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Based on interviews, policy and procedure review, and documentation in 1 of 31 emergency department (ED) records reviewed (Patient #1), it was determined the hospital failed to comply with all the requirements of 42 CFR 489.24 as it failed to provide a medical screening examination (MSE) for Patient #1 to determine whether or not an emergency medical condition (EMC) existed (refer to Tag C2406).

It was determined the hospital failed to include information regarding the protection of medical staff and employees who report alleged EMTALA violations within their EMTALA policies as per 42 CFR 489.24(e)(3).

In addition, the hospital failed to follow its EMTALA policy regarding documentation of specific risks and benefits for 2 of 10 ED patients with an EMC who were transferred to another medical facility (refer to Tag C2409).

Based on interviews, policy and procedure review and documentation in 1 of 31 emergency department (ED) records reviewed (Patient #1) it was determined that the hospital failed to provide a MSE for Patient #1 to determine whether or not an EMC existed. However, the findings reflected that hospital staff had immediately identified the failure to provide the MSE, had identified the cause for the failure, had developed and implemented a plan of correction, which included additional training for physicians and staff and self-reporting to the State Agency, before this investigation was initiated on 04/02/2012. Findings include:

1. Documentation on the "ED Chart Forms" for Patient #1 reflected that the patient presented to the ED on 03/16/2012 at 1229. The chief complaint was "facial twitching intermittent 2 wks" as documented by the triage nurse at 1232. The triage nurse further documented "Pt presents with facial twitching intermittently. Pt. states starts with 'warm sensation going up spine,' 'Pressure in Head' feels like not getting enough blood somewhere. Smiles crooked. Grip good." The patient's vital signs at 1232 were documented with a blood pressure of 151/88 and a pulse of 134. The chart lacked documentation of a pain assessment.

At 1258, the "ED Chart Forms" reflected "Pt called into triage to be informed that due to past encounters with [Physician C], [Physician C] refused to [treat] pt. RN spoke with [Employee #11] who would see pt. in clinic at 1540 today. Pt. stated that [he/she] 'did not have a problem with [Physician C], that was my [adult family member].' Pt was offered the clinic visit or [he/she] could go to Riverbend. Pt stated that [he/she] would go to Riverbend, and [he/she] walked out of triage. [Spouse] who was not in triage with pt. had asked to speak with [Physician C] which was denied."

Patient #1's ED Chart lacked physician documentation of an appropriate medical screening examination.

2. An interview with the triage nurse, Employee F, conducted on 04/03/2012 at 0950 reflected that Patient #1 had been in the ED two days before with "the same symptoms." Employee F stated that he/she told Physician C about the previous encounter where the patient presented with the same symptoms. He/she told Physician C "This patient is a difficult patient."

Employee F stated that Physician C said "[Patient #1] works here. I do not want to see this person." Employee F stated that "[Physician C] was adamant that [he/she] "would not deal with [the patient]." "It was the first time I've ever been put in this position. [He/she] [Physician C] wouldn't even look at the chart. [He/she] wanted nothing to do with [the patient]."

Employee F indicated that he/she went to the charge nurse and discussed the issue. The charge nurse then tried to make an appointment for Patient #1 with a nurse practitioner at the clinic, which is within the hospital.

3. An interview with the charge nurse, Employee E, conducted on 04/03/2012 at 0900 reflected that he/she first became aware of the incident concerning Patient #1 when Employee F told him/her that the patient was requesting to be examined. The charge nurse reflected "[Employee F] came in following triage saying "[he/she] is back, tests have already been done, CT (computed tomography) Scan and MRI (magnetic resonance imaging).' Physician C will not look at the patient or see [him/her]." The charge nurse further stated "in my 27 years [as a nurse] I have never had the experience of a physician refusing to see a patient." Employee E stated that Physician C said "I won't see [him/her], I won't look at the chart." The charge nurse recognized the patient needed to be medically screened so he/she walked across the hospital entrance to the clinic and spoke to the nurse practitioner. He/she discussed the issue and obtained an appointment time of 1540 for the patient.

