HospitalInspections.org

Based on observation, interview, review of medical record documentation for 4 of 20 encounters of individuals who presented to the hospital for emergency services (Patients 2, 6, 7 and 12), review of the central log, review of internal investigation documentation, review of medical staff rules and regulations, 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:
* Required posting of EMTALA signs;
* Provision of MSEs; and
* Appropriate transfers of patients.

Findings include:

1. Regarding the posting of signs refer to the findings identified under Tag A2402, CFR 489.20(q).

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

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


44104

Based on observation, interview and review of policies and procedures, it was determined the hospital failed to enforce EMTALA policies and procedures that ensured the posting of signage, that specified individuals' EMTALA rights with respect to examination and treatment for emergency medical conditions and women in labor, in all areas likely to be noticed and where individuals waited for examination and treatment.

Findings include:

1. Review of the P&P titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated effective "8/2019" reflected " ... Signage - means the signs posted by the Hospital in its dedicated ED(s), L&D/Perinatal department(s) and in a place or places likely to be noticed by all individuals entering the dedicated ED(s), ), (sic) L&D/Perinatal department(s), as well as those individuals waiting for examination and treatment. The signage must inform individual (sic) of their rights under EMTALA. Each Hospital will post signage in the dedicated ED and L&D/Perinatal Department specifying ... the rights of individuals under the law with respect to examination and treatment for emergency medical conditions ... the rights of women who are pregnant and are having contractions ... whether the hospital participates in the Medicaid program ... "

2. During a tour of the ED on 10/27/2020 beginning at 1045 with the EDM and other hospital staff, the following observations were made:
* The main ED waiting room included a section that was divided by movable partitions into two separate waiting areas. In one of the two waiting areas, 13 chairs were observed, and two EMTALA signs were observed posted on the walls. The EMTALA signs were not conspicuously posted as one of the EMTALA signs was partially obscured by the partition and was not fully visible. The other EMTALA sign was not readable from eight of the 13 chairs because the sign was posted too far away from the chairs to be read. No other EMTALA signs were observed in that waiting area. These observations were confirmed during an interview with the EDM at the time of the observation. The EDM confirmed all individuals waiting for exam and treatment would not have the opportunity to see the required EMTALA signage.



44104

Based on interview, review of central log and medical record documentation for 2 of 2 encounters of individuals who presented to the hospital for emergency services and did not receive an MSE (Patients 2 and 7), review of internal investigation documentation, review of medical staff rules and regulations, 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 an MSE within the capabilities and capacity of the hospital, and that hospital staff did or said nothing to dissuade patients from staying at the hospital for the provision of an MSE:
* Patient 2 who presented to the hospital for emergency services left the hospital without receiving an MSE for reasons that were unexplained and without attempts to provide the patient with information about the risks of leaving, and without the patient signing an AMA form, in accordance with hospital P&Ps; and there was a lack of documentation that staff did or said nothing to dissuade the patient from staying at the hospital to be evaluated for an EMC.
* Patient 7 who presented to the hospital for emergency services for a head fracture and bleed did not receive an MSE as upon arrival the patient was directed by hospital staff that he/she should go to another hospital.

Findings include:

1. The P&P titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated effective "08/2019" was reviewed and reflected:
* "Emergency Medical Condition - An Emergency Medical Condition (EMC) means ... A 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 ... Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy ... Serious impairment to bodily function; or ... With respect to a pregnant woman who is having contractions, an EMC means ... That there is inadequate time to effect a safe transfer to another hospital before delivery, or ... that transfer may pose a threat to the health or safety of the woman or the unborn child."
* " ... Triage does not constitute a Medical Screening Exam. Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital, or order to prioritize when the individual should be seen by a physician or other qualified medical personnel."
* " ... 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 ... "
* " ... 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 ... 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 ... Inform the patient of the risks of not having the medical screening ... Ask the patient to sign the AMA form acknowledging they understand the risks of leaving without the medical screening ... 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 medical staff rules and regulations titled "Policies and Procedures Professional Staff Providence Health & Services - Oregon," dated as last revised 09/22/2019, was reviewed and reflected " ... Medical Screening Examinations: Medical screening examinations will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition."

