HospitalInspections.org

Based on interview, review of documentation in 3 of 10 medical records of patients who were transferred from SAMC to other facilities for specialty services not available at SAMC (Patients 4, 5 and 10 ), and review of hospital policies and procedures and other documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure compliance in the following areas:
* Appropriate transfers of patients.

Findings included:

1. Regarding appropriate transfers refer to the findings identified under Tag A2409, CFR 489.24(e)(1)-(2).

Based on interview, review of documentation in 3 of 10 medical records of patients who were transferred from SAMC to other facilities for specialty services not available at SAMC (Patients 4, 5 and 10 ), including a psychiatric patient, Patient 10, who had not been accepted by the receiving facility, 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 that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved:
* The receiving facility had not agreed to accept the patient for transfer in all cases.
* The physician certification that the benefits of transfer outweighed the risks of transfer did not reflect that patient specific, individualized risks and benefits of transfer had been identified.
* Documentation related to transfer arrangements was unclear and incomplete and did not ensure appropriate transfers were effected, and included qualified personnel and transportation equipment.

Findings include:

1. The policy and procedure titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance -- SAHS dated as approved 03/05/2019, 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 (the physician must counter-sign the form in the event a QMP signs the Certification), which must contain a summary of the risks and benefits upon which the Certification is based. If the individual consents to the physician-certified transfer, reasonable efforts should be made to have the individual sign the Patient Consent To/Request For Transfer form indicating the individual's consent to the physician-certified transfer. If the individual consents but 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."
* "...Appropriate Transfer Of Individuals with Un-stabilized EMC. Any transfer of an individual in an unstable EMC...must be conducted in the following manner...Prior to transferring the individual, the Hospital must confirm that the receiving medical facility has available space and qualified personnel for treatment of the individual and the receiving medical facility must agree to accept the individual. The Hospital must document in writing the receiving medical facility's acceptance of the transfer, including the name of any accepting physician...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..."

2. The hospital's medical staff "Rules & Regulations," dated "Adopted by the Board on the 28th day of May, 2019 were reviewed and reflected the following:
* "...Unstabilized Emergency Medical Conditions. A patient with an unstabilized emergency medical condition may only be transferred to another medical facility if either the physician certifies that the medical benefits reasonably expected from treatment of the patient at another medical facility outweigh the risks of transfer, or the patient requests in writing a transfer against medical advice. Any transfer of a patient with an unstabilized emergency medical condition must be conducted in compliance with EMTALA and the requirements set forth in the Hospital's EMTALA Compliance Policy."

3. a. Review of state agency licensing records reflected that Unity Center for Behavioral Health is located in Portland, Oregon and is a licensed satellite location and a department of LEMC through which LEMC provides psychiatric emergency services and psychiatric inpatient services.

b. The ED record of Patient 10 was reviewed and reflected the patient presented to the ED by police on 09/18/2019 at 1752 with a chief complaint of "needs medical clearance."

* The Lifeways MSW "Data/Service/Activity" notes dated "9/18/2019 5:40 PM to 6:50 PM" reflected "...[Washington County individual] expressed to this clinician via phone that the client would need to be transported to the emergency Psychiatric center at Unity...[Washington County individual] stated that [he/she] would inform the staff at Unity that the client would be coming."

* The Lifeways MSW "Crisis Assessment & Stabilization Plan" dated "9/18/2019 5:55 PM to 6:30 PM" reflected "Mental status of person and assessment of dangerousness...Reports Auditory/Visual Hallucinations, tearful affect, Client broke out in song during this assessment, paranoid, poor eye contact, flight of thoughts..."

* The "ED Physician Notes" dated "Time Seen" 09/18/2019 at 1756 reflected a MSE was conducted that included CBC with differential, CMP, alcohol level, urinalysis, drug screen, TSH, glucose and HCG. The "History of Present Illness" reflected "...past medical history of schizophrenia presenting to the emergency department with gross disorganization...recently discharged from state hospital to a group home, over the past several days has become clear that they are unable to safely care for patient and [he/she] has had escalating behavioral and psychotic disturbances...in custody of state...signed out to me pending final medical clearance labs. These returned with findings of mild hyponatremia, otherwise no other evidence of major metabolic derangement or infectious process...I did interview patient and [he/she] is disorganized, making nonsensical statements at times...Several times in the department here [he/she] has had behavioral outbursts and threatened to elope...required IM Haldol, Ativan, Benadryl during one period of behavioral disturbance that we were unfortunately unable to de-escalate without medications...awaiting inpatient psychiatric placement as well as transportation. [He/she] is medically cleared at this time."

