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Based on interviews, documentation in 16 of 20 medical records reviewed of patients who presented to the hospital for a MSE (Patients 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17), review of central log documentation, and review of policies and procedures, it was determined the hospital failed to develop and enforce its EMTALA policies and procedures related to transfer of patients with EMCs, including a woman in labor, and maintenance of a central log.

Findings include:

1. Refer to findings identified under Tag C2409, CFR 489.24(e)(1-2), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to transfer of patients with EMCs, including a woman in labor.

2. Refer to findings identified under Tag C2405, CFR 489.20(r)(3), which reflects the hospital's failure to develop written EMTALA policies and procedures related to the required central log.

Based on documentation in 11 of 20 medical records reviewed of patients who presented to the hospital for a MSE (Patients 1, 2, 3, 5, 6, 7, 8, 9, 10, 16, and 17), review of central log documentation, and review of policies and procedures, it was determined the hospital failed to develop EMTALA policies and procedures to ensure the maintenance of a central log which contained complete, clear and accurate information about patients who presented to the hospital for a MSE and their disposition from the hospital.

Findings include:

1. Hospital policies and procedures were reviewed:
* "Emergency Treatment and Active labor Act (EMTALA) Patient Transfers Between Facilities", dated as last revised "6/12";
* "Medical Screening Examination", dated as last revised "8/2013";
* "Perinatal Triage and Medical Screening Examination", dated as last revised "10/13";
* "Transfer of Maternal Perinatal Patient", dated as last revised "10/13";
* "Obstetric Patients", dated as last revised "11/13";
* "Triage of Pregnant Patients Flow Sheet", undated and numbered 10802;
* "Pediatric Trauma Admit Transfer", undated and numbered 10762;
* "Pregnant Trauma Patient", undated and numbered 12637;
* "ED Practice Guideline: Triage Adult", dated as last revised "04/2014";
* "ED Practice Guideline: Pediatric Patients", dated as last revised "07/2014";
* "ED Practice Guideline: Delayed Admission", dated as last revised "07/2014"; and
* "Patient's Leaving ED Before Treatment is Completed", dated as last revised "7/2013".

The policies and procedures contained no reference to the maintenance of, or documentation requirements for, a central emergency services log.

2. The FBC log entry for Patient 1 reflected a discharge date and time of 09/28/2014 at 0625 and a discharge disposition of "Home or Self Care". However, the record for Patient 1 lacked documentation of the time of discharge and reflected that the patient who was having contractions and had ruptured membranes was sent to another hospital, OHSU, by the RN and the MD to deliver a baby. In addition, the "Expected Delivery", "Gestational Age", and "Attending" physician spaces on the log were blank for Patient 1.

3. The FBC log entry for Patient 2 reflected a discharge date and time of 07/11/2014 at 1432 and a discharge disposition of inpatient admission. However, the record for Patient 2 reflected the date and time of admission as 07/11/2014 at 1208, a discrepancy of 2 hours and 24 minutes.

4. The FBC log entry for Patient 3 reflected a discharge date and time of 08/19/2014 at 1400 and a discharge disposition of "Home or Self Care". However, the record for Patient 3 reflected that the discharge date and time was "None".

5. The FBC log entry for Patient 5 reflected a discharge date and time of 08/20/14 at 1730 and a discharge disposition of "Home-Health Care [Service]". However, the record for Patient 5 reflected that the discharge date and time was "None" and that the RN provided discharge instructions to the patient on 08/20/2014 at 1902, a discrepancy of one hour and 32 minutes. In addition, the record lacked evidence that the patient was receiving services from a home health care agency.

6. The FBC log entry for Patient 6 reflected a discharge date and time of 08/25/2014 at 1130 and a discharge disposition of "Still a Patient". There was no documentation in the FBC record to reflect that the patient left the FBC or to explain the disposition entry recorded on the log.

7. The FBC log entry for Patient 7 reflected an arrival date and time of 09/04/2014 at 0955. The space on the log for the reason for visit or chief complaint was blank.

8. The FBC log entry for Patient 8 reflected an arrival date and time of 09/04/2014 at 1919. The record of Patient 8 reflected the patient's arrival date and time as 09/04/2014 at 0200, a discrepany of 17 hours and 19 minutes.

9. The FBC log entry for Patient 9 reflected an arrival date and time of 09/18/2014 at 1506. The space on the log for the reason for visit or chief complaint was blank.