3. a. The central log for Patient 2 reflected that he/she presented to the ED on 02/03/2020 at 1834 with chief complaint of "Headache - Adult New Onset." The ED disposition on the log was recorded as "LWBS after Triage."

3. b. The medical record for Patient 2's 02/03/2020 encounter was reviewed and included:
* At 1834 "Patient arrived in ED ... Arrival Complaint Headache."
* At 1835 "Registration Completed."
* At 1853, RN notes reflected "Pain Body Location: head Pain Rating (0-10): Rest: 6 ... Chief Complaints Updated Headache (Adult - New Onset Or New Symptoms)," and vital signs were recorded.
* At 1854, RN "ED Triage Notes" reflected "PT to ER w/ c/o HA. PT states 'I would like someone to look at my head (sic) I have been here before for the same thing ... "
* At 1854, RN notes reflected " ... Patient Acuity: 4."
* At 1855, RN notes reflected "Full Triage Complete."
* At 1857, RN notes reflected "Patient transferred From room EDWT room to EDWTFT."
* The next RN notes, at 2057 reflected "Patient dismissed ... ED Disposition set to LWBS after Triage ... ED AMA/LWBS ... "
* An untimed entry under "Disposition" reflected "LWBS after Triage ... PT states [he/she] wishes to leave. Would not wait to sign paperwork. PT advised to return if s/s worsened."

The record contained:
* No documentation the patient received an MSE.
* No documentation staff explained or attempted to explain the importance of having a MSE to rule out whether or not he/she had a medical condition that needed treatment in accordance with hospital P&Ps.
* No documentation staff informed the patient of the risks of leaving prior an MSE in accordance with hospital P&Ps.
* No documentation staff asked the patient to sign an AMA form acknowledging he/she understood the risks of leaving without an MSE in accordance with hospital P&Ps. Although the record reflected the patient "Would not wait to sign paperwork," there was no documentation that described what "paperwork" the patient would not wait to sign.
* No other documentation in the record related to the circumstances and reasons the patient wanted to leave prior to an MSE.
* There was a lack of documentation that hospital staff did or said nothing to dissuade the patient from staying at the hospital to be evaluated for an EMC.

3. c. During an interview and review of Patient 2's medical record with the EDM on 01/06/2021 at 1545, the EDM confirmed the medical record reflected:
* No documentation the patient received an MSE.
* No documentation the patient was evaluated by a physician or other LIP.
* No documentation of labs or diagnostic testing.
* No documentation that an AMA form was completed or that the patient was informed of the risks of leaving without an MSE.

3. d. During an interview with the EDM and EDD on 01/19/2021 at 1555, they confirmed Patient 2's medical record contained no documentation that reflected the reason the patient left the hospital without an MSE. An opportunity to provide additional information related to the circumstances and reason the patient left without an MSE was provided. The EDM and EDD confirmed there was no other documentation or information that described the reason the patient left without an MSE.

4. a. During an interview with the EDD on 10/27/2020 at 1620, the EDD provided the following information regarding an incident involving Patient 7:
* The PMMC ED CN got a phone call from an individual at the VA regarding Patient 7. The patient was at an outpatient appointment at the VA. The patient had a brain bleed and a possible skull fracture and VA staff had told the patient to go to PMMC ED for evaluation.
* The PMMC ED CN told the PMMC ED physician the patient was coming to the PMMC ED. The PMMC ED physician said the patient "shouldn't come here. We don't have any neurology."
* The patient presented to PMMC ED by private vehicle with his/her spouse.
* The patient checked into registration.
* The PMMC ED CN went out to the ED lobby and told the patient he/she "would likely have to transfer to ARRMC because PMMC did not have neurosurgery services."
* The patient then left the PMMC and went to ARRMC for emergency services.
The EDD confirmed the patient presented to PMMC for emergency services, engaged in a conversation with the PMMC ED CN, and then left PMMC ED to go to another hospital for emergency services. The EDD confirmed PMMC did not triage Patient 7 or provide the patient an MSE to determine whether or not an EMC existed.
* The EDD stated he/she did not know what the patient's condition was when he/she presented to the ED or when he/she left without an MSE.

