Based on interview and record review, the facility (Facility A) failed to comply with CFR 489.24 by failing: 1. To ensure an appropriate medical screening examination (MSE) occurred, and was documented, for three of 17 sampled obstetrical patients (Patients 1, 4, and 14). This resulted in Patient 1 leaving the facility and being transferred to Facility B without a MSE, Patient 4 leaving the Labor & Delivery (L&D) Unit without a MSE, and Patient 14 being seen in L&D without documented evidence a MSE was done by a provider (Refer to A2406); 2. To ensure stabilizing treatment within the capabilities of the facility was provided prior to two of 17 sampled obstetrical patients (Patients 1 and 4) being directed to go to either Facility B or Facility C. This resulted in the facility not knowing if Patients 1 and 4 were in a stable condition in order to be discharged or transferred to other acute care facilities (Refer to A2407); and 3. To ensure the transfer of one of 17 sampled obstetrical patients (Patient 1) occurred in a safe manner when Patient 1 was not provided a medical screening examination, was not determined to be in a stable condition prior to being transferred to Facility B, and was transferred via private vehicle by a family member to Facility B (25.2 miles away from Facility A). This had the potential to result in harm or death to Patient 1 and her infant (Refer to A2409).

Based on interview and record review, the facility (Facility A) failed to ensure an appropriate medical screening examination (MSE) occurred, and was documented, for three of 17 sampled obstetrical patients (Patients 1, 4, and 14). This resulted in Patient 1 leaving the facility and being transferred to Facility B without a MSE, Patient 4 leaving the Labor & Delivery (L&D) Unit without a MSE, and Patient 14 being seen in L&D without documented evidence a MSE was done by a provider. Findings: During a tour of the L&D Unit on November 29, 2017, at 9:25 a.m., the unit had 15 beds (5 Labor, Delivery, Recovery, and Postpartum Rooms; 1 Labor Room; 9 Labor, Delivery, and Recovery Rooms); 4 triage/observation gurneys/beds; 2 recovery gurneys; and 3 Operating Rooms/Delivery Rooms. a. On November 29, 2017, the record for Patient 1 was reviewed. The "Labor and Delivery Assignment Log" dated November 8, 2017, indicated Patient 1 arrived at Facility A's L&D Unit, at 10:07 p.m., with the chief complaint of labor, at 40 weeks gestation (term pregnancy 39 to 40 weeks gestation). In addition, the Log indicated Patient 1 left Facility A, at 10:34 p.m., "sent to (Facility B)." The "Face Sheet" for Patient 1 indicated she was being seen to rule out labor. The "Admission" record dated November 8, 2017, indicated Patient 1 presented to L&D, at 10:08 p.m., with the chief complaint of labor, was being seen as an outpatient, was assigned to a triage bed, was discharged at 10:34 p.m., the discharge provider was Physician 2, and the patient's disposition was "HOME - Discharge to Home or Self Care (Routine Discharge)." There was no documented indication Patient 1 received a nursing maternal and fetal assessment. There was no documented indication Patient 1 was seen by a provider and a medical screening examination was performed. b. On November 29, 2017, the record for Patient 4 was reviewed. The "Labor and Delivery Assignment Log" dated November 8, 2017, indicated Patient 4 arrived at Facility A's L&D Unit at 9:36 p.m., with the chief complaint of labor, at 40 and 3/7 weeks gestation. In addition, the Log indicated Patient 4 was discharged home on November 8, 2017, at 10:31 p.m. The "Face Sheet" for Patient 4 indicated she was being seen to rule out labor. The "Admission" record dated November 8, 2017, indicated Patient 4 presented to L&D, at 9:36 p.m., with the chief complaint of labor, was being seen as an outpatient, was assigned to a triage bed, was discharged at 10:31 p.m., the discharge provider was Physician 2, and the patient's disposition was "HOME - Discharge to Home or Self Care (Routine Discharge)." There was no documented indication Patient 4 received a nursing maternal and fetal assessment. There was no documented indication Patient 4 was seen by a provider and a medical screening examination was performed. During an interview with Unit Secretary (US) 1, on November 30, 2017, at 1:09 p.m., she stated when a patient arrived at the L&D unit she would request the patient's insurance card and identification; and then would ask how many pregnancies she had, the patient's due date or number of weeks pregnant, and why she had come to the facility. US 1 stated she would place the patient's information in the "Labor and Delivery Assignment Log" and enter the information in the electronic medical record. US 1 stated she would then notify the L&D Charge Registered Nurse (RN) of the patient's arrival, and the L&D Charge RN would come to the desk and see the patient or would give instructions on what to do. US 1 stated on the evening of November 8, 2017, the unit was busy when Patients 1 and 4 arrived; and Patients 1 and 4 were requested to wait in the waiting room which was in the hallway outside the L&D unit. US 1 stated she paged the L&D Charge RN (CRN 1) who instructed her to call the House Supervisor (ACM 2). US 1 