all records available, specifically the Transfer Order and the Transfer Certificate, had been sent with the patient to GSMC. 7.f. Internet/GPS distance calculators reflected that LGSMC in Portland, Oregon is approximately is approximately 189 air miles and approximately 22 minutes flight time from rural SAH Hospital in Pendleton, Oregon. 8.a. Regarding Patient 17, the FBC Daily Floor Census sheet for 07/31/2025 was reviewed. It included an entry under the “Outpatient” section of the sheet that Patient 17’s “Time In” for an unspecified “[OB check]” was 1106, and their “Time Out” was “Transfer.” Under the “Patient Transfers” section of the sheet it reflected for Patient 17 that the “Receiving Facility” was “Emmanual [sic],” the transportation mode was blank, and the “Reason for Transfer” was “[Preeclampsia].” 8.b. The medical record for Patient 17’s 07/31/2025 ED encounter was reviewed, reflected that an MSE was conducted by MD G, and included the following information: * At 1316 MD G electronically signed an OB Provider Admission Physical and Note that reflected: “Chief Complaint: ... [Headache (HA)] ... 33 2/7 weeks ... [Diagnosis approximately two weeks] ago [with] pre-eclampsia, presented to [FBC] today [with complaint of onset] of severe HA last [night] 7/10, has taken 2.5 mg acetaminophen/6 hours no help ... [Assessment]: Pre-eclampsia [with] severe features by [symptoms] now with severe-range [blood pressure (BP)], needs transfer to acute-care facility due to prematurity, established [with Maternal Fetal Medicine (MFM)] at [LEMC] in Portland. Will begin [magnesium] sulfate for seizure prophylaxis. Will begin Betamethasone course. Will [transfer with] IV labetalol [as needed] severe-range BPs. Will contact MFM Portland for transfer ...” * At 1415 an RN wrote on the FBC Flowsheet that “Life flight arrived to unit, assumes care of pt.’ 8.c. A Patient Transfer Order form in Patient 17’s medical record was signed by MD G. The “Time” it was signed was unknown as the space was blank. The form contained more information related to the transfer: * “Destination hospital: “[LEMC].” * The section for “Equipment” reflected “ALS.” * “Mode of transfer” was recorded as “Helicopter.” 8.d. A Physician Initiated Transfer Certificate of Transfer form in Patient 17’s medical record was signed by MD G at 1247 and contained “Risks versus Benefits” information: * Under “Benefits:” was written “Higher level of care.” * Under “Risks:” was written “Worsen or Demise enroute.” * Pre-printed language under “Risks” stated “All transfers have the inherent risks of traffic delays, accidents during transport, inclement weather, rough terrain or turbulence, and the limitations of equipment and personnel in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient.” 8.e The medical record for Patient 17 did not contain clear and complete information about the patient’s transfer. * On the Physician Initiated Transfer Certificate form the meaning of “Benefits: Higher level of care” was not clear and specific to Patient 17. It did not describe what capability or capacity LGSMC had to benefit Patient 17 that was not available at SAH. * On the Physician Initiated Transfer Certificate form the meaning of “Worsen or Demise enroute” was not clear and specific to Patient 17. There was no documentation on the transfer form or elsewhere in the medical record to reflect what “worsen” meant for Patient 17 and their unborn infant, and if “Demise” applied to both the patient and the unborn infant. 8.f. Internet/GPS distance calculators reflected that LEMC in Portland, Oregon is approximately 189 air miles and approximately 22 minutes flight time from rural SAH Hospital in Pendleton, Oregon. 9.a. During interviews with the DPCQ, ED Manager, and Informatics Director (ID) on 08/13/2025 beginning at approximately 1000 they confirmed that benefits and risks identified on the physician certifications for ED Patients 5, 14, 15, and 16 above were not patient specific. 9.b. During interviews with the DPCQ, FBC Manager, and ID on 08/13/2025 beginning at approximately 1415 they confirmed that benefits and risks identified on the physician certifications for FBC Patients 7, 17, and 19 above were not patient specific. ************************************************”