HospitalInspections.org

Based on observation, review of recorded video footage, interviews, review of medical records and other documentation for 3 of 23 patients who presented to the hospital's ED (Patients 1, 2 and 17), review of central log documentation, and review of policies, procedures and other documents, it was determined the hospital failed to enforce its EMTALA policies and procedures in the following areas:
* Provision of MSEs; and
* Maintenance of a central log.

Findings included:

1. Refer to findings identified under Tag A2406, CFR 489.24(a) and (c) which reflects the hospital's failure to enforce its EMTALA policies and procedures related to the provision of MSEs for Patients 1, 2 and 17.

2. Refer to the findings identified under Tag A2405, CFR 489.20(r)(3), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to the central log for Patient 17.

Based on observation, review of recorded video footage, interviews, review of medical record and other documentation for 1 of 23 patients who presented to the hospital's ED (Patient 17), review of the central log, and review of policies and procedures it was determined the hospital failed to enforce its EMTALA policies and procedures to ensure that the central log contained information that identified every patient who presented to the ED.

Findings include:

1. Refer to findings identified under Tag A2406, CFR 489.24(a) and (c), for Patient 17. Those findings reflect that Patient 17 presented to the ED, was not entered on the central log, and did not receive a MSE.

Based on observation, review of recorded video footage, interviews, review of medical records and other documentation for 3 of 23 patients who presented to the hospital's ED (Patients 1, 2 and 17), and review of policies and procedures and other documents, it was determined the hospital failed to enforce its policies and procedures to ensure that each patient who presented to the ED received a MSE to determine whether or not an EMC existed:
* Patient 17 presented to the hospital's ED where a request for medical services was made in response to respiratory symptoms the patient was experiencing. Although Patient 17 was not triaged and did not receive a MSE, the ED RN provided Patient 17 with an oxygen tank and an oxygen mask, and was sent to another hospital.
* Patients 1 and 2 presented to the hospital's ED and were triaged by the RN. The MD did not conduct a MSE for either Patient 1 or Patient 2 but made outpatient clinic appointments for each patient later the same day.

Findings include:

1. The hospital's policy and procedure titled "Medical Screening Examination", dated as last revised "08/2013", was reviewed. The document stipulated "Patients who present to the ED requesting medical services will receive a [MSE], regardless of their ability to pay, to determine if an [EMC] exists. This examination is performed by a qualified LIP: always by the emergency physician or nurse practitioner in the ED setting."

The hospital's policy and procedure titled "PHRMH: Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities", dated as last revised "01/2015", was reviewed. It stipulated that "A physician...will perform a [MSE]...to determine whether or not an emergency medical condition exists and treat the patient or stabilize the patient's condition within the capability and capacity of the [ED]...Triage examinations performed by care providers not designated to perform MSE do not constitute a MSE."

"EMTALA SBAR & Education" documents identified for "Professional Staff" and "Nursing Staff", dated January 2015, were reviewed. Those documents included excerpts of policies which reflected "An individual who is not a patient is assumed to have 'Come to the [ED]' if any of the following...conditions are met...a request on behalf of the individual will be considered to exist if a prudent layperson would believe that the individual needs examination or treatment based upon their observations of the individual's behavior or appearance."

The "Providence Code of Conduct" dated January 2014 was reviewed. It reflected that "Providence complies with the [EMTALA]...We screen and provide stabilizing treatment to everyone who comes to a Providence hospital requesting examination or treatment for an emergency condition."

2. The electronic ED record of Patient 17 was reviewed. It contained the patient's name; address; birthdate; age of 18 years-old; the name of a "Guarantor"; insurance information was "Medicaid Out of State"; admission type was "Emergency"; "Means of Arrival" was "Walk-in"; a PHRMH medical record number; and a PHRMH account number. All other fields and spaces on the multi-page electronically generated record were blank. Those included, but were not limited to: arrival date and time; discharge date and time; discharge disposition; discharge destination; chief complaint; labs; imaging; medications; ED diagnosis; physician orders; discharge orders; etc. The record contained no documentation of triage or a MSE. There was no documentation by an RN, an MD, or any other hospital personnel.