stated when ACM 2 arrived at the L&D Unit, US 1 was instructed to go to the waiting room and have both Patients 1 and 4, with their significant others, brought into the L&D Unit. US 1 stated CRN 1 and ACM 2 spoke with Patients 1 and 4 together with their significant others, and stated the L&D Unit was full, they were not sure when beds would be available, and both Facility B and C had available Labor & Delivery beds. US 1 stated both Patients 1 and 4 then left the L&D Unit. US 1 stated Patient 1 was going to Facility B, and Patient 4 was undecided as to where she was going or what she would do. US 1 stated she discharged Patients 1 and 4 from the electronic medical record system, and documented their discharge on the "Labor and Delivery Assignment Log." In addition, US 1 stated Patient 4 returned to the L&D Unit, on November 8, 2017, at 11:01 p.m., stating she wanted to be seen at Facility A. US 1 stated she had no EMTALA training and did not know what EMTALA meant. During an interview with the House Supervisor (ACM 2), on November 29, 2017, at 2:25 p.m., the ACM 2 stated the Assistant Clinical Managers (ACM) act as and rotate working in the role of the House Supervisor, and she was the House Supervisor on the evening of November 8, 2017. The ACM 2 stated before the evening of November 8, 2017, she had heard the words "EMTALA" but did not know what they meant, and had not had any "EMTALA" training at the facility. The ACM 2 further stated on November 8, 2017, at 10:15 p.m., she was called by the L&D Charge RN (CRN 1) who stated to her the L&D Unit had no physical beds available, and there were two patients in the waiting room waiting for evaluation for labor (Patients 1 and 4). The ACM 2 stated when she arrived on the L&D Unit, the CRN 1 stated L & D had no beds, there were two patients in the waiting room who had not been assessed, and CRN 1 did not know what to do. When asked if there was other space available which could be used to assess a laboring patient, the ACM 2 stated there were two gurneys in the recovery room, three OR/Delivery Rooms, and she was uncertain if there were any postpartum rooms available at that time. The ACM 2 stated she asked US 1 to call Facility B to see if they had any beds available. The ACM 2 stated she spoke with both Patients 1 and 4, and their significant others, and told them they were uncertain as to how long before a L&D bed would become available, it was "necessary to send (the patients) to Facility B," and she apologized for the inconvenience. The ACM 2 stated both Patients 1 and 4 left the L&D Unit but Patient 4 did return later. In addition, the ACM 2 stated she called Facility B on November 9, 2017, at 12:15 p.m., to check on Patient 1, and when she spoke with Physician 1, that was when she had an "ah ha moment." The ACM 2 stated the patients should never have left the facility without a medical screening examination, and if a patient was transferred to another facility, the facility policy and procedure on transfers should be followed to ensure a safe transfer. During an interview with the Manager Labor & Delivery (MLD), on November 30, 2017, at 10:05 a.m., she reviewed the records for Patients 1 and 4, and was unable to find documentation of a MSE, nursing assessments and reassessments, and maternal/fetal monitor strips for Patient 1 on November 8, 2017, between 10:07 p.m. to 10:34 p.m., and for Patient 4 between 9:36 p.m. to 10:31 p.m. The MLD stated the L&D RNs do not do the medical screening examinations for obstetrical patients. The MLD stated the MSE was done by a Certified Nurse Midwife or a Physician. The MLD stated Patients 1 and 4 should have been provided a MSE before they were discharged /transferred from Facility A. The facility policy and procedure titled "Compliance With Emergency Medical Treatments" last reviewed by the facility December 2015, revealed "... Medical screening must be offered to any individual presenting for examination or treatment of an emergency medical condition, as stated by the patient. ... Medical screening is a process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist. ... The medical screening is a continuous process reflecting ongoing monitoring in accordance with an individual's needs. Monitoring will continue until the individual is stabilized or appropriately transferred. Reevaluation of the patient must occur prior to discharge or transfer. ..." The facility policy and procedure titled "EMTALA: Medical Screening of Patients" last reviewed by the facility October 2017, revealed "... All patients shall be logged, medically screened, and transferred in accordance with the provisions of this policy and procedure, which complies with the federal Emergency Medical Treatment and Active Labor Act (EMTALA). ..." The facility policy and procedure titled "Medical Screening, Examination, Treatment, and Preparation for Transport" last reviewed by the facility September 2016, revealed "All pregnant women presenting to the Labor and Delivery Department requesting examination or treatment will have a medical screening examination by a provider, regardless of ability to pay. ... Under EMTALA law, a pregnant woman experiencing contractions is in labor unless a provider certifies and documents