10. The FBC log entry for Patient 10 reflected an arrival date and time of 07/29/2014 at 0952. The space on the log for the reason for visit or chief complaint was blank.

11. The ED log entry for Patient 16 reflected an arrival date and time of 09/02/2014 at 1217. The chief complaint was incomplete and recorded as "Right leg".

12. The ED log entry for Patient 17 reflected an arrival date and time of 08/02/2014 at 2108 and reflected the disposition from the ED as "Eloped". However, the record of Patient 17 included an entry by the RN recorded on 08/02/2014 at 2317 that reflected the patient "left ama."

Based on interviews, documentation in 6 of 6 medical records reviewed of patients who were evaluated to have an EMC and were transferred or directed to other hospitals (Patients 1, 11, 12, 13, 14 and 15), and review of policies and procedures, it was determined that the hospital failed to enforce its EMTALA policies and procedures to ensure that appropriate transfers of patients with EMCs were conducted. An appropriate transfer for Patient 1 was not conducted as a physician or a qualified medical person had not signed the required certification, the receiving hospital had not been contacted and agreed to accept the patient, medical records were not sent with the patient, appropriate transportation with qualified personnel was not used, and patient-specific risks of transfer were not identified. In addition, the risks of transfer were not patient-specific for Patients 11 through 15.

Findings include:

1. *The hospital policy and procedure titled "Emergency Treatment and Active labor Act (EMTALA) Patient Transfers Between Facilities", dated as last revised "6/12", was reviewed. The policy required "Transfers are made physician-to-physician...The patient may be transferred only when the receiving hospital or facility has consented to accept the patient...All pertinent medical information shall accompany the patient being transferred and the transfer shall be effected through qualified personnel and transfer equipment."

The policy reflected "Emergency Medical Condition (EMC) means...A medical condition manifesting itself by acute symptoms of sufficient severity...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...With respect to a pregnant woman who is having contractions...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."

The procedure portion of the above document reflected "Prior to transfer, an explanation of the need to transfer and the alternative to transfer will be made to the patient. Risks and benefits will be summarized verbally and written on the Patient Transfer Form...Patients may be transferred (1) at their own request...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...The evaluating care provider will place a call to the receiving care provider and health care facility. The necessary information will be relayed. The receiving facility must (1) be informed of the transfer and (2) agree to accept the patient, provide appropriate medical treatment and have space and qualified personnel available...The referring and receiving care providers share the responsibility for patient transfer and they should consult regarding the arrangements and details for patient transfer, including the method of transportation. The care provider arranging transportation is responsible for determining what additional care is required before transfer, and what capabilities should be available en route (sic)...Accompanying records sent with patient...A 'Transfer form'... must be completed for each transfer...The nurse caring for patient is responsible for calling a nursing report to the receiving facility unit. Report should be documented in nurses' notes including name of nurse receiving report...Transfer summary should be completed and nursing goals addressed prior to transfer...Documentation to occur on patient's chart (1) Notification of acceptance by the receiving heath care facility (2) How patient is transferred (3) Records that accompanied the patient (4) Reasons for transfer... (5) Note by the physician of the patient's condition at the time of transfer (6) Notification of patient's family (7) Explanation of benefits and risks are explained to patient/family."

* The Professional Staff Policies and Procedures, dated as last revised 07/25/2014, were reviewed. These were part of the Professional Staff Bylaws and applied to MDs and other LIPs. "Article XVII. Additional Policies, 1.F. Medical Screening Examinations" reflected that the professional staff had designated RNs with specified experience and qualifications as "qualified medical personnel who may be permitted to perform medical screening examinations" for OB patients.

"Article XVII. Additional Policies, 1.G. Against Medical Advice (AMA) Discharges" reflected "When the patient leaves the Hospital without an opportunity to be given an explanation of the risks of leaving, the medical record should include any attempts to explain the risks and to request that the patient sign a release form."

"Article XVII. Additional Policies, 2.K. Emergency Medical Record" reflected "If a patient is transferred to another facility, the transfer process shall be fully documented in the medical record. If a patient leaves the Hospital against medical advice (AMA), this shall also be noted. A copy of the record of emergency services provided shall be communicated to the Member, practitioner or agency responsible for any follow-up care."

* The hospital policy and procedure titled "Perinatal Triage and Medical Screening Examination", dated as last revised "10/13", was reviewed. The policy reflected "Labor as defined by EMTALA, is the process of childbirth beginning with the latent phase of labor or early phase of labor and continuing through delivery of the placenta. A woman experiencing contractions is in true labor unless a qualified medical person...certifies that after a reasonable time of observation the woman is in false labor."

