HospitalInspections.org

Based on observation, interviews, review of documentation in clinic notes and the ED record of 1 of 1 patient who presented to the hospital's on campus outpatient clinic with chest pain (Patient 8), review of documentation in the ED record of 1 of 1 pregnant patient who presented to the ED with possible leg clots (Patient 11), review of documentation in 2 of 2 medical records of patients who were transferred from SAMCBC to other hospitals for services not available at SAMCBC (Patients 10 and 14), and review of hospital policies and procedures and other documentation, it was determined that the hospital failed to develop and enforce its EMTALA policies and procedures to ensure compliance in the following areas:
* Medical Screening Examinations;
* Appropriate transfers of patients; and
* Whistleblower protection.

Findings included:

1. Regarding MSEs refer to the findings identified under Tag C2406, CFR 489.24(a) and (c).

2. Regarding appropriate transfers refer to the findings identified under Tag C2409, CFR 489.24(e)(1-2).

3.a. Regarding whistleblower protection: The policy and procedure titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance -- SAHS dated as approved 05/18/2018, was reviewed and contained no language related to the required EMTALA whistleblower protection.

b. The policy and procedure titled "Non-Retaliation," dated as approved 10/16/2018 was provided and reviewed. It reflected "No one at any level of the organization is permitted to engage in retaliation against a colleague for...Reporting in good faith a concern related to safety or quality of patient care, workplace safety, the Organizational Integrity Program, or a potential violation of applicable laws, regulations, or rules." The policy included only general anti-retaliation language and indicated it applied to "potential violations of applicable laws, regulations, or rules." It did not distinguish what laws, regulations or rules it was applicable to, and did not include any reference to EMTALA or the specific EMTALA whistleblower requirements required by this CFR.

c. The "Trinity Health Code of Conduct" was provided and reviewed. Page 8 reflected that EMTALA required hospitals with a DED to provide a MSE to any individual who comes to the ED before asking questions about their ability to pay for services. Page 27 reflected general anti-retaliation language applicable "to those who report issues and concerns in good faith, including potential violations of our Code of Conduct." It did not include any information about EMTALA whistleblower protection as required by this CFR.

d. During an interview with the RDES on 12/11/2018 at 1640, he/she confirmed the hospital had no whistleblower policy and procedure specific to EMTALA.

Based on observation, interviews, review of documentation in clinic notes and the ED record of 1 of 1 patient who presented to the hospital's on campus outpatient clinic with chest pain (Patient 8), review of documentation in the ED record of 1 of 1 pregnant patient who presented to the ED with possible leg clots (Patient 11), and review of policies and procedures and other documentation, it was determined the hospital failed to develop and enforce its EMTALA policies and procedures to ensure patients who presented for emergency services were provided a MSE examination to determine if an EMC existed as follows:
* Patient 8 was not provided assistance, monitoring and/or transported to the ED to ensure a MSE would be conducted to determine whether or not an EMC existed.
* Patient 11 was not provided a MSE within the capabilities of the hospital which included laboratory and/or other diagnostic tests routinely available in the hospital, to determine whether or not an EMC existed.

Findings include:

1. The following policies and procedures were reviewed:

a. The policy and procedure titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance -- SAHS dated as approved 05/18/2018, was reviewed. It stipulated:
* "Any individual who comes to Saint Alphonsus (the 'Hospital') seeking an examination and treatment of a potential emergency medical condition will receive a screening examination to determine the existence of any emergency medical condition..."
* "...Hospital Property: The term, 'Hospital Property' includes the following...Main Campus...The Hospital's main campus, including parking lots, sidewalks, and driveways that are contiguous to the Hospital's main buildings, and other areas or structures located within two hundred fifty (250) yards of the Hospital's main buildings that provide patient services for Hospital patients."
* "...Medical Screening Exam ('MSE'); An examination conducted by a physician or Qualified Medical Personnel, within the 'capability of the Hospital', to determine whether an individual has an EMC."
* "...Capability of the Hospital: Those services which the Hospital is required to have as a condition of its license, as well as Hospital ancillary services routinely available to the Dedicated Emergency Department."
* "...Patient Refusal To Accept MSE, Treatment...If an individual refuses a MSE or treatment...explain the risks and benefits of the proposed services and make reasonable efforts to have the individual sign the Informed Consent To Refuse Offered Services form. If the individual refuses to sign the form, document the risks and benefits explained to the individual, the efforts taken to have the individual sign the form, and the individual's refusal to do so..."