that after a clinically appropriate time of observation, the woman is not in labor. Unless a pregnant woman experiencing contractions is certified by the provider not to be in labor, it will be considered a TRANSFER (not a discharge) under current EMTALA law, if she is sent home or to another facility. Therefore: A woman in labor is not to be transferred (or discharged ) unless the transfer is an appropriate transfer under section 489.24(d)(1) of the federal EMTALA law. ... Any pregnant woman seen in L&D and experiencing contractions must have a medical screening examination by a provider. The documentation on all pregnant women who leave (Facility A) L&D undelivered must include a statement as to whether they were "stable" or "not stable" after a clinically appropriate time of observation. ..." c. On November 29, 2017, beginning at 10:30 a.m., the Labor and Delivery ( L & D) Assignment Log for the month of July 2017 was reviewed. The Log indicated Patient 14 presented to the L&D unit on July 23, 2017, at 11:30 p.m., was 26 1/7 weeks pregnant with complaints of "decreased fetal movement and chest pain," and was discharged home July 24, 2017, at 12:09 a.m. A review of Patient 14's record indicated Patient 14 presented to the Emergency Department (ED) on July 23, 2017, at 10:02 p.m., with complaints of shortness of breath, right sided chest pain, and decreased fetal movement. The record indicated Patient 14, "...has not felt the usual fetal movements which she had been feeling..." There was no indication in the record that ED staff examined Patient's 14's abdomen or checked her unborn fetus' heart rate. The record indicated, "...Discussed with...OB/GYN, will discharge to Labor & Delivery for fetal monitoring." The record indicated Patient 14 was discharged from the ED on July 23, 2017, at 11: 25 p.m., and instructed to walk to the L&D unit for further evaluation. The record indicated Patient 14 arrived at the L&D unit on July 23, 2017, at 11:30 p.m. The record indicated Registered Nurse (RN) 1 assessed Patient 14 at 11:40 p.m., and placed an external fetal monitor (EFM-device applied to the abdomen to continuously measure and graph fetal heart rate and uterine tone/contractions and used to determine fetal well-being and presence of labor) on Patient 14. The record further indicated Patient 14 was discharged by RN 1 from the L&D unit 39 minutes later. There was no documented evidence a medical screening exam by a provider was performed for Patient 14 in the L&D unit between July 23, 2017, at 11:30 p.m., and July 24, 2017, at 12:09 a.m. On November 29, 2017, at 2:09 p.m., Patient 14's record was further reviewed with the Clinical Informatics Specialist (CIS) and the Assistant Clinical Manager (ACM) 1. The CIS and ACM 1 were unable to find in the record and confirmed there was no documented evidence of a medical screening exam in L&D by a provider for Patient 14. On November 29, 2017, at 3 p.m., ACM 1 was further interviewed. ACM 1 stated patients, at 26 weeks pregnant, who presented to the L&D unit would check in at the desk and then assessed by an RN . The ACM stated the RN would place the EFM on the patient to check the fetus' heart rate and for possible uterine contractions. ACM 1 stated the RN would notify the provider on-call the patient was present in the L&D unit. ACM 1 stated the provider on-call that day would do the medical screening exam on the patient, and give direction to the RN on what the patient needed, or if the patient could be discharged home. ACM 1 stated the facility expected providers to document a plan of care for each patient that included the patient's chief complaint, medical screening examination by the provider, and treatment plan. On November 30, 2017, at 11:54 a.m., Patient 14's record was reviewed with the Manager Labor and Delivery (MLD). The record indicated Patient 14 was placed on the EFM on July 23, 2017, at 11:36 p.m., and the EFM discontinued at 11:46 p.m. (a total time of 10 minutes). The record indicated the "toco" (part of the EFM device placed on the abdomen to check for uterine contractions) was not adjusted properly and did not record a complete graph during the 10 minute time it was on. During a concurrent interview, the MLD stated the facility policy was to apply the EFM for "no less than 20 minutes." The MLD confirmed Patient 14's EFM strip was not adequate to evaluate Patient 14 for fetal well-being and uterine contractions. The facility policy and procedure, titled, "EMTALA:Medical Screening of Patients," last revised October 2013, was reviewed. The policy indicated, "...All patients accepted for care in Labor and Delivery shall receive a prompt medical screening examination by an appropriately privileged physician, a member of an approved post-graduate medical education program, or a Certified Nurse Midwife..." The policy and procedure, titled, "...Fetal Monitoring," last revised October 2016, was reviewed. The policy indicated, "...Purpose:...To determine fetal well-being and uterine activity...All intrapartum patients will be monitored for a minimum of 20 minutes on admission...Apply toco transducer...set baseline at 20 mmHg (mmHg-unit of measure)...Reposition transducers as needed in order to maintain a clear recording..."