The charge nurse returned to the ED and informed Physician C that he/she had been able to arrange an appointment with a nurse practitioner (Employee 11) in the clinic later in that afternoon. The charge nurse then asked to meet the patient in the triage room. He/she also requested the triage nurse to stand outside the triage room so he/she could confirm the conversation the charge nurse was having with the patient. The charge nurse informed the patient that "Physician C would not see him/her due to past encounters. I told him/her that I had an appointment for him/her to see [Employee 11] at 1540 or he/she could go to Riverbend [Sacred Heart Riverbend Hospital], I told him/her it is your choice." "I knew in the past he/she had been to Riverbend but I made the appointment for him/her here." The charge nurse continued to say, "the patient said he/she would go to Riverbend." He/she left the room and [the patient] said to his/her significant other "I have to go to Riverbend," and they left.

The charge nurse stated "I had not denied him/her treatment, I found him/her a place to be seen!"

In clarifying the interaction, the charge nurse stated "The doctor said [he/she] would not see [Patient #1] and wouldn't look at the chart. [He/she] wouldn't have anything to do with it." In addition, the charge nurse stated "I got the feeling [ Physician C] didn't want to get in the middle of legal issues." The charge nurse stated that [Physician C] didn't make or request any other arrangement to assure the MSE was completed. When asked who could complete the MSE, he/she stated, "By policy, it is just the physician."

The charge nurse was asked to describe the symptoms the patient presented with. The charge nurse said, "He/she was having a 'twitch' in her cheek. He/she needed to be seen by a care provider according to EMTALA. I knew he/she was upset and had been crying in the waiting room."

4. A telephone interview with Patient #1 was conducted on 04/04/2012 at 0910. Physician C had refused to complete a medical screening exam on the patient on 03/15/2012. Patient #1 informed the surveyors that he/she was in Bend, Oregon, being evaluated by a neurologist. He/she stated "I've been having health issues since January when my symptoms turned more neurological." He/she continued to describe the symptoms as "I get a funny feeling in my head, spasms in my face, lightheaded and a warm feeling in my spine. On March 18, 2012 around 1100, it started again. I was scared and asked my [adult family members] to take me to the hospital. I got triaged, was having neurological stuff then waited in the waiting room for about 20 minutes. The nurse came out and said [Physician C] refuses to see you because of past issues when you brought your [adult family member] in. About a year ago I brought my [adult family member] to the hospital and [Physician C] said [he/she] wasn't going to do anything for my [adult family member]...we left and I took him/her to Sacred Heart Riverbend Hospital (SHRB) [located 22 miles from Cottage Grove Community Hospital (CGCH)]. I reported Physician C to the board." Patient #1 further stated the "[he/she] had worked at CGCH for several years and [he/she] doesn't care about [his/her] [adult family member's] visit from a year ago. I just want to go to my hospital when I need care. I am in Bend now because I need a neurologist."

The patient stated that the nurse "said he/she could be seen in the clinic at 3:40 which was in 3-4 hours. I didn't feel I could wait so I just went to McKenzie Willamette Medical Center (MWMC)" [located approximately 19 miles away].

5. An interview with Physician C was conducted on 04/04/2012 at 1130. [He/she] stated the alleged event occurred on a Sunday when there were fewer hospital and clinic staff available and no security scheduled. Physician C reflected he/she remembers the triage nurse coming up to [him/her] stating "We have a situation here. I need to let you know about it. This patient was seen Friday by [Physician B] and the situation got really out of hand." The triage nurse stated the patient's behavior escalated to the point of becoming threatening and hostile and [Physician B] had to request a mental health evaluation for the patient. Physician C then stated the triage nurse said the patient was an employee at the hospital and Physician C became more concerned. He/she said "it occurred to me this is a patient I've seen before, not only as a patient but also with his/her family...my previous experiences with the patient were also volatile." I asked who it was, he/she showed me his/her name on the chart. I said, I don't think I can see this patient unless it's an emergency, if it's an emergency then bring him/her back." The triage nurse said "no, no stable, vital signs stable...seen for same thing before." Physician C stated that he/she told the triage nurse to find alternative plans, such as someone else to see him/her but he/she didn't specify whom it should be. The physician stated "In hindsight, my assumption was it would be in the ED, I wish I had specified the ED."