4. b. During an interview on 10/27/2020 at 1340 with the QMC, the QMC indicated the hospital had conducted an investigation following the incident involving Patient 7. The report of that investigation titled "EMTALA Concern SBAR," was provided and reviewed. The report reflected the incident occurred on 03/02/2020 at 2217 and included the following:
* "A patient with a head injury was told by PMMC Charge RN (under direction of docs) to go to [ARRMC] and did not receive a MSE."
* " ... A VA patient was sent here for a head fracture and bleed seen on CT earlier that day at the VA."
* "Investigation Findings Summary ... The VA believed this patient needed emergency care and instructed [him/her] to come to the PMMC ED ... patient arrived to PMMC and was registered in the ED when the charge RN had a conversation with [him/her] that led to [him/her] leaving PMMC and going over to RRMC ... The physician never saw the patient as [he/she] was not notified of the patient's arrival nor was [he/she] a part of the conversation between the RN and patient ... "
The report reflected that Patient 7 presented to the ED for emergency services including evaluation of a medical condition. Patient 7 left the hospital based on a conversation with the ED CN, and did not receive a MSE.

4. c. The hospital's central log included an entry for Patient 7 that reflected:
* "Arrival Date ... 3/2/2020"
* "Chief Complaint" was blank.
* "ED Attending" was blank.
* "Status ... Canceled"
* "Disposition" was blank.
* "Diagnosis" was blank.

4. d. An untitled EPIC document for Patient 7 was reviewed and reflected:
* "Visit Information ... Arrival 03/02/2020 2217"
* "Department ... Emergency Department"
* "First Attending" followed by a blank space.
* "Chief Complaint None"
* "ED Diagnosis None"
* "ED Disposition None"
* "ED Treatment Team None"

4. e. A "Registration History Report" for Patient 7 reflected:
* "Registration History for the Patient Encounter" followed by:
"3/2/2020 10:17 PM patient encounter created"
"3/2/2020 10:17 PM Visit hospital account assigned"
"3/2/2020 10:17 PM Visit account assigned"
"3/2/2020 10:17 PM Visit coverage assigned"

There were no other documents related to Patient 7's 03/02/2020 arrival and encounter at the hospital. There was no documentation that reflected Patient 7 was triaged or vital signs collected. There was no documentation that reflected the hospital provided an MSE to determine whether or not an EMC existed. This was confirmed during an interview with the EDM on 01/19/2021 at 1535.

Based on interview, review of documentation in the medical records for 2 of 3 pediatric patients (Patients 6 and 12) who were transferred from PMMC to other hospitals for further examination and stabilizing treatment that were not within PMMC's capabilities or capacity, and review of hospital policies and procedures, it was determined that the hospital failed to develop and enforce it's EMTALA policies and procedures to ensure that it affected appropriate transfers for patients who required further examination and stabilizing treatment to rule out, remove or resolve potential EMCs as follows:
* For Patient 6, physician certification of risks and benefits of transfer lacked identification of patient specific, individualized risks.
* For Patient 12, the transfer was not affected using appropriate transportation with qualified personnel; and transportation documentation was contradictory and unclear.

Findings include:

1. The P&P titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" effective "08/2019" was reviewed and included the following:
* "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 ... at their own request ... at the request of a legally responsible person on the patient's behalf or ... if physician or qualified care provider certifies in writing that the benefits of transferring the patient to another facility outweigh the risk ... The care provider will also determine what transportation equipment is needed; including the use of necessary and medically appropriate measures during the transfer."
* "Patients refusing a medically indicated transfer to another facility must sign the "INFORM CONSENT REFUSE PHS" form. The original should be sent to HIM to be scanned in to the patient's chart. 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 ... Explanation of benefits and risks are explained to patient/family."
* " ... the transfer shall be effected through qualified personnel and transfer equipment."

