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Based on review of video recordings, interview, review of medical record documentation for 7 of 20 individuals who presented to the hospital for emergency services (Patients 7, 8, 10, 15, 16, 19 and 20), review of the ED central log, review of internal investigation documentation and review of hospital policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured it met its EMTALA obligations in the following areas:
* To maintain a central log that was complete, and accurately reflected all individuals who presented for emergency services, the reasons they presented and their dispositions from the ED.
* To provide MSEs for all individuals who presented to the hospital for emergency services.
* To not delay examination and/or treatment in order to inquire about the individuals' insurance or payment status.
* To obtain or attempt to obtain written and informed refusal of MSEs.

This deficiency was previously cited on the previous EMTALA survey completed on 01/31/2019.

Findings included:

1. Refer to the findings identified under Tag C2405, CFR 489.20(r)(3), that reflects the hospital's failure to maintain a complete and accurate ED central log.

2. Refer to the findings identified under Tag C2406, CFR 489.24(a)&(c), that reflects the hospital's failure to ensure all individuals who presented for emergency services received a MSE.

Based on review of video recordings, interview, review of medical record documentation for 7 of 20 individuals who presented to the hospital for emergency services (Patients 7, 8, 10, 15, 16, 19 and 20), review of the ED central log, review of internal investigation documentation and review of hospital policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured an ED central log was maintained for completeness, and accurately reflected all individuals who presented for emergency services, the reasons they presented and their dispositions from the ED:
* EMS staff brought a patient to the hospital by ambulance and were directed by hospital staff to take the patient to another hospital. The ED log lacked an entry to reflect the patient had presented to the hospital.
* Incomplete and unclear ED log entries included chief complaints, the dispositions from the ED, and duplicate entries that had conflicting information.

This deficiency was previously cited on the previous EMTALA survey completed on 01/31/2019.

Findings include:

1. The hospital's P&P titled "EMTALA Guidelines for Emergency Department Services" dated as effective 05/23/2019 was reviewed. It included the following direction: "The Emergency Department shall maintain a central log documenting the following information: Each individual presenting to the ED seeking assistance. Whether or not the individual refused treatment. Whether or not the individual was refused treatment. Whether the individual was transferred, admitted and treated, stabilized and transferred or discharged."

2. The ED central log included an entry for Patient 15 that reflected he/she presented to the hospital for emergency services on 12/12/2019 at 2052 and was assigned an ED provider. The log spaces for "acuity," "[chief complaint]," "ed disposition," "discharge date" and "disposition type" were all blank.

A second log entry for Patient 15 reflected that he/she presented to the hospital on 12/12/2019 at 2055, three minutes later, with a chief complaint of "Dizziness" and was discharged from the ED on 12/12/2019 at 2310.

It was not clear why there were two log entries that reflected the patient presented at two different times.

3. The ED central log included an entry for Patient 19 that reflected he/she presented to the hospital for emergency services on 12/29/2019 at 0910 and was assigned an ED provider. The log spaces for "acuity," "[chief complaint]," "ed disposition," "discharge date" and "disposition type" were all blank.

A second log entry for Patient 19 reflected that he/she presented to the hospital on 12/29/2019 at 0905, five minutes earlier, with a chief complaint of "rash" and was discharged from the ED on 12/29/2019 at 0950.

It was not clear why there were two log entries that reflected the patient presented at two different times.

4. The ED central log included an entry for Patient 20 that reflected he/she presented to the hospital for emergency services on 12/31/2019 at 0833 and was assigned an ED provider. The log spaces for "acuity," "[chief complaint]," "ed disposition," "discharge date" and "disposition type" were all blank.

A second log entry for Patient 20 reflected that he/she presented to the hospital on 12/31/2019 at 0827, six minutes earlier, with a chief complaint of "fever" and was admitted to the hospital on 12/31/2019 at 1035.

It was not clear why there were two log entries that reflected the patient presented at two different times.

5. In addition, there were nine other entries on the log for nine other patients who presented between 08/11/2019 and 12/29/2019 that were incomplete. The spaces on those log entries for "acuity," "[chief complaint]," "ed disposition," "discharge date" and "disposition type" were all blank.

6. Refer to the findings cited under Tag C2406, CFR 489.24(a)&(c), Medical Screening Exam, that reflects that Patient 7 presented to the hospital for emergency services, did not receive a MSE and was not entered into the ED log; and that the ED central log entries for Patients 8, 10 and 16 were incomplete.