b. The policy and procedure titled "SAMC Clinic Emergency Medical Condition (EMC) Triage," dated as approved 10/27/2016 was reviewed. It stipulated:
* "...Saint Alphonsus is committed to providing patients with delivery of care that improves outcomes and facilitates the appropriate level of care for health problems in a timely and responsive manner. In the event of an Emergency Medical Condition (EMC) that occurs at a Saint Alphonsus Medical Group (SAMG) clinic site, the following process shall be followed."
* "...Emergency Medical Conditions may include, but are not limited to, the following...Chest pain...shortness of breath, asthma, COPD symptoms...Pregnant Woman..."
* "...Procedure...Appraisal of Emergencies...When a patient presents at a SAMG clinic with an EMC, or if an EMC develops during the visit, the triage nurse, provider, or other healthcare professional trained in basic life support (BLS) will be notified immediately to tend to the individual as appropriate to the outpatient setting."
* "...Initial Treatment and Referral...If a patient is determined to potentially have an EMC, clinic staff will take the following steps...Stabilization procedures will be started, including BLS by trained personnel if necessary...A provider will be notified immediately to attend to and assess the patient's condition...If a provider is not immediately available, emergency medical personnel (9-1-1) will be notified...If a provider is available and determines that the patient has an EMC, 9-1-1 will be called for emergent transport to the hospital...If a provider determines that the patient does not have an EMC, the patient will be stabilized and, if necessary, admitted to the hospital directly or treated and released as determined by the evaluating provider..."

c. The policy and procedure titled "Patient and Visitor Emergencies on Hospital Grounds," dated as approved 05/14/2018 was reviewed. It stipulated:
* "...Associates and volunteers shall follow the guidelines below when encountering a visitor, volunteer, or employee who becomes ill, faints, or is injured at Saint Alphonsus Medical Center-Baker City (SAMC-BC). The Hospital is committed to compliance with the provisions of the Emergency Medical Treatment and Active Labor Act ('EMTALA')."
* "...Procedure...In Case of an Emergent Situation inside the Hospital building...Code Blue Team or Rapid Response Team (RRT) will respond to emergencies...Refer to the Code Blue Response or Rapid Response Team (RRT) policies for details on response..."

d. The policy and procedure titled "Rapid Response Team (RRT)," dated as approved 05/15/2018, was referenced from the "Patient and Visitor Emergencies on Hospital Grounds" policy and stipulated:
* "...Policy Statement: Saint Alphonsus Medical Center-Baker City recognizes and responds to changes in a patients' condition by calling the rapid response team (RRT)."
* "...This policy applies to patients and visitors within the building, including patient care and non-patient care areas..."
* "...The team will respond immediately when a rapid response is called and care will be provided according to ACLS standards."
* "...In order to activate the team, the patient's assigned nurse, patient, or family member will call the Clinical Coordinator directly 4-7774. The Clinical Coordinator will then call the team members..."
* "...The nurse caring for the patient shall supply the following information to the RRT...Admission diagnoses...Current vital signs...Appropriate labs...Current problems...The RRT will assist in gathering information, including assessing the patient condition and organizing information with the RN in charge to be communicated to the physician...The attending physician should be notified of the patient condition, assessment and concerns...The RRT should be documented in power chart..."

e. The policy and procedure titled "Code Blue Response," dated as approved 05/22/2018, was referenced from the "Patient and Visitor Emergencies on Hospital Grounds" policy and stipulated:
* "...The Code Blue Team will respond to patients who are unresponsive to provide resuscitation according to the American Heart Association standards (ACLS, PALS, NRP, BLS)."

2. During an interview with the QRM on 12/10/2018 at 1700 he/she stated that the hospital had conducted an internal investigation of an allegation they had received that a patient who presented to the on-campus outpatient clinic desk area with complaints of chest pain had been directed to leave the clinic and find his/her own way to the ED. The allegation included that the patient was not offered assistance by hospital clinic staff, no ambulance was called, the patient left the clinic, got into his/her own car and drove around to the ED on the other side of the hospital.