Based on interview and record review, the facility (Facility A) failed to ensure stabilizing treatment within the capabilities of the facility was provided for two of 17 sampled obstetrical patients (Patients 1 and 4) prior to being directed to go to either Facility B or Facility C. This resulted in the facility not knowing if Patients 1 and 4 were in a stable condition in order to be discharged or transferred to other acute care facilities. Findings: a. On November 29, 2017, the record for Patient 1 was reviewed. The "Labor and Delivery Assignment Log" dated November 8, 2017, indicated Patient 1 arrived at Facility A's L&D Unit, at 10:07 p.m., with the chief complaint of labor, at 40 weeks gestation (term pregnancy 39 to 40 weeks gestation). In addition, the Log indicated Patient 1 left Facility A, at 10:34 p.m., "sent to (Facility B)." The "Face Sheet" for Patient 1 indicated she was being seen to rule out labor. The "Admission" record dated November 8, 2017, indicated Patient 1 presented to L&D, at 10:08 p.m., with the chief complaint of labor, was being seen as an outpatient, was assigned to a triage bed, was discharged at 10:34 p.m., the discharge provider was Physician 2, and the patient's disposition was "HOME - Discharge to Home or Self Care (Routine Discharge)." There was no documented indication Patient 1 received a nursing maternal and fetal assessment. There was no documented indication Patient 1 was seen by a provider and a medical screening examination was performed. There was no documented indication Patient 1's condition upon leaving Facility A, and Patient 1 was stable for transfer to Facility B. b. On November 29, 2017, the record for Patient 4 was reviewed. The "Labor and Delivery Assignment Log" dated November 8, 2017, indicated Patient 4 arrived at Facility A's L&D Unit at 9:36 p.m., with the chief complaint of labor, at 40 and 3/7 weeks gestation. In addition, the Log indicated Patient 4 was discharged home on November 8, 2017, at 10:31 p.m. The "Face Sheet" for Patient 4 indicated she was being seen to rule out labor. The "Admission" record dated November 8, 2017, indicated Patient 4 presented to L&D, at 9:36 p.m., with the chief complaint of labor, was being seen as an outpatient, was assigned to a triage bed, was discharged at 10:31 p.m., the discharge provider was Physician 2, and the patient's disposition was "HOME - Discharge to Home or Self Care (Routine Discharge)." There was no documented indication Patient 4 received a nursing maternal and fetal assessment. There was no documented indication Patient 4 was seen by a provider and a medical screening examination was performed. There was no documented indication Patient 4 was stable for discharge or transfer to another acute care facility. During an interview with the Manager Labor & Delivery (MLD), on November 30, 2017, at 10:05 a.m., she reviewed the records for Patients 1 and 4, and was unable to find documentation of a MSE, nursing assessments and reassessments, and maternal/fetal monitor strips for November 8, 2017, between 10:07 p.m. to 10:34 p.m. for Patient 1, and between 9:36 p.m. to 10:31 p.m. for Patient 4. The MLD stated Patients 1 and 4 should have been evaluated and stabilized prior to discharge or transfer. The facility policy and procedure titled "Compliance With Emergency Medical Treatments" last reviewed by the facility December 2015, revealed "... The medical screening is a continuous process reflecting ongoing monitoring in accordance with an individual's needs. Monitoring will continue until the individual is stabilized or appropriately transferred. Reevaluation of the patient must occur prior to discharge or transfer. ..." The facility policy and procedure titled "Medical Center Transfer Policy (With Exclusion of Transfers for Procedures)" last revised by the facility December 2015, revealed "... The Medical Center must use its available resources to provide ongoing evaluation and stabilizing treatment as required by law and may not transfer the patient for care that is within the scope of its services, privileges of the medical staff and facility. ... A patient is considered "stable" for transfer if the transferring physician has determined within reasonable clinical confidence that the patient may be transferred without material deterioration in his/her condition ... (Facility A) shall provide medical treatment within it's capacity 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 patient record shall reflect the vital signs and condition of the patient at the time of the transfer. ..." The facility policy and procedure titled "Medical Screening, Examination, Treatment, and Preparation for Transport" last reviewed by the facility September 2016, revealed "... The documentation on all pregnant women who leave (Facility A) L&D undelivered must include a statement as to whether they were "stable" or "not stable" after a clinically appropriate time of observation. ... Nursing Responsibilities in Preparation for Transport: ... Maternal and Fetal assessments must be done prior to transfer and documented appropriately. ..."