Based on review of video recordings, interview, review of medical record documentation for 4 of 20 individuals who presented to the hospital for emergency services (Patients 7, 8, 10 and 16), review of internal investigation documentation and review of policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured that every individual who presented to the hospital for emergency services received a MSE within the hospital's capability and capacity, and that hospital staff did nothing to dissuade patients from staying at the hospital for the provision of a MSE:
* EMS staff brought a patient to the hospital by ambulance and transferred the patient into the ED by gurney. A MSE was not provided and hospital staff instead directed EMS staff to take the patient to another hospital in another town.
* Individuals who presented to the hospital for emergency services left the hospital before receiving a MSE for reasons that were unclear or unexplained and after insurance information had been obtained.

Findings include:

1.a. The hospital's P&P titled "EMTALA Guidelines for Emergency Department Services" dated as effective 05/23/2019 included the following direction: "A critical access hospital (CAH) that operates a dedicated Emergency Department is subject to the requirements of EMTALA ... All patients presenting to the [SCHHC] Emergency Department and seeking care for a medical condition, or presenting elsewhere on the hospital's entire main campus and requesting examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf, must be accepted and evaluated regardless of the patient's ability to pay or insurance status. The medical screening examination and/or stabilization services shall not be delayed in order to inquire about insurance or payment status."

1.b. The hospital's "Medical Staff Rule & Regulations" dated as approved 07/12/2016 included the following direction: "All patients in the Emergency Department will be seen and evaluated in the order of severity of their problem ... No exceptions shall be made ... All patient who present to the hospital and who request examination and treatment for an emergency medical condition or active labor, shall be evaluated for the existence of an emergency medical condition, or where applicable, active labor by the Emergency Physician or Nurse Practitioner ..."

2.a. During interview with the CEO, CNO, CIO and RQCO on 01/13/2020 beginning at 1500 they provided the following information in relation to an individual, Patient 7, who presented to the hospital for emergency services on 11/08/2020:
* An EMS ambulance arrived at the hospital with Patient 7 who had been in a pedestrian versus vehicle accident.
* The ED physician met the ambulance at the doorway and told the EMS staff to take the patient to BAH in Coos Bay.
* Patient 7's name was not identified, he/she was not registered as an ED patient and he/she did not receive a MSE by the physician.
* The hospital was made aware of the failure when the contracted ED physician reported the incident to his/her employer who then contacted the hospital on 11/12/2019.
* The hospital immediately initiated an investigation that included interview with staff present at the time of Patient 7's encounter and EMS staff.
* Nursing staff on duty at the time of Patient 7's encounter, that included an agency RN, reported that they were aware that Patient 7 should have been seen but didn't feel it was their place to contradict the ED physician.
* The contracted ED physician was removed from the ED schedule.
* The hospital implemented new EMTALA training for all ED staff, CN staff and patient registration staff.
* The hospital entered into a contract with a new company for its contracted ED physicians effective 01/01/2020.

2.b. The hospital's "EMTALA Investigation 11.08.2019" was reviewed and reflected: "This patient was brought to SCHHC Emergency Department and entitled to a medical screening exam and any necessary emergency treatment to ensure stability prior to transfer to Bay Area Hospital, if needed. This did not occur ... Investigation begun upon receipt of report on 11/11/19 and completed 11/13/19." The "actions" portion of the investigation document reflected the interviews conducted to identify what occurred, and the communications, training's and change of contracted ED company referred to during the interview described under 2.a. above. However, the action plan did not include plans for monitoring to ensure the failure to provide a MSE did not recur.

2.c. Video-recordings of the hospital's exterior ambulance entrance and the interior ED entrance were reviewed with the CIO on 01/13/2020 beginning at 1610. During interview at that time it was revealed that staff had not reviewed the video previously, or as part of the investigation. The exterior and interior camera views revealed the following course of events on 11/08/2019 beginning at 1946:
* At 1946 an ambulance arrived to the ambulance entrance.
* At 1947 EMS staff removed a gurney from the back of the ambulance on which Patient 7 was observed. The patient was seated upright and was awake and moving.
* At 1948 EMS staff transported the patient on the gurney into the hospital, and once inside through the internal ED doors into the ED. The internal doors were not completely closed and there was a partial view of EMS staff who stood in place just inside the entrance to the ED.
* At 1950 EMS staff exited the ED with the patient on the gurney, placed the gurney back in the ambulance and drove away from the hospital.