During interview with the CNO on 10/28/2015 at 1045 he/she stated that between 0900 and 1000 on 10/19/2015 the PHRMH ED Manager had received a call from the OHSU ED Manager about a patient who had presented to the OHSU ED that morning. The CNO stated that the report was that the patient had presented first to PHRMH, had not received a MSE but was provided with an oxygen tank for transport to OHSU in a private vehicle.

The CNO stated that the hospital's electronic record system confirmed that Patient 17 had presented to the ED on 10/19/2015 as initial demographic information had been entered. However, the "visit was canceled." The CNO identified the RN who was on duty when Patient 17 presented to the ED and indicated that the RN had submitted a written statement that described his/her interactions with Patient 17 and the patient's representatives. The CNO described the contents of that statement and provided it for review.

The written statement dated 10/20/2015 was reviewed and reflected that the RN had worked the night shift, from 10/18/2015 at 1900 until 10/19/2015 at 0730. The statement reflected that "At approximately 5AM a [parent] presented...at the admitting desk saying [he/she] had 2 [children] that were ill, that they were on their way to OHSU and the oxygen tank they had for one of the daughters was almost empty was there any way they could get a tank so they could be on their way. I walked the [parent] back to an exam room to show [him/her] our oxygen tank...[He/she] did say that her [children] had colds, that one of the [children] had spina bifida and was on oxygen...but had not needed oxygen...until the illness started. The [parent] explained that the child had a stuffy nose and that an oxygen mask would be more helpful because the nasal cannula that was being used was not very useful so that was given to [the parent] also. I did say to the [parent] that [he/she] was welcome to check the child in, that by giving [him/her] the oxygen tank I was in no way trying to talk [him/her] out of having [the child] seen here...On the way to the van they were in, the [other parent] had gotten the child out of the van and [the child] was in [his/her] wheelchair. I did not observe [the child] as [the child] was literally right outside their van, in a parking space, in the dark - the [parent] said they were going on to OHSU...The [other parent] then put the child back into the van and they went on their way."

During the interview with the CNO on 10/28/2015 he/she stated that the RN should have seen the patient, triaged the patient, and transferred the patient. He/she stated that the RN should have told the parent that "we can't give you anything without the patient being seen by a physician." The CNO further stated that "oxygen is a medication and we can't give that without an order...giving the oxygen was not the right thing to do." The CNO stated that if the parents objected to the patient being seen the RN should have had them sign an AMA form and if they refused to sign the form the RN should have charted that. The CNO also stated that in a case like this where a patient refused evaluation or treatment and there was knowledge that the patient was planning to go to another hospital, the RN should make a "courtesy call" to that hospital's ED and tell them that the patient had been at PHRMH, had refused to be seen, and was on the way to their facility.

On 10/28/2015 at 1450 the RN who interacted with Patient 17 and Patient 17's parents on 10/19/2015 was interviewed with the ED Manager and the Quality Management Coordinator present. The RN stated that he/she had worked in the hospital's ED for 20 years. During the interview he/she reiterated the events as written in the statement identified in the above paragraph with some additional information. The RN stated that a ED registrar came into the main ED and asked the RN to speak to a person who had presented to ED registration. The RN stated he/she proceeded to the ED registration window and spoke with a person who said he/she was taking his/her child to OHSU and wanted the hospital to provide an oxygen tank for the trip. The RN stated that the department has oxygen tanks to dispense to HH patients with physician's orders. The RN stated that "I told [the parent] I could give [him/her] an oxygen tank that was larger than the one [he/she] had." The RN stated that "I didn't want [the parent] to think [he/she] had to check in to get oxygen" and indicated he/she said to the parent "I don't want you to think you shouldn't check in." The RN said he/she asked the parent "You don't want your [child] to be checked in?" to which the parent said "No." The RN confirmed that he/she accompanied the parent into the ED where the parent him/herself checked the flowmeters on oxygen tanks attached to the gurneys in Trauma Bay 3 and Trauma Bay 4. The RN stated "[The parent] knew what [he/she] was doing...I think [he/she] would have let me do it." The parent determined that the tank on the Bay 4 gurney was full enough and that tank was removed. In addition, the RN confirmed that he/she provided an oxygen mask at the parent's request. The RN stated that after the oxygen tank was removed he/she walked out of the ED with the parent and observed the second parent standing next to a van in the parking lot. The RN stated that the child was in a "special wheelchair" in front of the second parent. The RN stated the he/she watched while the parent removed the child's oxygen nasal cannula and placed the mask and turned on the new oxygen tank. The RN stated that "one time I said 'so you don't want to stay here and check in?'" The parent said no. The RN indicated that he/she watched them go towards the van but didn't wait for them to get in because he/she didn't know how to get those wheelchairs into the vans. The RN stated that they drove off after he/she went back into the ED "I think." The RN stated that "after the fact" he/she thought he/she should have had them sign a "release of care" or refusal of treatment. "I did not offer that...I didn't think of that at the time."