Documentation of the investigation included the following: "Patient came in and was told to go to ED by [MA] for chest pressure and pain. Patient declined to go to ED so [MA] came and got...[RN1] to talk to patient and [he/she] let [him/her] know [he/she] would check with the providers. [RN1] came back to patient and let [him/her] know that [PA] had advised [patient] go to the ED because of [his/her] hx of a-flutter. Patient said that [he/she] did not want to go to the ED and [RN1] let [him/her] know that there was not really any option that we did not have the capacity to treat A-flutter in the clinic. Patient then stated that [he/she] needed to call [his/her significant other] and let [him/her] know, and then [he/she] would go there. [RN1] left patient in the waiting room to make [his/her] call, patient then left...Standard process in clinic is that all patients referred or ask (sic) to go to ED are escorted by colleagues to ED."

3. During tour of the clinic with the RDES and EDS on 12/11/2018 at 1450, the following observations were made:
* The clinic was located inside the main hospital building.
* The clinic registration area, clinic waiting area, and the corridor leading to the clinic had no signs or other directions indicating how to locate the ED from the clinic.
* The outside entrance to the clinic had 6 stairs leading up to it from the sidewalk and was located on the other side of the hospital from the entrance to the ED.

4. Observation and measurement of the route from the outside entrance of the clinic to the outside entrance of the ED by car were made on 12/11/2018 and the distance was determined to be approximately 0.3 miles.

5. A clinic note dated 09/11/2018 at "3:04 PM" by RN1 reflecting Patient 8's clinic encounter was reviewed. It reflected:
* "Comments...Patient with hx A-flutter, in clinic today c/o 'uneasy feeling in chest, and chest discomfort x several days. [He/she] is not wanting to go to the ER. Spoke with [PA] who advises patient needs to utilize the ER as we do not have the capability to treat A-flutter in clinic."

There was no documentation of:
* An evaluation of the patient by the PA or any other LIP.
* An assessment of the patient by RN1 or any other nurse.
* Follow up communication with the patient after RN1 spoke to the PA who advised that the patient go to the ED.
* Whether the patient was offered or provided assistance to the ED.
* Whether the patient was informed of the risks of not going to the ED.
* The time the patient left the clinic and his/her condition at that time.
* Communication with the ED of the patient's potential arrival there.

6. During interview on 12/11/2018 at 0940 RN1 provided the following information that revealed that Patient 8's clinic record did not contain complete and accurate documentation about the clinic encounter:
* RN1 confirmed he/she wrote the clinic encounter notes in finding 5.
* RN1 stated that Patient 8 came into the clinic around noon on 09/11/2018. The patient did not come in with anyone. The patient did not have an appointment and did not receive clinic services on 09/11/2018.
* The patient initially spoke with a MA who told RN1 the patient was in the clinic waiting area with chest pain and refused to go to the ER.
* RN1 went to the waiting area to talk to the patient. The patient told RN1 that he/she had a history of atrial flutter and he/she had been having chest pain and chest pressure for 2 days.
* RN1 went back into the clinic and spoke with the PA who told RN1 the patient couldn't be treated in the clinic for his/her cardiac condition. The PA told RN1 the patient needed to be evaluated in the ED.
* RN1 went back to the clinic waiting area and told the patient he/she had spoken to the PA, and the PA could not see him/her. RN1 told the patient to go to the ED.
* RN1 stated the patient "was frustrated because I told [him/her he/she] needed to go the ER."
* RN1 stated the patient was sitting in a chair in the clinic waiting area the entire time RN1 interacted with him/her. RN1 stated he/she did not assess the patient, including vital signs or his/her ability to stand, walk or otherwise get to the ED. RN1 stated "I just watched [him/her] and looked at [his/her] respirations." RN1 stated he/she did "no other assessment besides visual" and the patient "didn't look like he/she was in distress."
* RN1 stated "At some point [the patient] conceded to go to the ER."
* RN1 stated "[He/she] agreed to go to the ER" but refused assistance getting there.
* RN1 stated "I said something to the effect of 'can I help you down there?'" RN1 stated "[He/she] said 'No, I need to call my [significant other].'" RN1 stated "I said okay and then left." RN1 stated he/she did not see the patient after that.
* RN1 confirmed his/her clinic note that reflected the patient "was not wanting to go to ER" was inconsistent with his/her statement that the patient "agreed to go to the ER."
* RN1 confirmed there was nothing in the clinic note that reflected that he/she offered the patient assistance to the ED.
* RN1 stated the process for managing a patient who comes to the clinic with chest pain is "If the patient has chest pain and shortness of breath, call the rapid response. If the patient has chest pain and no shortness of breath, and no acute distress, then the process is to escort the patient to the ED."
* RN1 confirmed he/she did not escort the patient to the ED. RN1 also stated he/she did not provide the patient directions to locate the ED.
* RN1 stated his/her assumption was that the patient's significant other "picked [him/her] up and took [him/her]" to the ED.