When asked how many times Physician C had previously treated Patient #1, the physician responded "Just a few times, most interactions were when he/she was with his/her [adult family member]...he/she was most dramatic when he/she was with his/her [adult family member]." The physician stated that Patient #1 would threaten, become more volatile and throw things.

Physician C admitted that he/she had not communicated with the staff as clearly as he/she should have. Physician C did not feel that Patient #1 was his/her patient therefore didn't want to look at the patient chart. He/she worried about a HIPAA (Health Insurance Portability and Accountability Act) violation. Physician C stated "I wasn't assigned as his/her provider but I thought the on-call doctor may see him/her or [clinic nurse practitioner]. "That is why I didn't look at the record."

6. A review of the hospital's "EMTALA (Emergency Medical Treatment and Labor Act) Compliance policy last reviewed/revised 05/13/2010 reflected that "5.4.1. Emergency Department Licensed Independent Practitioners or other qualified medical personnel shall provide medical screening examinations. Registered nurses are responsible for determining the order in which patients receiving the screening examinations by physicians shall be seen pursuant to the triage policy. Physicians or other designated providers are responsible for determining whether the individual has an emergency medical condition using the capability of the ED, in consultation with other members of the medical staff and including ancillary services routinely available to the ED."

The policy further reflected, "5.6. Patients have a right to refuse offered medical screening and stabilizing treatment...Staff will not suggest to patients that they could leave or go elsewhere for care."

The policy further reflected, "8. Medical screening examination...Triage is not equivalent to a medical screening examination as triage merely determines the order in which patients will be seen, not the presence or absence of an emergency medical condition."

7. Review of the ED Staffing Schedule reflects: Day Shift: 2 RNs and 1 ERT (emergency room technician), Evening Shift: 2 RNs or RN & ERT, Night Shift: 2 RNs. ED Ward Clerks: 1 ward clerk scheduled from 1000-2200. ED MD (Doctor of Medicine) Schedule reflects: 1 MD scheduled every 12 hrs. The schedule on 03/18/2012 reflected a fully staffed schedule for physicians and staff. Security is scheduled from 2100-0500 nightly. This schedule was confirmed with the Patient Care Executive on 04/10/2012 at 1430.

The ED patient census was 27 patients on 03/18/2012. According to the ED Medical Director in an interview on 04/03/2012 at 0815, he/she stated the ED average daily census was approximately 35.

8. Review of personnel files of ED staff involved in the care of Patient #1 reflected that each one had completed EMTALA training per the hospital's previous policy requirement of "every two years."

9. The hospital submitted a Corrective Action Plan to the State Agency prior to the survey entrance date. During the coarse of the survey, the hospital administration formulated and submitted two revisions of the plan to meet all requirements. The Administrator submitted a revised document titled "Cottage Grove Community Hospital Plan of Action following March 18th, 2012 Emergency Department Possible EMTALA Incident" on 04/04/2012 at 1415.

The following action plan items were completed before the survey team arrived.