The policy included direction for a qualified Perinatal RN to conduct an initial evaluation of the patient and "Following evaluation and communication between RN and LIP, the LIP will provide direction to admit, discharge, or transfer the patient."

"Utilize the following guidelines if a patient...wishes to leave hospital: Provider informs the patient of the risks and benefits of the examination and/or treatment...Document the description of the examination and treatment that was refused by the patient...Follow hospital procedure related to consent for leaving hospital against advice (i.e. Against Medical Advice release)."

* The hospital policy and procedure titled "Transfer of Maternal Perinatal Patient", dated as last revised "10/13", was reviewed. The policy stipulated "A patient who meets the criteria of an emergency medical condition may not be transferred until she is stabilized unless...The patient requests a transfer, in writing, after being informed of the hospital's obligations under the law and the risks of transfer...An LIP signs a written certification 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 or unborn child."

The procedure included the following requirements for the RN: "Notify appropriate LIP of initial assessment findings...In most cases, the LIP will complete an examination of the patient prior to transfer...Telephone orders authorizing transfer may be accepted based on clinical situation. LIP to evaluate patient prior to transfer as appropriate per clinical status. Telephone orders must be signed by physician as contemporaneously as possible...Explain to the patient, prior to transfer, the need for transfer and the alternatives to transfer. Risks and benefits will be summarized verbally and written on the Patient Transfer form...Verify receiving facility can accept transfer and has the space and qualified personnel to treat the patient...Verify that transferring LIP has given SBARR to receiving LIP, and receiving LIP accepts the patient...The transferring LIP will maintain responsibility for the patient until patient arrives at the receiving facility...Provide nurse to nurse report to receiving facility and document transfer summary on EMR, and any appropriate paper forms. Nurse caring for patient is responsible for this report." Under the procedure section for "Transportation & Equipment" the RN was directed to notify the nursing supervisor to arrange for transportation. Under the procedure section for "Forms & Paperwork" the RN was directed to "Complete patient transfer form for each transfer...Print patient transfer summary from EMR...Copy of medical records not in EMR."

* The hospital policy and procedure titled "Trial of Labor After Cesarean Section", dated as last approved "4/14", was reviewed. The policy statement was "Providence Hood River Memorial Hospital [and three other named hospitals] do not offer a trial of labor after cesarean section delivery."

The procedure reflected that "Risk for uterine rupture in women with a previous uterine scar...increases...for women who proceed with a TOLAC after one cesarean delivery...LIP should be notified immediately after initial assessment of patient's presence on the maternity unit...Refer to procedures related to...Obstetric Emergencies...Initiate procedures for obstetric emergency and treatment of suspected fetal or maternal compromise...Anticipate need for hemorrhage management if patient has uterine rupture."

* The hospital policy and procedure titled "The Plan for the Provision of Care Providence Hood River Memorial Hospital", dated as last revised "3/2014", was reviewed. The policy reflected the hospital did not have a NICU. Under the "Scope of Service" it reflected "When critical care or specialty care, not available at PHRMH, is needed for newborn and pediatric patients, they will be transferred to a more comprehensive facility based on medical necessity and parent or guardian preference."

* The hospital policy and procedure titled "Patient's Leaving ED Before Treatment is Completed", dated as last revised "7/2013", was reviewed. The policy reflected "AMA: When a patient refuses to complete a medical screening examination, or consent to recommended treatment or transfer, risks and benefits should be discussed and an Informed Consent to Refuse form signed...the LIP should explain to the patient in understandable terms the risks of refusal of treatment or transfer...The nurse or LIP should complete the Informed Consent to Refuse form...The RN should document the patient's condition and circumstances surrounding the refusal of treatment or transfer in the medical record."

2. The medical record of Patient 1 was reviewed. The "Patient Demographics" section of the record reflected that the patient presented to the hospital's labor and delivery unit on 09/28/2014 at 0610.

The "OB Triage Care Record" reflected that at 0619 the RN documented the following: "Fetal Movement active...sterile vaginal exam per RN...bloody show...engaged...Cervical Dilation (cm) 3...Cervical Effacement 90%...Cervical Position 1 - mid...Cervical Consistency 0 - firm...Fetal Station - 2...Bishop Score Dilation 2...Effacement 3...Cervical Position 1...Cervical Consistency 0...Station 1...Total 7."