The RN confirmed the following additional information in response to questions during the interview:
* After the RN returned to the ED he/she informed the ED registrar that Patient 17 was not checking in, that "no one is checking in...I didn't know the patient's name."
* He/she did not notify or report that Patient 17 had presented to the ED to the ED physician on duty, to the other RN on duty, to the House Supervisor on duty, to the oncoming shift RNs, to the ED Manager.
* He/she did not document or record any of the events related to Patient 17 presenting to the ED. The RN stated "I didn't document anything."
* The RN stated that he/she did not document dispensing the oxygen tank with flowmeter and the mask in any record or system.
* The RN stated that he/she did not take Patient 17's vital signs or oxygen saturation level.
* The RN recalled that the parent had informed that RN that Patient 17 had a pulse oximeter but the parent "didn't say what the level was" except that it was "lower." The RN further recalled that he/she did see something with lights on in Patient 17's lap and thought it was the pulse oximeter.
* The RN stated he/she "was watching [parent] change the cannula, but didn't see [Patient 17's] face." The RN stated he/she observed "no loud breathing, no croupy cough, respirations seemed fine" but stated the "parents were concerned" because of Patient 17's low oxygen level, cough and cold.
* The RN stated that he/she didn't ask any questions of the parents about Patient 17's oxygen level or condition.
* The RN stated "No", the patient did not come into the hospital building at all. He/she stated that when he/she saw the patient, the patient was "not very close to the building...right next to the van in an empty parking spot."

On 10/28/2015 at 1410 the video-footage of the hospital's ED entrance recorded on 10/19/2015 between 0535 and 0556 was reviewed with the ED Manager and the Quality Management Coordinator present. The video-footage revealed the following images:
* 0539 - From out of frame, a person identified by hospital staff as Patient 17's parent walked into the hospital through the main ED entrance.
* 0540 - The parent exited the main ED entrance, a large van drove into the parking space closest to the main ED entrance, and the parent approached the van and opened the passenger side sliding door.
* 0541 - The second parent exited the driver side van door and the first parent re-entered the hospital through the main ED entrance.
* 0544 - The second parent, a third adult, and Patient 17 in a wheelchair exited the van and entered the hospital through the main ED entrance.
* 0545 - The second parent exited the main ED entrance alone, the first parent and the RN entered the frame from another direction with an oxygen tank, and the first parent re-entered the hospital through the main ED entrance. While standing immediately in front of the main ED entrance doors, the RN interacted with the second parent who had been given the oxygen tank.
* 0546 - The first parent, the third adult, and Patient 17 in the wheelchair exited the main ED entrance and joined the second parent and the RN immediately in front of the main ED entrance doors. The RN stood immediately next to and in front of Patient 17 during the interaction.
* 0547 - The RN re-entered the hospital while the two parents, the other adult, and Patient 17 remained in the parking lot.
* 0547 - Activity involved getting Patient 17 and the wheelchair back in the van.
* 0554 - The van backed out of the parking space and drove away from the building.

On 10/28/2015 at 1440 a tour of the hospital's ED was conducted. Observations from the parking lot reflected two doorways into and out of the ED. Parking spaces were observed to be immediately in front of the main ED entrance doors. The ED registration desk was located immediately to the right of the main ED entrance doors once inside the building. The other ED doors leading into the department from the outside were a short distance to the right of the main ED doors.

Review of the hospital's ED central log revealed no entries to reflect that Patient 17 had presented to the ED on 10/19/2015.