"Immediate counseling to MD involved with follow up discussion."
Responsibility - Hospital Administrator
Completion Date - March 18 and 21, 2012

"Immediate counseling of the involved triage/charge nurses regarding their actions and judgment in this case and EMTALA requirements in general."
Responsibility - Patient Care Executive
Completion Date - March 19, 2012

"The ED Medical Director sent an e-mail to the ED physicians reminding them of EMTALA requirements in every case."
Responsibility - ED Medical Director
Completion Date - March 20, 2012

"Social Work contacted patient and case management, coordination of care, set up for patient in concert with PCP (Primary Care Physician)."
Responsibility - Patient Care Executive and Social Work
Completion Date - March 20, 2012

"The Charge Nurse reviews all transfers on a real-time basis for EMTALA compliance."
Responsibility - ED Nurse Manager
Completion Date - March 20, 2012

"Discussion was facilitated with ED leadership and Administration to review the circumstances of the potential violation and to develop additional follow-up tasks."
Responsibility - ED Medical Director, Director of Risk, PHOR (Peace Health Oregon Region), CGCH Administrator, Patient Care Executive/Risk Manager
Completion Date - March 20, 2012

"Self-report of possible EMTALA violation to State."
Responsibility - Hospital Administrator, PHOR Risk Director
Completion Date - March 21, 2012

"Immediate educational e-mail was sent by CGCH Patient Care Executive to ED staff regarding EMTALA requirements."
Responsibility - Patient Care Executive
Completion Date - March 21, 2012

"Chain of Command Policy sent to all ED nursing staff with required reading and signature sheet."
Responsibility - Patient Care Executive
Completion Date - March 25, 2012

"ED Medical Staff receives EMTALA education at April 2, 2012 Medical Staff Meeting."
Responsibility - ED Medical Director and PCE (Patient Care Executive)
Completion Date - April 2, 2012 [4 of 8 physicians attended the meeting]

The following components of the action plan were completed while the surveyors were onsite:

"SLMG (South Lane Medical Group) Physician Coverage of Emergency Department Process is added to Orientation Manuals."
Responsibility - ED Nurse Manager: Nursing; Medical Director: Medical Staff
Completion Date - April 3, 2012

"Cottage Grove Community Hospital EMTALA Policy additional language added to reflect requirements for annual EMTALA education by nursing and medical staff."
Responsibility - Emergency Department Nurse Manager
Completion Date - April 3, 2012

"The EMTALA Policy stipulates that there will be no punitive action taken with any employee who reports is a possible EMTALA Incident."
Responsibility - Hospital Administrator
Completion Date - April 4, 2012

"The Medical Director or designee conducts a 100% retrospective weekly review of documentation of transfers. These reviews are reported monthly to the ED Medical Staff Committee, in turn reported to the CGCH Quality Committee and Governing Board."
Responsibility - ED Medical Director
Completion Date - April 4, 2012

The following components of the action plan had a projected date of April - May, 2012.

"Staff EMTALA online training required annually with competency testing (Changed from biannually)."
Responsibility - ED Nurse Manager
Completion Date - April 2, 2012

"Medical Staff EMTALA online training required annually."
Responsibility - Administrator/ Learning and Development
Completion Date - April, 2012

"Education/Coaching and Training for Medical Staff Re. Transfer Form Completion with Risks Identified and Documented."
Responsibility - Medical Director, Email to Medical Staff, Coaching with MD, Medical Staff Training at ED Med Staff Mtg.
Completion Date - April 3, 2012, April, 2012 and May 2012

"Development and delivery of 'Special ED Scenarios' for staff EMTALA Critical Thinking Training."
Responsibility - Patient Care Executive
Completion Date - Staff Meeting April/May 2012

"Medical Staff and Nursing Staff education and discussion regarding SLMG on call physician coverage of Emergency Department provided at staff meeting."
Responsibility - Patient Care Executive - nursing; Medical Director - medical staff.
Completion Date - April/May, 2012 - Nursing; May, 2012 - Medical Staff

10. Copies of all policy and procedure revisions and communications referred to in the hospital's plan of correction were reviewed and confirmed. The plan of correction was revised twice during the onsite investigation. It was verified that the original plan had been developed and implemented prior to the survey entrance conference and the revisions to the plan were in the process of implementation prior to the survey exit conference.