7. Review of the ED medical record for Patient 8 reflected the patient presented to the ED on 09/11/2018 at 1211 in a "Private Vehicle" with complaints of "Chest Discomfort," was provided a MSE by the ED provider, and was discharged home on 09/11/2018 at 1329.

Although the record reflected the patient received a MSE, there was no documentation that reflected Patient 8 had initially presented to the hospital clinic or that he/she was provided assistance, monitoring or transport to the ED to ensure a MSE would be conducted.

8. An email with the subject line "ED Documentation" was provided by the QRM on 12/10/2018 at 1700. Review of the email reflected it was dated 11/20/2018 at 1612 and was sent from the CM to numerous individuals. It reflected:
* "When a patient is in the clinic and we are referring them to go to the ED please see the process that we should be following when their response is Yes/No."
* "YES - When a patient is told they need to go to the ED and they say yes, we are to escort them there and have a warm handoff to the ED desk. This will need to be documented in the patients chart that he/she was advised to go to the ED, agreed and how they got there. If they agree but do not want your help getting there, explain to them that we want to make sure they make it there and don't have any issues on the way and strongly encourage them to allow your help. When they absolutely refuse your help then please make sure that you document this with the number of times you tried to help and their refusal."
* "NO - When a patient is told they need to go to the ED and they refuse, this must be documented that they refused and the patient must be informed of the risks that could come from declining to be seen. Strongly advise them they should get checked out and if your are concerned about having that conversation, please grab [RN] or myself and we can talk with the patient. Documentation is very important so be sure that you are entering that into the patients charts when they refuse to go to the ED and the patient leaves the clinic without being seen..."

There was no further information in the email that reflected what the process was for "referring" an individual from the clinic to the ED. For example, there was no information that reflected who would "escort" the individual to the ED, including qualifications of the individual; and how the individual would be "escorted," including if a wheelchair would be used, or if the individual would be expected to walk to the ED.

9. During an interview on 12/11/2018 at 0830 the RCSO stated the process for managing patients who presented to the clinic or elsewhere on hospital property with chest pain and requesting exam or treatment was "a nurse or a doctor or someone with BLS, somebody clinical" would take the patient to the ED for a MSE. The RCSO stated "usually they take a wheelchair." The RCSO stated "We don't want the patient to collapse on the way." However, review of the policies and procedures provided reflected they did not include this process. The RCSO stated the hospital had no policy and procedure that addressed this process. This was confirmed during an interview with the RCSO, RDES, RDPS and QRM on 12/11/2018 at 1050.