The "OB Triage Care Record" reflected that at 0621 the RN documented the following: "Amniotic Fluid Color clear...Amniotic Fluid Amount moderate...Amniotic Fluid Odor none...AmniSure Test...grossely (sic) ruptured."

The "OB Triage Care Record" reflected that at 0624 the RN documented the following: "Provider notification...On call provider...Method of Notification Phone...Request Evaluate - Remote...Notification Reason Membrane Status...Response See Orders...Notification Time 0621."

The "OB Triage Care Record" reflected that at 0629 the RN documented the following: "Fetal HR Mode auscultation...Baseline Rate 150...UA Mode other...10-15 mins per pt."

A progress note electronically "filed" by an RN on 09/28/2014 at 0625 reflected: "[MD] notified of pt status: pt grossly ruptured, 3/90/-2, UC's per pt about 10-15 mins, FHR for 3 mins at 150, ok to discharge without full NST. Plan to discharge to OHSU for VBAC." There was no other documentation by the RN after that note.

The "Lab Results" section of the record reflected that on 09/28/2014 at 0610 a specimen of amniotic fluid was collected for a "ROM (Amnisure) test and was sent to the hospital's lab. The "Final result" was recorded on 09/28/2014 at 0648 and was "Negative."

The only entry recorded under the "Discharge Instructions" section of the record was written as "None".

The "Patient Demographics" section of the record reflected the following: "Discharge Date/Time None...Discharge Disposition Home Or Self Care...Discharge Destination None."

There was no documentation related to implementation of the "plan to discharge to OHSU", including but not limited to: a written or telephone physician's order for "discharge to OHSU", communications with the patient about the assessment and plan, instructions given, risks and benefits discussed, physician to physician communications with OHSU, whether medical records were sent, mode of transportation arranged, who accompanied the patient, and time of discharge. In addition, there was no documentation to reflect that the patient refused an appropriate transfer.

A progress note electronically "filed" by an MD the following day on 09/29/2014 at 1615 reflected: "Patient called answering service 5:34 am 9/28/2014 and descirbed (sic) loss of fluid and blood tinged mucous, subsequently urinated. [Patient's] birth plan is VBAC at OHSU, advised to stop at triage in Hood River on [patient's] way to Portland and confirm ROM prior to proceeding to Portland. Per nurse at approximately 6:30 am FHT 150s, contractions Q 10-15 minutes, patient grossly ruptured, cervix 3/90/-2. Instructed not to wait for amniosure (sic) confirmation but to go directly to OHSU for labor management as previously planned. FHT reviewed 150s." There was no other documentation by the MD prior to or after that note.

* The patient's pre-natal OB records from a clinic in Hood River were provided and reviewed. Those reflected the patient's estimated date of delivery between 10/26/2014 and 11/04/2014. The patient's documented history included a prior C-section "due to breech", and other risk factors such as a congenital single kidney, pre-diabetes, and obesity.

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

* On 10/03/2014 at approximately 1330 the Associate Administrator of Patient Services and the Quality Management Coordinator were interviewed. They reported that on 09/29/2014 the PHRMH FBC Manager received an inquiry about Patient 1 who had presented to OHSU on 09/28/2014 in the a.m. where he/she delivered a newborn after arrival to that hospital. The Associate Administrator and Quality Coordinator reported that PHRMH staff started an investigation immediately and found that on 09/28/2014 at 0534 Patient 1 called his/her physician in Hood River with reports of loss of fluid and blood tinged mucus. The physician directed Patient 1 to go the PHRMH for a "labor check" before driving to OHSU for a VBAC. Patient 1 had an established birth plan to have a VBAC at OHSU as PHRMH does not provide VBAC by policy.

The Associate Administrator and Quality Coordinator stated that medical staff bylaws permit a FBC RN to conduct the MSE for pregnant women. They reported that Patient 1 arrived at PHRMH at 0610 and was checked by the FBC RN. The RN assessed the patient to be 3 cm. dilated, 90% effaced, -2 station, with ruptured membranes, and FHTs in the 150s for "3 to 4 mins". During the time in the FBC the patient was requesting to leave the hospital to go to OHSU, was "wanting to go AMA". The RN called the physician who directed the RN to send Patient 1 to OHSU for the planned VBAC. Patient 1 left the hospital with his/her spouse in a private vehicle.