* The RN notes on 09/18/2019 at 1900 reflected "...Pt has been Ordered (sic) of continued commitment for mental illness. pt (sic) states [he/she] wants to kill [him/herself] by taking pills."

* RN notes on 09/19/2019 at 0018 reflected "Security was called due to the pt pushing [his/her] way passed (sic)...the sitter and refusing to go back to [his/her] room - pt was being aggressive and threatening violence...[physician] came in room, explained that for safety reasons we were going to give [him/her] medication...security was in the hall for assistance if needed...pt rolled over adn (sic) aloud (sic) me to give [him/her] the shot - pt is laying in bed crying loudly."

* RN notes dated 09/19/2019 at 0921 reflected "Received call from...Lifeways. Pt to go to Unity Hospital in Portland. Secured transport is being arranged by them. Transport is not available until Friday."

* RN notes dated 09/20/2019 at 1100 reflected "Pt medicated with Haldol...Pt pacing in hall. Tentative transport time is 1600. Per [Washington County individual] the pt is on a mental hold based on [his/her] legal order of continued commitment from the state of Oregon..."

* RN notes dated 09/20/2019 at 1220 reflected "Pt becoming restless and reports anxiety...offered lorazepam and pt agrees at this time."

* RN notes dated 09/20/2019 at 1443 reflected "patient stressed out, pacing, crying, talking to [him/herself] and answering...CNAat (sic) [him/her] at all times."

* The Lifeways MSW "Data/Service/Activity" notes dated "9/20/2019 3:00 PM to 7:00 PM" reflected "...[Washington County individual] informed this treatment team that Unity hospital would accept the patient on a walk-in basis, due to familiarity, and the amount of times the patient had been to the facility. This treatment team discussed EMTALA and having to re-assess the patient...Patient was transported to Unity Hospital in Portland, OR by Mountain Secure Transport..."

* RN notes dated 09/20/2019 at 1511 reflected "Received phone call from [Washington County individual] at Washington County Behavioral Health who is pt's case worker...Discussed pt's behaviorsince (sic) [his/her] admit. Pt to go to Unity Behavioral Health in Multnomah County. Secured transportation to be here between 5-6 pm. [He/she] stated that the pt will be evaluated by staff when [he/she] arrives at the facility. No specific accepting doctor."

* RN notes dated 09/20/2019 at 1620 reflected "Pt agitated, walking around nurses station, cursing..."

* RN notes dated 09/20/2019 at 1857 reflected "pt given ativan after asking for something to calm [his/her] nerves...Lifeways here to see pt now (sic) Transport here to get pt as well."

* The "ER Dispo Form" dated 09/20/2019 at 1925 reflected:
- "Discharge/Transfer From ER Psychiatric facility...(transfer)..."
- "Accompanied by at Disposition From ER...secured transport by Washington County..."
- "Discharge Comments...Unity Behavioral Health"
- "Time of Departure from ER 09/20/2019 19:24"

* A 3-page transfer form with physician certification titled "Patient Consent to/Request for Transfer SAHS-0416" was reviewed and reflected the patient was transferred to "Unity Hospital" with a diagnosis of "SI." Page 3 of the form reflected:
- "Confirmation of available space and personnel" was preceded by an empty box. There was no documentation of confirmation of available space and personnel from the receiving facility.
- The areas on the form for documenting "Date/Time of Acceptance by Receiving Facility:" and "Name/Title of Physician Authorizing Acceptance" reflected "9/20/19 Unity Hospital per [Washington County individual] [at] Washington County behavioral health."
- "Report Called" was preceded by an empty box.
- "Report Given" was preceded by an empty box.
- The areas on the form for documenting "Name of Receiving RN:" and "Saint Alphonsus RN Signature:" reflected "pt accepted by [Washington County individual] [at] Washington county behavioral health."
- The "Mode of Transport" reflected "Transporting Agency: private transport" and "Private Vehicle...Accompanying Personnel...None Required."