10. The ED record of Patient 11 was reviewed and reflected:
* The patient presented to the ED by private automobile on 10/10/2018 at 1653 with a chief complaint of possible leg clots.
* At 1658 the RN triage notes reflected "...pt with [complaints of] multiple 'superficial blood clots...Track Acuity...3 Urgent...Pain Location Site #1: Leg Pain Location Modifier Site #1: Bilateral." The notes reflected vital signs were collected at 1658 and the patient's systolic blood pressure was elevated at 158 mmHg. No further vital signs were collected during the ED visit.
* The "ED Physician Notes" electronically signed by the physician and dated 10/10/2018 at 1739 reflected:
- The "History of Present Illness" reflected:
"The patient presents with lower extremity pain and lower extremity swelling. The onset was just prior to arrival and pt reports that [he/she] began having swelling of [his/her] bilat LE this weekend and some red/tender veins....[he/she] began taking asa now is better. Less swelling, less redness. Home hcg + today. On ivf/estrogen, gyn doc wanted [him/her] to come here to r/o dvt. The course/duration of symptoms is constant and improving. Type of injury: none. Location: Bilateral calf. The character of symptoms is pain and swelling. The degree at present is moderate. The exacerbating factor is movement. The relieving factor is none. Risk factors consist of none and as above. Prior episodes: none. Therapy today: none and asa. Associated symptoms: none. Additional history: Allergies: penicillin- Reaction: UNK , hives..."
- The "Review of Systems" reflected:
"Constitutional symptoms: Negative except as documented in HPI."
"Skin symptoms: Negative except as documented in HPI."
"Respiratory symptoms: Negative except as documented in HPI."
"Gastrointestinal symptoms: Negative except as documented in HPI."
"Genitourinary symptoms: Negative except as documented in HPI."
"Neurologic symptoms: Negative except as documented in HPI."
"Psychiatric symptoms: Negative except as documented in HPI."

- The "Past Medical/Family/Social History" reflected
"Medical history: Past Medical History Problem List..."
"Active"
"Female infertility"
"Gestational hypertension"
"PCOS (polycystic ovarian syndrome)"
"Resolved"
"Pregnant"

- The "Family history" reflected only "No family history items have been selected or recorded."
- The "Social history" was blank.

- The "Physical Examination" reflected
"Vital Signs/Measurements 10/10/2018 16:58...Systolic BP 158 mmHg HI"
"Skin: Warm, dry, pink, intact."
"Cardiovascular: Normal peripheral perfusion."
"Respiratory: Respirations are non-labored."
"Musculoskeletal: Normal ROM, normal strength, no tenderness, no swelling, no deformity, rle: 38.5, lle38, no ttp."
- The "Medical Decision Making" reflected:
"Differential Diagnosis: Degenerative joint disease...Results review: pts ob/gyn wants a dvt r/o as [he/she] is on hormones/ivf. I feel [he/she] is not presenting with clinical s/s of dvt, yet would need a US to r/o."
- The "Impression and Plan" reflected:
"Diagnosis Leg pain (...Discharge, Medical)"
"Plan...Condition: Unchanged...Disposition: Patient care transitioned to: 10/10/2018 17:39:00, [physician], for us..."

* The "Emergency Department Discharge Summary" electronically signed by the physician and dated 10/10/2018 at 1740 reflected:
- "Chief Complaint: clost in legs"
- "Problems Active Gestational hypertension Female hypertension Female infertility PCOS (polycystic ovarian syndrome)"
- "Discharge Diagnosis: Leg Pain."
- "Discharge Instructions:" was blank.
- The "ED Physician Documentation:" was followed by the same "History of Present Illness" and the same "Allergies" information reflected in the "ED Physician Notes" above.
- The "Medications Given During Medical Visit" reflected "None"
- The "Lab Results" was blank.
- The "Radiology" was blank.
- The "Follow Up:" was blank.

* The "ED Pat Ed" section electronically signed by the physician and dated 10/10/2018 at 1740 reflected:
- "Diagnosis: Leg pain."
- The "Follow-Up Instructions: [Patient 11] has been given these follow-up instructions:" was blank.
- "Laboratory Orders: None Ordered."
- "Radiology Orders: None Ordered."
- "Diagnostic Tests: None Ordered."
- "Medications Given During Medical Visit None."
- The "EKG and X-Rays:" reflected "The Emergency Department physician has looked at your lab tests, EKG, and/or other diagnostic tests and has given you an opinion..."
- The "Patient Education Materials...[Patient 11] has been given the following patient education materials:" was blank.
- The "Patient Visit Summary Signature" reflected "[Patient 11] has been given the following list of patient education materials, prescriptions and follow-up instructions:" was blank.