During the interview it was confirmed that an appropriate transfer "didn't happen" as there was "no MD to patient communication...no hospital to hospital communication...no RN to RN communication...nor did the RN complete transfer forms." They further reported that although Patient 1 was "wanting to go AMA", the patient was not presented with AMA forms to sign and there was no related documentation in Patient 1's medical record.

* The RN who cared for Patient 1 in the hospital's FBC on 09/28/2014 was interviewed on 10/03/2014 at 1610. He/she stated that at 0600 (on 09/28/2014) he/she received a phone call from the MD who provided notice that Patient 1 was coming to the hospital. The RN related that the MD reported that his/her patient was coming in to the FBC to rule out ROM, and that the patient had a history of previous C-section and had a birth plan to have a VBAC at OHSU. The MD provided orders for an Amnisure test and instructed the RN to call MD with result.

The RN stated that upon arrival at FBC the patient stated "Can we make this quick" and "the baby is moving". The patient reported "contractions every 15 minutes" and stated that he/she wanted to go to OHSU. The RN stated that he/she checked the patient's cervix, which was at 3 cm., and obtained a specimen for the Amnisure test. After the exam the patient was anxious to leave and asked if he/she could get dressed. The RN stated that after the patient was dressed the RN observed the patient's pants were "soaked", and based on the smell and amount assessed the patient to have "grossly ruptured" membranes. The RN reported that he/she contacted the MD by phone who directed the RN to "discharge" the patient to OHSU and "send with a piece of paper" to let OHSU know that the patient was "grossly ruptured." The RN reported he/she wrote on a "sticky note" the words "grossly ruptured" and the vaginal exam results of "3 90% -2". The RN reported he/she gave the "sticky note" to the patient with instructions to give it to the staff at OHSU. The patient left the FBC at 0625 with his/her significant other who was at the bedside during the FBC visit.

During the interview the RN stated that the patient wanted the FBC visit to be quick and that the patient "did not want to be stuck in Hood River and wanted to be on [his/her] way to OHSU for the VBAC." The RN stated the patient was "glad to be getting out of here." The RN confirmed that the only documentation sent with the patient was the "sticky note" and that no medical records were sent.

During the interview the RN described an appropriate EMTALA transfer. He/she stated that based on the RN assessment findings the physician would come in to the hospital to further evaluate the patient; the physician would call the other hospital to find out if the other hospital could accept the patient; there would have to be an RN to RN report; medical records would be printed and sent with the patient, including pre-natal records and labs; there would be an ambulance transport and the house supervisor would be contacted to help make those arrangements; and the appropriate transfer forms and documentation would have to be completed.

3. The medical record of Patient 11 was reviewed. The "Patient Demographics" section of the record reflected that the patient presented to the ED on 09/05/2014 at 2005 with a chief complaint of "Weakness, Dehydrated." The documentation in the record reflected that the patient had an extensive history of abdominal surgeries, perforated bowel, bowel obstruction, and related surgeries and procedures. In July 2014 he/she had "several surgeries related to close and open abdominal wound using mesh and bilateral skin advancement flaps" with subsequent debridement of necrotic skin in August 2014. The patient had been on TPN until 08/28/2014 and was continuing to receive wound treatments three times a week. As a result of a MSE conducted by an MD the patient was determined to have a bowel obstruction.

Patient 11 was transferred to OHSU on 09/06/2014 at 0045. Documentation on the electronic transfer form reflected that all aspects of an appropriate transfer were carried out except that the risks of the transfer were not individualized or patient specific. The risks were recorded as "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death...no other risks beyond those listed above are anticipated."

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

4. The medical record of Patient 12 was reviewed. The "Patient Demographics" section of the record reflected that the patient presented to the ED by ambulance on 09/08/2014 at 0814 with a chief complaint of "[motor vehicle crash]." The documentation reflected "the patient was struck by a car while crossing the street...at the knee level. [He/she] then rolled up onto the windhsield (sic) which cracked in several areas. The patient does not recall the accident..." A MSE was conducted by an MD and included a CT scan of the head with results that included: "In the setting of head trauma, the finding is concerning for subdural hematoma..." As a result of the MSE the MD documented his/her clinical impression as: "Concussion, with loss of consciousness of unspecified duration...Tibial plateau fracture, left, closed...Motor vehicle accident...Multiple system trauma victim." The MD documented that the "Hospital is currently on divert for admissions" and he/she made arrangements for a transfer.