During interview on 10/28/2015 at approximately 1530 the ED Manager stated that the electronic medical record entries that had been made for Patient 17 were not sufficient to have generated an entry that reflected Patient 17 on the ED electronic central log. The ED manager stated that the RN should have checked Patient 17 in, got the patient on oxygen, and the patient should have seen the doctor.

The Internet site "Mapquest" reflects OHSU in Portland, Oregon is 65 miles and one hour and 11 minutes drive time from PHRMH in Hood River, Oregon.

Documentation reflected that on 10/19/2015 Patient 17 presented to the OHSU ED and was admitted to the OHSU MICU with respiratory distress and sepsis.

3. The electronic ED record of Patient 1 was selected for review because the "Admitting Provider" entry on the ED central log for this patient denoted "No, Physician", and the "Last ED Provider" space on the log was blank.

The ED record reflected that the adult patient arrived in the ED on 09/01/2015 at 0819 and had a chief complaint of "Right Shoulder Pain." The record reflected that the RN completed triage of the patient at 0839. The next note in the record was recorded by the RN at 0847 and denoted "Appointment made by MD for 10:30 this am with [NP]." A second RN note recorded at 0851 reflected "Pt is able to make it to the appointment. [He/she] left happy that the MD had gone out of [his/her] way to make the appointment." The record reflected that Patient 1 was discharged from the ED at 0854. The discharge disposition and destination was recorded as "Home." The "Orders and Results" section of the record reflected no physician orders were generated or carried out. The "Notes" section of the record reflected no physician notes were recorded. The "After Visit Summary" section of the record reflected that no discharge instructions were provided.

There was no documentation in the record that reflected the patient received a MSE by the ED physician. Rather the record reflected that the physician made an appointment for the patient to be evaluated at a clinic.

The record reflected that the patient signed a "Conditions of Admission - Spanish" on 09/01/2015 at 0819. However, the hospital had not ensured that Patient 1 understood the hospital's obligation to provide him/her with a MSE, as the note recorded by the RN indicated that the patient's impression was that the physician "had gone out of [his/her] way" by making an appointment outside of the hospital.

During interview with the ED Manager on 10/28/2015 at 1615 he/she confirmed that a MSE for Patient 1 had not been documented as required by the ED physician.

4. The electronic ED record of Patient 2 was selected for review because the "Admitting Provider" and "Last ED Provider" spaces on the ED central log for this patient were blank.

The ED record reflected that the 3 year-old patient arrived in the ED on 09/01/2015 at 1220 and had a chief complaint of "Fever." The record reflected that the RN completed triage of the patient at 1241. The next note in the record was recorded by the RN at 1319 and denoted "call placed to One community health they will follow up with pt at [his/her] regularly scheduled appointment 1445 today, out pt cxr to be ordered by [a non-ED MD] office." The record reflected that Patient 2 was discharged from the ED at 1333. The discharge disposition and destination was recorded as "Home." The "After Visit Summary" section of the record reflected that no discharge instructions were provided.

The "Orders and Results" section of the record reflected that the ED physician generated an order for a CXR at the time the patient was discharged from the ED. That was the only diagnostic or treatment intervention ordered by the physician.

The "Imaging Orders" documentation reflected that a CXR was taken at 1351, 18 minutes after the patient was discharged to "Home" from the ED, and the results were read at 1409.

The "Notes" section of the record reflected no physician notes were recorded until 09/15/2015, 14 days after Patient 2's ED visit. The MD note reflected "I only saw this patient quickly as medical triage examination. The patient was referred to [his/her] primary care physician office and had an outpatient chest x-ray prior to leaving our facility. [MD name] 09/15/15 0907."

There was no documentation in the record that reflected the patient had received a MSE by the ED physician. Rather the record reflected that the physician ordered a CXR and sent the patient to a clinic for evaluation.

During interview with the ED Manager on 10/28/2015 at 1630 he/she confirmed that the note written by the MD 15 days after Patient 2's ED visit did not contain the elements of a MSE as required.

5. In an email communication from the CNO on 10/31/2015 at 2217 he/she confirmed PHRMH ED RNs are not designated to provide MSEs and that MSEs in the ED may be conducted only by LIPs.