Based on interview and record review, the facility (Facility A) failed to ensure the transfer of one of 17 sampled obstetrical patients (Patient 1) occurred in a safe manner when Patient 1 was not provided a medical screening examination, was not determined to be in a stable condition prior to being transferred to Facility B, and was transferred via private vehicle by a family member to Facility B (25.2 miles away from Facility A). This had the potential to result in harm or death to Patient 1 and her infant. Findings: On November 29, 2017, the record for Patient 1 was reviewed. The "Labor and Delivery Assignment Log" dated November 8, 2017, indicated Patient 1 arrived at Facility A's L&D Unit, at 10:07 p.m., with the chief complaint of labor, at 40 weeks gestation (term pregnancy 39 to 40 weeks gestation). In addition, the Log indicated Patient 1 left Facility A, at 10:34 p.m., "sent to (Facility B)." The "Face Sheet" for Patient 1 indicated she was being seen to rule out labor. The "Admission" record dated November 8, 2017, indicated Patient 1 presented to L&D, at 10:08 p.m., with the chief complaint of labor, was being seen as an outpatient, was assigned to a triage bed, was discharged at 10:34 p.m., the discharge provider was Physician 2, and the patient's disposition was "HOME - Discharge to Home or Self Care (Routine Discharge)." There was no documented indication Patient 1 had consented to the transfer. There was no documented indication the Physician had signed a certification that the medical benefits to the transfer out weighted the risks of being transferred. There was no documented indication Facility B had accepted Patient 1 as a transfer. There was no documented indication a provider at Facility B had accepted Patient 1. There was no documented indication the transfer was effected through qualified personnel and transportation equipment. There was no documented indication Patient 1 was transferred to Facility B in a safe manner. Patient 1 presented to Facility B, on November 8, 2017, at 11:04 p.m., with the chief complaint of uterine contractions at 40 weeks gestation. The documentation flow sheet dated November 8, 2017, at 11:14 p.m., indicated Patient 1 was dilated to 6.5 (the cervix opens, on a scale of 0 to 10 with 10 being completely dilated) centimeters (cm); 100% effaced (the stretching and thinning of the cervix, on a scale of 0 to 100%); and 0 station (used to describe the position of the baby's head in the pelvis area. 0 station is when the baby has dropped into the pelvis and the head is resting right at the level of the ischial spines. The ischial spines refers to the parts of the mother's pelvic girdle that protrudes inward toward the birth canal). The documentation flow sheet dated November 8, 2017, at 11:30 p.m., indicated Patient 1 was having uterine contractions every two to three minutes, and each contraction was lasting 60 to 100 seconds. At 11:59 p.m., Patient 1 was dilated to 8 cm. Patient 1 delivered vaginally a baby girl on November 9, 2017, at 12:37 a.m. (1 hour and 33 minutes after arrival to Facility B). During an interview with the House Supervisor (ACM 2), on November 29, 2017, at 2:25 p.m., the ACM 2 stated she was the House Supervisor on the evening of November 8, 2017. The ACM 2 stated before the evening of November 8, 2017, she had heard the words "EMTALA" but did not know what they meant, and had not had any "EMTALA" training at the facility. The ACM 2 further stated on November 8, 2017, at 10:15 p.m., she was called by the L&D Charge RN (CRN 1) who stated to her the L&D Unit had no physical beds available, and there were two patients (including Patient 1) in the waiting room waiting for evaluation for labor. The ACM 2 stated when she arrived on the L&D Unit, the CRN 1 stated L & D had no beds, there were two patients in the waiting room who had not been assessed, and CRN 1 did not know what to do. When asked if there was other space available which could be used to assess a laboring patient, the ACM 2 stated there were two gurneys in the recovery room, three OR/Delivery Rooms, and she was uncertain if there were any postpartum rooms available at that time. The ACM 2 stated she asked US 1 to call Facility B to see if they had any beds available. The ACM 2 stated she spoke with both patients (including Patient 1), and their significant others, and told them they were uncertain as to how long before a L&D bed would become available, it was "necessary to send (the patients) to Facility B," and she apologized for the inconvenience. The ACM 2 stated both patients left the L&D Unit. In addition, the ACM 2 stated she called Facility B on November 9, 2017, at 12:15 p.m., to check on Patient 1, and when she spoke with Physician 1, that was when she had an "ah ha moment." The ACM 2 stated the patient should never have left the facility without a medical screening examination, and if a patient was transferred to another facility, the facility