11. The finding reflected that on 03/18/2012 Patient #1 did not receive a MSE in accordance with the hospital's policies and procedures. The review of 30 other patient ED records revealed MSEs in all of the cases. Nine of those were for other patients who presented to the ED with a chief complaint consistent with neurological symptoms.

12. The failure on 03/18/2012 was determined not to be for lack of systems, policies and procedures, staff knowledge or awareness. Further evidence of that is the RN's immediate identification of the failure and his/her self-report to the Patient Care Executive (PCE). In response to the RN's self-report, management, executive, and medical staff responded timely and appropriately to develop and implement a plan of correction to prevent the failure from occurring again.

Based on interview, policy and procedure review, and documentation in 2 of 10 ED patients with an EMC who were transferred (Patients #24 and 30) it was determined that the hospital failed to comply with all the requirements of 42 CFR 489.24(e).

Findings include:

Review of documentation revealed that the hospital had developed a transfer form titled "PeaceHealth EMTALA Transfer Form," that addressed the elements of an appropriate transfer. Attached to each two-page transfer form was a double-sided form titled "Guidelines For Completing an EMTALA Transfer Form." Examples of medical risks and benefits of transfer were listed to assist the physicians and staff with completing the form appropriately.

Medical record #s 24 and 30 lacked documentation of the "risks of transfer" on the EMTALA Transfer form and documentation within the physician's dictation. These findings were discussed with the Patient Care Executive and Regional Risk Manager on 04/13/2012 at 1545. They reviewed the medical records and confirmed that each medical record lacked documentation of the patient-specific increased risks associated with being transferred.

1. Medical record #24: Documentation reflects that Patient #24 was an 88 year old individual who presented to the ED on 11/03/2011 at 0850 with right sided numbness and decreasing right hand grip. Documentation reflected an immediate MSE that included diagnostic imaging of the head and diagnostic blood and urine tests. Documentation reflected that Patient #24 had been seen in the ED the previous day with similar symptoms. The patient had been discharged home but when the symptoms recurred on 11/03/2011, he/she returned to the ED. The physician documented the intermittent symptoms may have been due to the newly diagnosed [cardiac arrhythmia] atrial fibrillation/flutter. Documentation reflected that the patient needed more specialized care than the hospital could provide therefore arrangements were made to transfer the patient to another facility. At the time of transfer, documentation reflected the patient was stable without neurological deficit.

Patient #24 was transferred to another facility with cardiovascular capability and capacity. The medical record lacked documentation of the physician's certification that the benefits of the transfer outweighed the specific risks of the transfer.

2. Medical Record #30: Documentation reflects that Patient #30 was a 73 year old individual who presented to the ED on 11/07/2011 at 1150 with a chief complaint of chest pain, shortness of breath and diaphoresis for 20 minutes. Documentation reflected an immediate MSE by the physician that included diagnostic radiological, ECG (electrocardiogram), blood and urine testing. Documentation reflected the ECG revealed an acute inferior myocardial infarction with right coronary occlusion. Documentation further reflected the immediate request for Life Flight to transfer Patient #30 to a local cardiovascular facility with available cardiac characterization capabilities.

Patient #30 was transferred to another facility with cardiovascular capability and capacity. The medical record lacked documentation of the physician's certification that the benefits of the transfer outweighed the specific risks of the transfer.

3. A review of the hospital's "EMTALA (Emergency Medical Treatment and Labor Act) Compliance policy last reviewed/revised 05/13/2010 reflected that "3. Certifications: An express written certification which may be made only by a physician and signed by that physician, that says that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual...Physician certification must contain a summary of the risks and benefits upon which it is based. Physician certification cannot simply be implied from the findings in the medical record. The certification must state the reason(s) for transfer..."

Documentation found in the medical records for Patients #24 and 30 did not include the increased risks of the transfers in addition to the benefits.