* The RN "ER Dispo Form" dated 10/10/2018 at 1735 reflected "Discharge/Transfer From ER...Acute care hospital..." The form reflected the patient departed from the ED at 1734, the "Mode of Departure From ER" was "Automobile," and the "Accompanied By at Disposition From ER..." was "Immediate family."
* The "Patient Consent to/Request for Transfer SAHS-0416" form was signed and dated by the physician on 10/10/2018 at 1733 and reflected the patient was transferred to "Ontario" with a diagnosis of "DVT R/O."
The "Risks of Transfer" section on the form had boxes next to each of the following choices:
- "Patient's medical condition may worsen during transfer;"
- "Patient injury due to vehicular accident or equipment failure during transfer;"
- "If patient is in labor, she may progress to delivery during transfer;" and "Other Risks."
The boxes next to "Patient's medical condition may worsen during transfer" and "Patient injury due to vehicular accident or equipment failure during transfer" were checked.
The "Mode of Transport" was "Private Vehicle," and "Accompanying Personnel" was "Other: [significant other]."

The record was unclear and inconsistent, and lacked documentation that reflected a MSE was conducted to the capability of the hospital for this pregnant patient with a possible DVT. For example:
* The physician notes reflected the patient was pregnant but there was no other information or evaluation of the pregnancy including how many weeks or months pregnant the patient was.
* No lab testing including D-dimer lab test.
* No Homan's sign test.
* No Radiology.
* The physician HPI notes at 1739 reflected "...presents with lower extremity pain and lower extremity swelling, the onset was just prior to arrival...Location: Bilateral calf...character of symptoms is pain and swelling. The degree at present is moderate. The exacerbating factor is movement. The relieving factor is none." However, the physician "Physical Examination" notes also at 1739 reflected "Skin: Warm, dry, pink, intact. Cardiovascular: Normal peripheral perfusion...Musculoskeletal: Normal ROM, normal strength, no tenderness, no swelling, no deformity..."
* The physician HPI notes at 1739 reflected the patient had "Allergies" to penicillin and the reaction was "UNK , hives." It was unclear if the allergic reaction was "UNK" or hives.
* The physician HPI notes at 1739 reflected "therapy today" was "none and asa." It was unclear if it was "none" or "asa."
* The physician HPI notes at 1739 reflected "risk factors" was "none and as above." It was unclear if it was "none" or "as above."
* At 1658 the RN documentation reflected the patient's blood pressure was elevated. However, there was no further evaluation of the patient's vital signs, including the elevated blood pressure prior to discharge.
* The "Ed Pat Ed" reflected "EKG and X-Rays: The Emergency Department physician has looked at your lab tests, EKG, and/or other diagnostic tests and has given you an opinion..." However, the record reflected no lab tests, radiology or other diagnostic tests were conducted.

* There was no documentation on the transfer form or elsewhere in the record that the physician had identified specific, individualized risks of transfer for this pregnant patient with a potential DVT.
* There was no documentation that reflected that the transfer was effected through qualified personnel and proper transportation equipment, including the use of any necessary and medically appropriate measures during the transfer for this pregnant patient with a potential DVT.

b. The ED record of Patient 11 was reviewed with the EDS on 12/11/2018 at 1425. The EDS stated "Ontario" referenced in the record as the receiving hospital was St. Alphonsus Medical Center, Ontario, OR. The EDS stated that US services were only available at SAMCBC Monday-Friday from 0800-1600. Therefore, the patient was transferred to St Alphonsus Medical Center, Ontario for US services not available at SAMCBC. The EDS confirmed the record lacked documentation that reflected the physician had identified specific, individualized risks of transfer for the patient. The EDS confirmed the record lacked documentation that the transfer was effected through qualified personnel and proper transportation equipment.

c. An email dated 01/02/2019 at 1530 from the RDPS confirmed a MSE was not conducted to the capability of the hospital. The email reflected "...D-dimer lab testing is within the capability of the hospital 24/7...In reviewing the chart I am not able to find any documentation of Homans, labs, or radiology."