2.d. Review of the ED central log revealed no evidence that Patient 7 had presented to SCHHC on 11/08/2019. There was no log entry for Patient 7.

2.e. Review of electronic ED records revealed no evidence that Patient 7 had an ED encounter at SCHHC on 11/08/2019. There was no ED record for Patient 7.

2.f. There was no evidence of documentation recorded by any staff that reflected Patient 7's encounter at the hospital on 11/08/2019.

2.g. An on-line distance between cities calculator reflected that BAH in Coos Bay, Oregon is approximately 27 miles and 45 minutes drive-time from SCHHC on rural, winding coastal highway.

3.a. The ED central log included an entry for Patient 8 that reflected he/she presented to the hospital for emergency services on 11/19/2019 at 1348 and was assigned an ED provider. The log spaces for "acuity," "[chief complaint]," "ed disposition," "discharge date" and "disposition type" were all blank.

* There was no documentation in the EHR to reflect that Patient 8 received a MSE. The only documentation in the EHR were "visit history" and "audit history" entries made by patient registration staff.

The "status" of the EHR "visit history" for the 11/19/2019 ED visit for Patient 8 was recorded as "Deleted."

The EHR "audit history" for that visit reflected that on 11/19/219 at 1351 patient registration staff entered the department as the ED, entered the assignment of the ED physician, and entered "Patient checked in ... MAINCOMPLAINT set to exam and labs for adapt program."

The "audit history" reflected that on 11/19/2019 at 1355 patient registration staff entered "DELETEDNOTE to pt needed to see [his/her] pcp for adept (sic) program exam."

The EHR registration documentation also reflected that registration staff had gathered the patient's financial and insurance information. Patient 8's insurance information reflected that he/she had "2 insurance policies on file." One of those was identified as "Medicare," the "Inquiry date" was identified as "checked on 11/19/2019" and the "Eligibility status" was recorded as "Eligible." The other insurance was identified as "WOAH (Medicaid Replacement - HMO)," the "Inquiry date" was identified as "checked on 11/19/2019" and the "Eligibility status" was recorded as "Unverified."

* There was no documentation in the record to reflect all staff who may have interacted with Patient 8 upon arrival at the ED, what was said to the patient and what direction the patient was provided. There was no documentation to reflect who made the determination that "pt needed to see [his/her] pcp" and why, and as the patient's insurance information had been verified by staff prior to a MSE it was unclear whether staff did or said something to dissuade the patient from staying. There was no documentation to reflect that a clinical staff person was contacted before the patient left the ED to verify the situation or that information about the risks of leaving without being seen were explained. There was no documentation to reflect why the ED record had been "deleted."

* During interview with the RQCO and RCM at the time of the record review on 01/14/2020 beginning at 1620 they confirmed the findings for Patient 8.

3.b. The ED central log included an entry for Patient 10 that reflected he/she presented to the hospital for emergency services on 11/22/2019 at 1449 and was assigned an ED provider. The log spaces for "acuity," "[chief complaint]," "ed disposition," "discharge date" and "disposition type" were all blank.

* There was no documentation in the EHR to reflect that Patient 10 received a MSE. The only documentation in the EHR were "visit history" and "audit history" entries made by patient registration staff.

The "status" of the EHR "visit history" for the 11/22/2019 ED visit for Patient 10 was recorded as "Deleted."

The EHR "audit history" for that visit reflected that on 11/22/219 at 1449 patient registration staff entered the department as the ED, entered the assignment of the ED physician, and entered "Patient checked in ... PATIENTINSURANCE set to WESTERN OREGON ADVANCED HEALTH (MEDICAID HMO) ... MAINCOMPLAINT set to knot on right hand."

The "audit history" reflected that on 11/22/2019 at 1509 patient registration staff entered "DELETEDNOTE to PT CHANGED [HIS/HER] MIND AND DID NOT WANT TO BE SEEN."

The EHR registration documentation also reflected that registration staff had gathered the patient's financial and insurance information. Patient 10's insurance information reflected that he/she had "WOAH (Medicaid Replacement - HMO)." The "Inquiry date" was identified as "checked on 11/22/2019" and the "Eligibility status" was recorded as "Eligible."