* Lifeways documentation subsequent to the patient's departure on 09/20/2019 reflected the following:
- The Lifeways MSW "Data/Service/Activity" notes dated "9/21/2019 2:45 AM to 8:00 AM" reflected "...At approximately, 2:45am...QMHP contacted [Physician at] (Unity Hospital). [Physician] was informed that the patient left St. Alphonsus Emergency Room...informed [Physician] that coordination was completed through [Washington County individual]...who informed this treatment team that the patient would be accepted through the Unity Psychiatric Emergency Services..."

- The Lifeways QMHA "Data/Service/Activity" notes dated "9/24/2019 11:24 AM to 11:24 AM" reflected:
"9/19 I received information that transportation had been set up...to transport [patient] to Unity in Portland where they have a PERS unit that can assess [him/her]..."
"9/20...I reached out to Unity and was told that there was no referral or record that the client would be accepted, and there were not beds..."
"9/23 I was notified that [patient] had been transferred on Friday to Unity in Portland..."

The record reflected the following aspects of an appropriate transfer were not carried out:

There was no documentation on the transfer form or elsewhere in the record that LEMC agreed to accept the patient, and had space and qualified personnel available to treat the patient as required by this CFR. Although Lifeways MSW notes dated 09/21/2019, subsequent to the patient's departure from SAMC, reflected that "coordination was completed" by a Washington County individual and the patient "would be accepted" at "Unity Psychiatric Emergency Services [LEMC]," there was no documentation that reflected who at LEMC the "coordination was completed" with. There was no documentation that LEMC had accepted the patient and had available space and qualified personnel to treat the patient. In fact, the RN notes on 09/20/2019 reflected there was no accepting physician at LEMC, and Lifeways QMHA notes on 09/24/2019 reflected that on 09/20/2019 the patient was not accepted at LEMC because LEMC had no beds for the patient who needed inpatient psychiatric services.

The transfer form reflected the patient was transferred by "Private Vehicle" with no accompanying personnel, whereas other documentation in the record reflected the patient was transferred by "secured transport." The documentation was unclear and provided no assurance that the transfer was effected through qualified personnel and transportation equipment during the transfer for this patient with SI.

In addition, there was no documentation that report was called and provided to LEMC, or the name of a receiving RN at LEMC in accordance with SAMC's usual process as indicated on SAMC's transfer form.

c. SAMC's scope of services document titled "Scope of Services," dated approved 05/16/2017 was reviewed and reflected no evidence of inpatient psychiatric services.

d. During interview with the ED NM on 10/22/2019 at 1515 at the time of Patient 10's record review he/she confirmed that SAMC had no inpatient psychiatric services. The ED NM confirmed that the following aspects of an appropriate transfer, required secondary to SAMC's lack of capability to provide further exam and stabilizing inpatient psychiatric treatment to Patient 10, had not been carried out:
* There was no documentation that LEMC agreed to accept the patient, and had space and qualified personnel available for the treatment of the patient. The ED NM stated "I don't see it."

e. A SAMC document dated 09/24/2019 related to Patient 10's ED visit was provided and reviewed with the VPO on 10/23/2019 at 0900. The document reflected that the SAMC failed to effect an appropriate transfer of Patient 10 as the receiving facility had not agreed to accept the patient for transfer and SAMC had not ensured the receiving facility had available space and qualified personnel to treat the patient as follows: "...the Malheur County Police brought [Patient 10] to Saint Alphonsus' Emergency Department for evaluation of [his/her] acute and chronic psychosis, the symptoms of which had been worsening...Saint Alphonsus provided a medical screening examination and stabilizing treatment within its capability to [Patient 10], and on September 20th, transferred [Patient 10] to Unity so that [he/she] could receive psychiatric services that were not available at Saint Alphonsus...Saint Alphonsus did not communicate directly with Unity to confirm Unity's capacity and acceptance of the patient, and instead, relied upon the representations of Washington County Behavioral Health."

f. During an interview with the VPO on 10/23/2019 at 0900 at the time of the document review in finding 3. e. the VPO confirmed Patient 10 was transferred from SAMC to LEMC (Unity Center for Behavioral Health) for psychiatric inpatient services. The VPO confirmed SAMC did not arrange an appropriate transfer for the patient as SAMC did not ensure LEMC had accepted the patient for transfer in accordance with SAMC's policies and procedures.

g. Online driving directions reflected LEMC Unity Center for Behavioral Health located in Portland, Oregon is 375 miles and 5 hours and 37 minutes driving time from SAMC located in Ontario, Oregon.

