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Based on interview, review of documentation in the medical records in 6 of 20 patients who presented to the hospital for emergency services (Patients 7, 8, 12, 16, 17 and 19), and review of hospital policies and procedures, 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; and
* Provision of MSEs.

Findings included:

1. Regarding provisions of MSEs refer to the findings identified under Tag A2406, CFR 489.24(a) & (c).

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

Based on interview, review of documentation in the medical records of 4 of 9 patients who presented to the ED for emergency services (Patients 8, 12, 17 and 19) and left AMA or LWBS, and review of policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that all patients were provided a complete and appropriate MSE, or that attempts were made to advise the patients of the risks of leaving before an MSE was completed.

Findings included:

1. The policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities," dated as revised "03/2019" was reviewed. It stipulated:

* "Emergency Medical Condition - An Emergency Medical Condition (EMC) means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and mental illness) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or parts ..."

* "Procedure Medical Screening Examination - Medical Screening Examination (MSE) - is an exam completed by qualified medical personnel to determine whether or not an EMC or active labor exists. A MSE may represent a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that involves performing ancillary studies and procedures. A complete and appropriate MSE will be performed on all individuals who come to the hospital requesting examination or treatment or attempts will be made to advise the patient of the risk of leaving before an MSE can be completed. An MSE will be completed regardless of an individual's ability to pay."

* "Qualified medical personnel who may be permitted to perform a MSE are defined as: Members with clinical privileges; and Registered Nurses ..."

* "If a patient presenting to ED(s) or L&D/Perinatal department(s) and while waiting for medical screening decides to leave without examination (AMA/LWBS) the following steps should be taken if at all possible:
a. Explain to the patient it is important to have the medical screening to rule out whether or not they have a medical condition that needs treatment;
b. Use an interpreter if the patient has limited English proficiency, or use an alternate means of communication;
c. Inform the patient of the risks of not having the medical screening;
d. Ask the patient to sign the AMA form acknowledging they understand the risks of leaving without the medical screening;
e. Document on the medical record the above information and if they refuse to sign the AMA, document that on the record as well."

2. The ED medical record for Patient 8 reflected [he/she] presented to the ED on 01/28/2019 at 2242 with a chief complaint of "Abdominal pain." The ED triage note at 2254 reflected "Pt crying in triage. [Family] states [his/her] skin is red and pt has been in pain. Pt lwbs earlier this evening."
* At 0031 on 01/29/2019 an RN note reflected "went out and spoke with family. States I hoped I could get their child back in the next 20 to 30 minutes. [Family] verbalized understanding."
* No documentation of a MSE was found in the medical record.
* At 0032 on 01/29/2019 a RN note reflected "ED disposition set to AMA/LWBS." There was no documentation in the record that the risks of not having a MSE were explained to the patient/family and a signed AMA form was not found or any documentation that the patient/family refused to sign the AMA form, per the hospital policy.
* There was no further documentation of the circumstances surrounding the patient leaving prior to receiving a MSE.

3. The ED medical record for Patient 12 reflected [he/she] presented to the ED on 02/15/2019 at 2225 with a chief complaint of "chest pain." The ED triage note at 2226 reflected "Past couple days pt has had chest pain, L shoulder pain, sob. States [he/she] has a hx of panic attacks, work has been adding stress. States this feels different than past attacks." The patient was triaged and an EKG was done.
* At 2325 on 02/15/2019 an RN note reflected "ED Dispostition set to LWBS after Triage."
* There was no documentation of the circumstances surrounding the patient leaving the ED prior to a MSE.
*Although the record reflected an EKG was done, there was no documentation that reflected further evaluation of the patient's medical condition or that a MSE had been completed. There was no documentation in the record that the risks of not having a MSE were explained to the patient and a signed AMA form was not found or any documentation that the patient refused to sign the AMA form, per the hospital policy.

4. The ED medical record for Patient 17 reflected [he/she] presented to the ED on 03/03/2019 at 2319 with a chief complaint of "vaginal pain." The RNs ED triage note at 2340 reflected "Awoke crying painful in [his/her] genitals, [family] tried warm and cool bath with no relief, [family] thinks there might be a scratch there and thought [he/she] saw a splinter."
* At 0119 on 03/04/2019 a RN note reflected "ED Disposition set to LWBS after Triage."
* There was no documentation of the circumstances surrounding the patient leaving the ED prior to a MSE.
* There was no documentation that reflected further evaluation of the patient's medical condition or that a MSE had been completed. There was no documentation in the record that the risks of not having a MSE were explained to the patient/family and a signed AMA form was not found or any documentation that the patient/family refused to sign the AMA form, per the hospital policy.