policy and procedure on transfers should be followed to ensure a safe transfer. During an interview with the Manager Labor & Delivery (MLD), on November 30, 2017, at 10:05 a.m., she reviewed the record for Patient 1, and was unable to find documentation of a medical screening examination; stabilizing treatment; and an appropriate transfer to Facility B which included consent, physician certification, acceptance by the receiving facility, acceptance by the receiving physician, and the transfer was effected through qualified personnel and transportation equipment. The MLD stated Patient 1 should have been seen by a provider, and if deemed stable for transfer, should have been consented to the transfer, physician certification should have been provided, the acceptance of the receiving facility and receiving physician should have been documented, and Patient 1 should have been transferred to Facility B through qualified personnel and transportation equipment. The facility policy and procedure titled "EMTALA: Medical Screening of Patients" last reviewed by the facility October 2017, revealed "... All patients shall be logged, medically screened, and transferred in accordance with the provisions of this policy and procedure, which complies with the federal Emergency Medical Treatment and Active Labor Act (EMTALA). ..." The facility policy and procedure titled "Compliance With Emergency Medical Treatments" last reviewed by the facility December 2015, revealed "... The medical screening is a continuous process reflecting ongoing monitoring in accordance with an individual's needs. Monitoring will continue until the individual is stabilized or appropriately transferred. Reevaluation of the patient must occur prior to discharge or transfer. ..." The facility policy and procedure titled "Medical Center Transfer Policy (With Exclusion of Transfers for Procedures)" last revised by the facility December 2015, revealed "... The Medical Center must use its available resources to provide ongoing evaluation and stabilizing treatment as required by law and may not transfer the patient for care that is within the scope of its services, privileges of the medical staff and facility. ... A patient is considered "stable" for transfer if the transferring physician has determined within reasonable clinical confidence that the patient may be transferred without material deterioration in his/her condition ... (Facility A) shall provide medical treatment within it's capacity 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 patient record shall reflect the vital signs and condition of the patient at the time of the transfer. The patient shall be accepted for care by a physician with privileges at the receiving hospital. ... The transfer shall be effected using proper personnel and equipment, as well as necessary and medically appropriate life support measures. ... The hospital staff will complete the Interhospital Transfer Summary. The physician will sign the form acknowledging the assessment and confirming the patient's condition remains compatible with transfer. The patient/representative will sign the form acknowledging they have received medical screening, examination, and evaluation by a physician, or other appropriate personnel and that they have been informed of the reasons and agree to the transfer. ..." The facility policy and procedure titled "Medical Screening, Examination, Treatment, and Preparation for Transport" last reviewed by the facility September 2016, revealed "... Unless a pregnant woman experiencing contractions is certified by the provider not to be in labor, it will be considered a TRANSFER (not a discharge) under current EMTALA law, if she is sent home or to another facility. Therefore: A woman in labor is not to be transferred (or discharged ) unless the transfer is an appropriate transfer under section 489.24(d)(1) of the federal EMTALA law. ... The standard procedure for effecting a transfer is: The physician and the nursing supervisor are to identify a receiving hospital and contact the receiving hospital to assure that the hospital has available space qualified personnel and will accept the patient. The physician contacts a physician at the receiving hospital who agrees to accept the transfer and treat the patient. The physician and nurse ensure that all EMTALA transfer paperwork is completed ... The L&D Nurse, Charge Nurse or Nursing Supervisor arranges for appropriate ambulance transport for the patient. Any pregnant woman seen in L&D and experiencing contractions must have a medical screening examination by a provider. The documentation on all pregnant women who leave (Facility A) L&D undelivered must include a statement as to whether they were "stable" or "not stable" after a clinically appropriate time of observation. ... Nursing Responsibilities in Preparation for Transport: ... Maternal and Fetal assessments must be done prior to transfer and documented appropriately. ..."