4. a. The ED record of Patient 4 was reviewed and reflected the patient presented to the OB unit on 05/08/2019 at 1430 with a chief complaint of "OB Check."

* The "OB Triage/Admission Assessment Form" dated 05/08/2019 at 1504 reflected "Reason for Admission: lost mucous plug, twin early gestation, short cervix...Acute, needs to be seen immediately..."

* The "Nursing Progress Note Form" dated 05/08/2019 at 1534 reflected "...summary of care prepare for transport by air ambulance...2 grams of ampicillin given, 1 liter of Lactated ringers...unable to determine cervical dilation baby A low transverse cervix posterior."

* The "Physician Notes" electronically signed by the physician and dated 05/08/2019 at 1624 reflected a MSE was conducted and stabilizing treatment provided that included history and physical exam, ultrasound, and urinalysis. The notes reflected "...Patient presents with loss of fluid clear positive fetal movement...twin with shortened cervix presented for LOF at 1:30 at home...Initial exam [positive] ROM [positive], Ffn positive...Impression and Plan...Cervix measured at 3.1 cm...Plan: Labor (Transfer to St Lukes, Boise)."

* The "Discharge/Depart Form" dated 05/08/2019 at 1710 reflected:
- "Discharge Date and Time 05/08/2019 16:50"
- "Discharge Transport Mode Stretcher"
- "Discharged/Accompanied by Other: st. (sic) lukes (sic) transport team, and facilities..."
- "Discharged/Released to Acute care hospital..."
- "Discharge Comments 29 1/7 weeks, with twin gestation, PROM [at] 1320 5/08/2019, [SAMC Physician] transfer care to St. Lukes (sic) Medical center (sic), boise (sic), idaho (sic)...patient transported...with maternal transport at 1750."

* A 3-page transfer form with physician certification titled "Patient Consent to/Request for Transfer SAHS-0416" was reviewed and reflected the "Receiving Facility" was "St Lukes Boise" and the diagnosis was "Preterm Labor [with] twins, SROM 29 1/7: GA:
Page 3 of the form reflected:
- "Mode of Transport...Air St Lukes"
The physician certification of "Risks and Benefits of Transfer" section reflected:
- "Benefits of Transfer...Availability of the following specialty care or services currently unavailable at Saint Alphonsus: NICU, twin gestation"
- The "Risks of Transfer" was following by a checked box next to the preprinted generic language "Patient is in labor and may progress to delivery during transfer." There were no other risks identified.

The record reflected the following aspects of an appropriate transfer were not carried out:
* There was no documentation on the physician certification form or elsewhere in the record of patient specific, individual risks of transfer for the mother who was preterm at 29 weeks gestation with SROM or the unborn twins who required a NICU.

b. The hospital's scope of services document titled "Scope of Services," dated approved 05/16/2017 was reviewed and reflected no evidence of NICU services. The document reflected "Services Not Provided...Neonatal Intensive Care..."

c. During interview with the OB NM and CN on 10/22/2019 at 1500 at the time of Patient 4's record review it was confirmed that SAMC did not have a NICU and therefore lacked capability and capacity to care for the unborn twins. The lack of patient specific individual risks of transfer was reviewed with the OB NM and CN. No additional information was provided.

d. Online flight calculator reflected SLBMC located in Boise, Idaho is approximately 30 minutes flight time from SAMC located in Ontario, Oregon.

5. a. The ED record of Patient 5 was reviewed and reflected the patient presented to the OB unit on 05/23/2019 at 1835 with a chief complaint of "OB Check."