5. The ED medical record for Patient 19 reflected [he/she] presented to the ED on 03/07/2019 at 2209 with a chief complaint of "pregnant and bleeding." The RN ED triage note at 2217 reflected "Patient states last period December 28th, bleeding for over a week with last two days large multiple clots and abd cramping. Patient has not had pre-natal care."
* At 2354 a ED Physician ordered an OB ultrasound that was not completed.
* At 0000 on 03/08/2019 a RN note reflected "ED Disposition set to LWBS after Triage."
* There was no documentation of the circumstances surrounding the patient leaving the ED prior to a MSE.
* There was no documentation that reflected further evaluation of the patient's medical condition or that a MSE had been completed. There was no documentation in the record that the risks of not having a MSE were explained to the patient and a signed AMA form was not found or any documentation that the patient refused to sign the AMA form, per the hospital policy.

6. During interview with the QMC and EDM on 04/17/2019 at the time of the medical record review they confirmed findings 2, 3, 4 and 5 and stated that there was no other documentation in the medical records that reflected AMA forms were signed, that the patient/family refused to sign the form or that the patient had the risks explained about leaving prior to receiving a MSE.

Based on interview, review of documentation in the medical records of 2 of 2 pediatric patients transferred to other hospitals by private vehicle (Patients 7 and 16), review of hospital policies and procedures, it was determined that the hospital failed to develop and enforce its EMTALA policies and procedures for patients seeking emergency services to ensure that it affected appropriate tranfers of patients for whom an EMC had not been ruled out, removed or resolved:
* Appropriate modes of transportation with qualified medical personnel and transportation equipment.

Findings included:

1. The policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities," dated as revised "03/2019" was reviewed. It stipulated:

* "Objectives ... to ensure proper documentation of transfer ... To provide guidelines to support the continuum of care when patients must be transferred between facilities."

* "Rationale ... This policy applies to all patient populations presenting to an ED (including pediatric patients), L&D or Perinatal Department, or anywhere on hospital property with an emergency medical condition needing treatment or transfer to or from any Providence hospital."

* "Capability - of the hospital means that there is physical space, equipment, supplies, and specialized services that the hospital provides (e.g. Surgery, Psychiatry, Obstetrics, and Intensive Care). Capability of the hospital staff means the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses (including that of the on-call physicians)."

* "Transfer - means the movement of an individual outside a hospital at the direction of any person authorized by ... the hospital, but does not include such a movement of an individual who (a) has been declared dead, or (b) leaves the facility without the permission or against medical advice of any such person, or (c) is transported between campuses or departments of one hospital."

* "Procedure ... Prior to transfer, an explanation of the need to transfer and the alternative to transfer will be made to the patient. Individualized risks and benefits will be summarized verbally and documented on the Patient Transfer Form or physician documentation in the medical record. Stabilized patients may be transferred to another hospital if the patient so desires. Patients may be transferred (1) at their own request, (2) at the request of a legally responsible person on the patient's behalf or (3) if physician or qualified care provider certifies in writing that the benefits of transferring the patient to another facility outweigh the risk ... Arrangements for proper conveyance will then be made; a physician or qualified care provider will determine the safest method of transport ... The referring and receiving care providers share the responsibility for patient transfer and they should consult regarding the arrangements and details of patient transfer, including the method of transportation. The care provider arranging transportation is responsible for determining what additional care is required before transfer. The care provider will also determine what transportation equipment is needed; including the use of necessary and medically appropriate life support measures during the transfer."

* "Patients refusing a medically indicated transfer to another facility must sign the "INFORM CONSENT REFUSE PHS" form ... If the patient refuses to sign the form, charting in the EMR must indicate that the person has been informed of the risks and benefits of the transfer and the reasons for the individual's refusal."