* There was no documentation in the record to reflect all staff who may have interacted with Patient 10 upon arrival at the ED, what was said to the patient and what direction the patient was provided. There was no other information to reflect why the patient changed his/her mind and as the patient's insurance information had been verified by staff prior to a MSE it was unclear whether staff did or said something to dissuade the patient from staying. There was no documentation to reflect that a clinical staff person was contacted before the patient left the ED to verify the situation or that information about the risks of leaving without being seen were explained. There was no documentation to reflect why the ED record had been "deleted."

* During interview with the RQCO and RCM at the time of the record review on 01/14/2020 beginning at 1600 they confirmed the findings for Patient 10.

3.c. The ED central log included an entry for Patient 16 that reflected he/she presented to the hospital for emergency services on 12/13/2019 at 1139 and was assigned an ED provider. The log spaces for "acuity," "[chief complaint]," "ed disposition," "discharge date" and "disposition type" were all blank.

* There was no documentation in the EHR to reflect that Patient 16 received a MSE. The only documentation in the EHR were "visit history" and "audit history" entries made by patient registration staff.

The "status" of the EHR "visit history" for the 12/13/2019 ED visit for Patient 16 was recorded as "Deleted."

The EHR "audit history" for that visit reflected that on 12/13/219 at 1139 patient registration staff entered the department as the ED, entered the assignment of the ED physician, and entered "Patient checked in ... PATIENTINSURANCE set to WESTERN OREGON ADVANCED HEALTH (MEDICAID HMO) ... MAINCOMPLAINT set to uti symptoms."

The "audit history" reflected that on 12/13/2019 at 1229 patient registration staff entered "DELETEDNOTE to pt left."

The EHR registration documentation also reflected that registration staff had gathered the patient's financial and insurance information. Patient 16's insurance information reflected there was "1 insurance policy on file" and was "WOAH (Medicaid Replacement - HMO)." The "Inquiry date" was identified as "checked on 12/13/2019" and the "Eligibility status" was recorded as "Eligible."

* There was no documentation in the record to reflect all staff that may have interacted with Patient 16 upon arrival at the ED, what was said to the patient and what direction the patient was provided. There was no other information to reflect why the patient "left" and as the patient's insurance information had been verified by staff prior to a MSE it was unclear whether staff did or said something to dissuade the patient from staying. There was no documentation to reflect that a clinical staff person was contacted before the patient left the ED to verify the situation or that information about the risks of leaving without being seen were explained. There was no documentation to reflect why the ED record had been "deleted."

* During interview with the RQCO and RCM at the time of the record review on 01/14/2020 beginning at 1430 they confirmed the findings for Patient 16. At 1445 the RCM stated that in regards to Patient 16 having come to the ED with "uti symptoms," the patient "was not here for ER. [He/she] was in for labs."

* The RCM returned later on that date at 1505 and stated that he/she had just called the staff person who registered the Patient 16 on 12/13/2019 and the staff person stated that Patient 16 had said that he/she couldn't stay and had to pick up some family members.

3.d. The hospital's undated P&P titled "Emergency Room Registration Procedures" was reviewed. It included the following direction: "All Emergency Department Registration staff will do a 'QUICK REGISTRATION' only on all patient (sic) that presents (sic) to [SCHHC] Emergency Department. Once the 'Quick Registration' is done the registrar will notify the ED that there is a patient waiting. At no point during this first process will the registrar ASK for insurance information or have any paperwork signed. Once patient is seen by a medical physician the registrar can then ask for insurance and get all necessary paperwork signed by the patient. At any time during the patients (sic) visit, nursing can send in the spouse or a child's parent so a registrar can complete the registration."

The P&P contained unclear information where it reflected: "At any time during the patients (sic) visit, nursing can send in the spouse or a child's parent so a registrar can complete the registration." It was not clear what kind of information the patient's representative would be asked for to "complete the registration." The hospital must also not do or say anything to a representative acting on behalf of the patient, such as a family member, that would cause the representative to take the patient and leave the hospital without a MSE or appropriate treatment.

3.e. During interview with the RCM on 01/14/2020 beginning at 1445 he/she stated that the "only time" registration staff may "delete" medical records is if the record was "accidentally" generated in the first place. He/she stated it was the "policy that they can't delete."