Based on interview, review of documentation in 2 of 2 medical records of patients who were transferred from SAMCBC to other hospitals for services not available at SAMCBC (Patients 10 and 14), review of documentation in 1 of 1 medical record of a pregnant patient who presented to the hospital with possible leg clots and was transferred to another hospital for further evaluation, and review of policies and procedures, it was determined that the hospital failed to develop and enforce its EMTALA policies and procedures to ensure that it effected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved:
* Appropriate mode of transfer was not effected and documented for Patients 10 and 11.
* Patient specific, individualized risks of transfer had been identified for Patients 10 and 11.
* There was no documentation that reflected medical records were sent to the receiving facility and transfer documentation was inaccurate for Patient 14.

Findings include:

1. The policy and procedure titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance -- SAHS," dated as approved 05/18/2018, was reviewed. It stipulated:
* "...Transfer...Circumstances Permitting Transfer. An individual in an unstable EMC may only be transferred to another medical facility in either of the following circumstances...Physician Certification. A physician or QMP makes a determination, based on information available at the time of transfer, that the medical benefits to the patient reasonably expected from treatment at another medical facility outweigh the risks of transfer; in the case of a woman in labor, the benefit and risk assessment will include the risks and benefits to the woman and her unborn child...The physician or QMP must complete and sign the Physician Certification on Saint Alphonsus' Patient Consent To/Request for Transfer form... which must contain a summary of the risks and benefits upon which the Certification is based..."
* "...Appropriate Transfer Of Individuals with Un-stabilized EMC. Any transfer of an individual in an unstable EMC...must be conducted in the following manner...The transfer must be effected through qualified personnel and proper transport equipment, including the use of any necessary and medically appropriate life support measures during the transfer..."
* "...The Hospital must provide the receiving medical facility with all relevant records available at the time of transfer, including...the individual's history, signs and symptoms, preliminary diagnosis, test results, and treatment provided...Other relevant medical records not readily available at the time of the individual's transfer must be sent as soon as practicable after transfer to the receiving medical facility."

2.a. The ED record of Patient 10 was reviewed and reflected:
* The patient presented to the ED on 10/08/2018 at 1136 with a chief complaint of "Mental Eval."
* The "ED Physician Notes" electronically signed by the physician and dated 10/08/2018 at 1514 reflected a MSE was conducted. The "Medical Decision Making" reflected "Differential Diagnosis: Depression, suicide risk.: The "Impression and Plan" reflected "Diagnosis Feeling like committing suicide..."
* The QMHP "New Directions Northwest Crisis Service Note" dated "Time In: 10/8/2018 11:40 AM Time Out: 10/8/2018 12:15 PM" reflected "[Patient] reported a suicide attempt within the last 2 weeks...Pt is seen in the ED late this morning...endorses thoughts of anxiety, intrusive thoughts to harm or kill [him/herself]...states 'I lose control. I'm very capable of hurting people...engaged in self harm as recently as Friday, reportedly has cuts 'all over' [his/her] chest...Although pt denies current plans to harm others, [he/she] has been aggressive toward [his/her] significant other." The "Screener Recommendations" reflected "...Hospitalization...Should [he/she] decline to participate voluntarily, it is recommended pt be placed on an NMI due to concern for danger to self and others." The "Summary" reflected "...it is recommended pt receive inpatient services due to concern for safety toward [him/herself] and others."
* The RN notes dated 10/08/2018 at 1813 reflected "...still waiting to 'get the go (sic) from Intermountain...'"
* The RN notes dated 10/09/2018 at 0630 reflected "...RN [at] Intermountain states [physician] accepts pt..."
* The RN "ER Dispo Form" dated 10/09/2018 at 0643 reflected the patient departed from the ED on 10/09/2018 at 0642, the "Mode of Departure From ER" was "Automobile," and the "Accompanied By at Disposition From ER..." was "Other: Driver."
* The "Patient Consent to/Request for Transfer SAHS-0416" form was signed and dated but not timed by the physician on 10/09/2018. The form reflected the patient was transferred to "Intermountain" with a diagnosis of "Depression-Suicidal Ideation." The "Risks of Transfer" section on the form had boxes next to each of the following choices:
- "Patient's medical condition may worsen during transfer;" "Patient injury due to vehicular accident or equipment failure during transfer;"
- "If patient is in labor, she may progress to delivery during transfer;" and
- "Other Risks."
The boxes next to "Patient's medical condition may worsen during transfer" and "Patient injury due to vehicular accident or equipment failure during transfer" were checked.
The "Mode of Transport" reflected "Transporting Agency: New Directions NW" and "Other: Auto." The "Accompanying Personnel:" reflected "Other: New Directions Driver."