2. a. The medical record of seven-year old Patient 6 reflected that he/she presented to the ED by ambulance on 02/28/2020 at 1052 and " ... after having seizure at school ... EMS reports that pt was not breathing on own when they arrived with sats in the 60s ... on 2 L oxygen via NC Responsive to painful stimuli." The patient was triaged and an MSE was conducted that included HPI, physical exam, labwork, head CT and a chest X-ray.
* Physician notes electronically signed by the physician and dated 02/28/2020 at 1414 reflected the clinical impression was status epilepticus, hypercarbia, and pneumonia of both lower lobes due to infectious organism. The notes further reflected "11:47 consult [physician] neurology ... [He/she] states we need to get the Panda team down and transport to OHSU directly to ICU if possible ... 12:04 Patient had a tonic clonic [seizure], suction of mouth was applied, patient is non responsive staring off to the right ... was given Ativan and seizure resolved, the patient is still unable to answer questions ... talked to parents about possibly having to put patient on ventilator ... 13:46: Report given to [PANDA] and they are ready to transport the patient ... "
* The record reflected the patient was transferred to OHSU by "Mercy Flights" with PANDA team.
* The record contained a "Patient Transfer" document signed by the physician and dated 02/28/2020 at 1223 that reflected the "Patient specific transfer risks" of transfer were "Worsening in route." It was not clear what "Worsening in route" meant for Patient 6.

There was no documentation of physician certification of patient specific, individualized risks of transfer on the transfer document or elsewhere in the medical record.

2. b. During an interview and review of Patient 6's medical record with the EDM and other hospital staff on 01/06/2021 at 1530 the following information was provided:
* The EDM stated the patient was diagnosed with status epilepticus and was transferred to OHSU for pediatric ICU services that were not available at PMMC.
* The EDM confirmed the record lacked physician certification of patient specific, individualized risks of transfer. The EDM stated "I'm not seeing anything." No further information was provided.

2. c. An Internet distance calculator reflected that OHSU, where the patient was transferred to, was approximately 225 flight miles and 55 minutes flight-time from PMMC.

3. a. The medical record of four-year old Patient 12 reflected that he/she presented to the ED on 04/22/2020 at 1634 with a chief complaint of seizures.
* At 1641, RN triage notes reflected " ... child here with [parent]. [Parent] reports child had seizure at day care, has video showing seizure like activity, no hx of. Also reports child was incontinent of urine."
* The record reflected an MSE was conducted that included HPI, physical exam, lab work, and a head CT.
* At 1704, RN notes reflected "Level of Consciousness lethargic ... Post ictal ... Cry ... strong ... Mood/Behavior: tearful ... "
* At 1711, RN notes reflected a peripheral IV line was placed in the patient's right antecubital.
* Physician notes electronically signed by the physician and dated 04/22/2020 at 1827 reflected " ... CT shows a rounded hyperdensity ... in the right frontal lobe that could represent a (sic) extra-axial lesion such as meningioma ... "
* The record contained a "Patient Transfer" document signed by the physician and dated 04/22/2020 at 1830 that reflected:
- "Reason for Transfer: Service unavailable" and "Patient specific transfer benefits: Patient is a pediatric seizure patient and would benefit from a pediatric and neurologist consult."
- Pre-printed language on the document reflected "The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support. After discussion with the receiving physician, the patient and/or family, the agreed mode of transportation is:" This was followed by an electronic entry "ALS, Private auto."
- Vital signs recorded were "BP: (!) 105/76 Heart Rate: 99 Resp: 18 Temp: 37.4 C. (99.3 F)"
* At 1905, RN notes reflected "Report given to RN ... at ARRMC. [Parent] to transfer Pt to ARRMC in Private vehicle per MD. Emtala packet/paperwork given to [parent] to present on arrival to Rogue. Pt IV covered with Curlix, and flushed ... "
* The record reflected the patient was "discharged" at 1910.

There was no documentation in the medical record that reflected PMMC arranged an appropriate transfer for the pediatric patient that included transportation with qualified personnel and transportation equipment, and the patient's representative subsequently refused an appropriate transfer. There was no documentation that the patient's representative was informed of the risks of refusing an appropriate transfer and signed a refusal form in accordance with the hospital's P&P.

3. b. During an interview and review of Patient 12's medical record with the EDM and other hospital staff on 01/06/2021 at 1455, the EDM provided the following information:
* The EDM confirmed the patient was transferred to ARRMC for pediatric neurology services that were not available at PMMC.
* The EDM stated the patient was driven to ARRMC by private vehicle with a parent and an IV in his/her arm.
* The EDM stated the patient was not transported with "ALS" as reflected on the transfer document. The EDM stated that was "contradictory" and "should not be in there."
* The EDM confirmed the record contained no documentation that the patient's representative was informed of the risks of transporting the patient by private vehicle without qualified personnel and transportation equipment.