Patient 12 was transferred to LEMC on 09/08/2014 at 1501. Documentation on the electronic transfer form reflected that all aspects of an appropriate transfer were carried out except that the risks of the transfer were not individualized or patient specific. The risks were recorded as "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death...no other risks beyond those listed above are anticipated."

Mapquest reflects LEMC in Portland, Oregon is 63 miles and one hour and 7 minutes drive time from PHRMH in Hood River, Oregon.

5. The medical record of Patient 13 was reviewed. The "Patient Demographics" section of the record reflected that the patient presented to the ED on 09/21/2014 at 1950 with a chief complaint of "allergic reaction meds". A MSE was conducted by a DO who documented "...recently [patient] was hospitalized for swelling of the left hand which was concerning for infection...treated by rheumatology, hand surgery and infectious disease specialist...history of Crohn's disease and psoriatic arthritis presents with oral fevers (sic) chills, fatigue, increased swelling of the left hand, cough, generalized malaise...increased joint pains...recently started on Remicade and methotrexate...diffuse swelling to the left thumb and index finger which are also quite tender with palpation...While in the ED [he/she] became febrile to 100.4 and then later to 102.6...Since the patient has had a complicated history involving multiple specialties we believe [he/she] would benefit from transfer...Patient with fever who is immunocompromised..."

Patient 13 was transferred to PPMC on 09/22/2014 at 0125. Documentation on the electronic transfer form reflected that all aspects of an appropriate transfer were carried out except that the risks of transfer were not individualized or patient specific. The risks were recorded as "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death...no other risks beyond those listed above are anticipated."

Mapquest reflects PPMC in Portland, Oregon is 59 miles and one hour and 3 minutes drive time from PHRMH in Hood River, Oregon.

6. The medical record of Patient 14 was reviewed. The "Patient Demographics" section of the record reflected that the patient presented to the ED on 09/20/2014 at 0846 with a chief complaint of back pain and head laceration after falling off a ladder. A MSE was conducted by a DO who documented "...fell off of a ladder while at work this morning...It is estimated that [patient] fell from the fifth round (sic), struck the ladder on the way down and landed on the ground...was dizzy and confused for at least 20 minutes after the incident...complains of back pain and head laceration and headache...Subarachnoid hemorrhage following injury...CT scan of the head shows a very tiny area of subdural blood in the mid brain and also very tiny amount of subarachnoid blood on the right posterior parietal area...Neurosurgery at Legacy Emmanuel (sic) has been consulted...Radiology also had lumbar spine films and is suspicious for a small compression fracture of T12..."

Patient 14 was transferred to LEMC on 09/20/2014 at 1155. Documentation on the electronic transfer form reflected that all aspects of an appropriate transfer were carried out except that the risks of the transfer were not individualized or patient specific. The risks were recorded as "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death...no other risks beyond those listed above are anticipated."

Mapquest reflects LEMC in Portland, Oregon is 63 miles and one hour and 7 minutes drive time from PHRMH in Hood River, Oregon.

7. The medical record of Patient 15 was reviewed. The "Patient Demographics" section of the record reflected that the patient presented to the ED on 09/03/2014 at 0656 with a chief complaint of "generalized swelling and shortness of breath with exertion." A MSE was conducted by a DO who documented "...presents with edema of [his/her] legs and arms...shortness of breath...associated symptoms include rash...swelling started 4-5 days ago...decreased breath sounds and rales in the bases of [his/her] lungs...severe edema to the upper and lower extremities...diffuse erythema and warmth to the right arm consistent with cellulitis...Labs were drawn which shows significant findings other (sic) white blood cell count of 122,000..." Documentation of blood work conducted reflected numerous values not within normal limits and flagged, including an elevated WBC count of 122.0 (normal range 3.9 to 10.6 10^9/L) flagged as a critical high. The DO documented "Since we do not have hematology oncology available at this hospital...transfer to Portland to get specialty care. Patient and family informed of the results of [his/her] tests and spelled (sic) diagnosis of leukemia and the plan to transfer..."

Patient 15 was transferred to PPMC on 09/03/2014 at 1118. Documentation on the electronic transfer form reflected that all aspects of an appropriate transfer were carried out except that the risks of the transfer were not individualized or patient specific. The risks were recorded as "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death...no other risks beyond those listed above are anticipated."

Mapquest reflects PPMC in Portland, Oregon is 59 miles and one hour and 3 minutes drive time from PHRMH in Hood River, Oregon.