* There was no documentation on the transfer form or elsewhere in the record that the physician had identified specific, individualized risks of transfer of this suicidal patient.
* There was no documentation on the transfer form or elsewhere in the medical record that reflected that the transfer was effected through qualified personnel and proper transportation equipment, including the use of any necessary and medically appropriate measures during the transfer of this suicidal patient. Although the transfer form reflected the "Transporting Agency" was "New Directions NW" and "Other: Auto," and the "Accompanying Personnel" was "Other: New Directions Driver." There was no information about the type of transportation vehicle, qualifications of the driver who accompanied the patient, transportation equipment, and any necessary and medically appropriate measures.

b. The ED record of Patient 10 was reviewed with the EDS on 12/11/2018 at 1400. The EDS confirmed the findings under 2.a. above. The EDS stated "Intermountain" referenced in the medical record was Intermountain Hospital, an acute inpatient psychiatric hospital. The EDS confirmed the patient was transferred to Intermountain Hospital for psychiatric services not available at SAMCBC.

c. Online driving directions reflected Intermountain Hospital in Boise, ID is 128 miles and 1 hour and 54 minutes driving time from SAMCBC.

3.a. The ED record of Patient 14 was reviewed and reflected:
* The patient presented to the ED by ambulance on 11/04/2018 at 1133 with a chief complaint of "GSW to face."
* At 1135 the RN notes on the "Trauma Flowsheet" reflected "2 yr old child self inflicted GSW to Face. R) eye entry site..."
* The "ED Physician Notes" electronically signed by the physician and dated 11/04/2018 at 1944 reflected a MSE was conducted that included imaging and lab testing, and stabilizing treatment provided.
* The "Impression and Plan" reflected "Traumatic intracranial hemorrhage...Penetrating head trauma...Reported gun shot wound...Condition: Critical..."
* The transfer form titled "Patient Consent to/Request for Transfer SAHS-0416" was signed and dated but not timed by the physician on 11/04/2018. The form reflected the patient was transferred to "St Als Baker City." However, "St. Als Baker City" is where the patient was to be transferred from and the "Transfer Information" on the "Trauma Flowsheet" reflected the receiving facility was "St Alphonsus Boise." The transfer form reflected the patient was transferred by "Lifeflight," "ALS," and "Air Ambulance." The "Transfer Date & Time" reflected 11/04/2018 but no time was recorded.
The transfer form also reflected: "Documentation: COPY the following (as applicable) & send with patient along with completed Consent To/Request For Transfer Form." This was followed by boxes next to each of the following choices:
- "Available Medical Records;"
- "Fetal Heart Tracing;"
- "Lab Reports;"
- "EKG;"
- "X-ray copies/report;"
- "Routing slip;"
- "Other;"
- "No history of multi-resistant organism;"
- "Yes, history of multi-drug resistant organism."
None of the boxes were marked.

* There was no documentation on the transfer form or elsewhere in the record that reflected medical records were sent to the receiving facility.

b. The ED record of Patient 14 was reviewed with the EDS on 12/11/2018 at 1435. The EDS confirmed the documentation in the record did not reflect that medical records were sent to the receiving facility.

4.a. Refer to the findings identified under Tag C2406, CFR 489.24(a) and (c) regarding Patient 11 that reflected a MSE was not conducted to the capabilities of the hospital and the patient, who was pregnant with a potential DVT, was transferred to St. Alphonsus Medical Center, Ontario, OR for further evaluation. The transfer was not carried out in accordance with hospital policies and procedures as follows:
* The physician had not identified specific, individualized risks of transfer for the pregnant patient who had a possible DVT.
* The transfer was not effected through qualified personnel and proper transportation equipment, including the use of any necessary and medically appropriate measures during the transfer. The pregnant patient who had a possible DVT was transferred by private vehicle with a significant other.

b. Online driving directions reflected St. Alphonsus Medical Center, Ontario, OR is 76 miles and 1 hour and 12 minutes driving time from SAMCBC.