* The RN "Handoff Form" dated 05/23/2019 at 1912 reflected "Anticipated Events...Pt here c/o ctrx and ROM. ROM plus is negative. VE 2/5/-3. 18g in left hand...Pt is aware that [he/she] is being transferred to Boise."

* The H&P electronically signed by the CNM and dated 05/23/2019 at 2006 reflected a MSE was conducted and stabilizing treatment was provided. The H&P reflected "Physical Exam...Temperature 98.4...Pulse 129...BP: 113/66...Obstetric Exam...Cervix Dilation: 2 Fetal Station: -3 Fetal Station Calculation: -3 Cervical Consistency: Medium...Presenting Part: Vertex...Heart rate regular rhythm. Lungs clear to auscultation. Abdomen soft and non tender. No edema. Impression and Plan...EDD: 07/06/2019 EGA: 33 weeks 5 days...Diagnosis: Preterm labor...33.5 weeks in preterm labor...Plan: Admit to (Labor & Delivery), Labor (Prepare to transport)..."
* The "Discharge Depart Patient (Order):" unclearly reflected "To: Skilled nursing facility...5/23/2019 20:06..."

* The "Discharge/Depart Form" dated 05/23/2019 at 2142 reflected:
- "Discharge Transport Mode Stretcher"
- "Discharged/Released to Acute care hospital..."
- "Discharge Comments report given to transport team then called to...St. Lukes (sic) Downtown and gave report.
- "Discharge Date and Time 05/23/2019 20:36"

* A 3-page transfer form with physician certification titled "Patient Consent to/Request for Transfer SAHS-0416" was reviewed and reflected the patient was transferred with a diagnosis of "Preterm Labor."
- The "Receiving Facility" section was blank.
Page 3 of the form reflected:
- The "Mode of Transport" section reflected both "Transporting Agency: Air St (sic) Lukes (sic)" and "Ground Ambulance." It was unclear if air transport or ground ambulance was used for the transfer.
- The "Accompanying Personnel:" section was not filled out. The following options were blank "EMT/Paramedic," "Nurse," " Other," and "None Required."
The physician certification of "Risks and Benefits of Transfer" section reflected:
- The "Benefits of Transfer:" section reflected only "Patient request." There were no other benefits of transfer identified.
- The "Risks of Transfer:" section reflected the following preprinted generic options were identified as the risks of transfer: "Patient injury due to vehicular accident or equipment failure during transfer," "The patient's following medical condition may worsen during transfer:" followed by a blank line, "Patient is in labor and may progress to delivery during transfer," and "Other Risks:" followed by a blank line.

The record reflected the following aspects of an appropriate transfer were not carried out:
* There was no documentation on the physician certification or elsewhere in the record of patient specific, individual risks of transfer for the mother who was preterm at 33 weeks gestation with SROM or the unborn child.
* The physician certification reflected the "Benefits of Transfer" was "Patient request." There were no other benefits of transfer identified and no information that reflected the reason the patient requested the transfer.
In addition, documentation related to transfer arrangements, including the mode of transport and qualified personnel accompanying the patient was unclear and incomplete.

b. The hospital's scope of services document titled "Scope of Services," dated approved 05/16/2017 was reviewed and reflected no evidence of NICU services. The document reflected "Services Not Provided...Neonatal Intensive Care..."

c. During interview with the OB NM and CN on 10/22/2019 at 1450 at the time of Patient 5's record review the following information was revealed:
* It was confirmed that SAMC did not have a NICU and therefore lacked capability and capacity to care for the unborn child.
* It was confirmed that the patient was transferred to SLBMC.
* It was confirmed that the transfer form reflected that "Patient request" was checked as a benefit of transfer. However, it was stated that the patient did not request to be transferred but instead "Patient request" was checked on the transfer form because the patient had a choice between two hospitals that each had a NICU, and he/she "requested" to be transferred to SLBMC.
* The lack of patient specific individual risks of transfer was reviewed with the OB NM and CN. No additional information was provided.

d. Online flight calculator reflected SLBMC located in Boise, Idaho is approximately 30 minutes flight time from SAMC located in Ontario, Oregon; and online driving directions reflected SLBMC is approximately 57 miles and 56 minutes driving time from SAMC.