* "Documentation to occur on patient's chart ... Notification of acceptance by the receiving health care facility ... How patient is transferred (method of conveyance) ... Records that accompanied the patient ... Reasons for transfer, i.e., per Dr. Smith's request, or per family request, etc. ... Note by the physician of the patient's condition at the time of transfer ... Notification of patient's family ... Explanation of benefits and risks are explained to patient/family."

* "All pertinent medical information shall accompany the patient being transferred and the transfer shall be effected through qualified personnel and transfer equipment."

2.a. The ED medical record for 22-month old Patient 16 reflected he/she presented to the ED on 03/03/2019 at 1109 "for evaluation of a right ear laceration. [Family] states that the patient was playing on the couch and fell, hitting [his/her] right ear on the coffee table."
* A Physician note on 03/03/2019 at 1138 reflected "Linear laceration involving the cartilage at the right lateral mid ear extending through the helix, scaphoid fossa and antihelix."
* At 1142 on 03/03/2019 the ED Physician noted a Pediatric ENT physician was paged through the Providence Regional Transfer Center and responded at 1156 recommending consulting a Plastics Specialist at OHSU or Randall Childrens Hospital. The medical record reflected that "the parents had no preference," the ED physician called the on-call Plastics Physician at OHSU and he/she accepted the transfer.
* The ED RN note dated 03/03/2019 at 1302 reflected "Who was provided with discharge information or care facility report? pt" and "Was this transportation mode assessed for optimal patient safety? no"
* The "Patient Transfer" form electronically signed by the ED physician on 03/03/2019 at 1236 reflected "Patient specific transfer benefits: Facial Trauma eval/tx."The section for "Summary of transfer risks:" reflected preprinted generic language "All transfers have the risk of traffic accidents, bad weather and /or road conditions as well as limitations of personnel and equipment during transport." The section "patient specific transfer risks:" section reflected "Bleeding." The form reflected the "mode of transportation was Private auto."
* Although the record reflected in an RN note on 03/03/2019 at 1300 that the parents would drive the patient to OHSU, there was no documentation that reflected the physician arranged an appropriate transfer for this 22-month old patient who had a facial trauma and was at risk for bleeding that included qualified personnel and transportation equipment, or that the family/responsible person refused such arrangements. There was no documentation of a written refusal that reflected the family/responsible person was informed of the risks and benefits of the transfer and the reasons for refusal. There was also a lack of documentation reflecting the risks and benefits of going by "private auto" had been discussed with the family/responsible person.

b. During interview with the QMC and EDM on 04/17/2019 at the time of the medical record review, they confirmed there was no documentation in the record that reflected the physician arranged an appropriate transfer that included qualified medical personnel and transportation equipment.

3.a. The ED medical record for 2-year old Patient 7 reflected [he/she] presented to the ED on 01/22/2019 at 2123 with a chief complaint of "fits of intermittent abdominal pain following a vomiting illness last night to early this morning, rhinorrhea, and fatigue."
* At 0214 on 01/23/2019 an ED Physician note reflected "complains of abdominal pain with palpation but is not guarding. I do not find any focal tenderness and appendicitis is lower on the differential based on this history and exam. We discussed at length the options including blood work, serial abdominal exams and repeat imaging ..." Legacy Randall Children's Hospital ED was consulted and accepted the patient for ED to ED transfer for ongoing evaluation.
* The "Patient Transfer" form electronically signed by the ED physician on 01/23/2019 at 0307 reflected "Patient specific transfer benefits: Further assessment/evaluation and management of [his/her] abdominal pain." The section for "Summary of transfer risks:" reflected preprinted generic language "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport." The section "Patient specific transfer risks:" reflected "Worsening pain, potential infection or intussusception." The form reflected the "mode of transportation was Private auto."
* Although the record reflected "the [family] prefers to drive [him/her], there was no documentation that reflected the physician arranged an appropriate transfer that included qualified personnel and transportation equipment, or that the family/responsible person refused such arrangements. There was no documentation of a written refusal that reflected the family/responsible person was informed of the risks and benefits of the transfer and the reasons for refusal. There was also a lack of documentation reflecting the risks and benefits of going by "private auto" had been discussed with the family/responsible person.

b. During interview with the QMC and EDM on 04/17/2019 at the time of the medical record review, they confirmed there was no documentation in the record that reflected the physician arranged an appropriate transfer that included qualified medical personnel and transportation equipment.