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Based on observation, interview, review of medical records and other documentation in 10 of 20 patients who presented to the hospital for emergency services (Patients 1, 3, 4, 8, 9, 11, 14, 16, 17 and 18), and review of hospital policies and procedures and other documents, 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.
* Maintenance of a central ED log.
* Provision of MSEs.
* Appropriate transfers of patients.

Findings included:

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

2. Regarding the central log refer to the findings identified under Tag A2405, CFR 489.20(r)(3).

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

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

Based on observation and interview it was determined the hospital failed to develop and enforce EMTALA policies and procedures that ensured the posting of signage that specified patients' EMTALA rights in all areas likely to be noticed and where patients waited for examination and treatment.

Findings include:

1. The hospital policy and procedure titled "EMTALA Rights and Responsibilities," dated "Effective Date: 06/29/2016" was reviewed. It reflected "... Posting of Individuals' EMTALA Rights. St. Charles shall post in its dedicated emergency departments, and in other locations likely to be noticed by individuals entering the dedicated emergency departments and waiting for examination and treatment, conspicuous signs specifying the individuals' rights under EMTALA."

2. During tour of the ED on 02/06/2018 at 1543 with QIC, EDM and FBCM, it was observed that the department had one primary ambulatory entrance, one ambulance entrance, 14 treatment rooms, one transport hold room and two hallway treatment areas (areas in the ED hall between ED treatment rooms).
* There was no EMTALA signage observed in the patient registration and triage area.
* There was one EMTALA sign posted to the left of the secure ED entrance door that separated the registration, triage and waiting areas from the treatment area and rooms.
* There were no other EMTALA signs posted inside or outside of the ED including in waiting areas, triage rooms, and in treatment rooms; in areas where patients wait for exam and treatment.
* These findings were confirmed with the EDM and QIC at the time of the tour on 02/06/2019.

3. A tour of the FBC was conducted on 02/06/2018 beginning at 1610 with the QIC and the FBCM. Staff present during the tour confirmed that individuals who were in labor presented to the FBC department for a MSE.
* There was no EMTALA signage observed in the patient and visitor waiting area and entrance into the unit.
* The registration area attached to the main nursing station desk had one EMTALA sign posted behind the main nursing station desk. The sign would not likely be visible to a patient sitting in a wheelchair during registration processes.
* There were no other EMTALA signs in the FBC department.
* This finding was confirmed with the FBCM during the tour on 02/06/2019.

Based on interview, review of central log documentation, and review of policies and procedures, it was determined the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure maintenance of a central log that contained clear and accurate information about the presentation and disposition of each patient who came to the hospital seeking emergency services, including women who presented to the Maternity Department in labor, or with possible EMCs related to pregnancy.

Findings include:

1. The hospital policy and procedure titled "EMTALA Rights and Responsibilities, " dated as effective 06/29/2016 was reviewed. It reflected:
* "Each person who comes to the emergency department seeking treatment of a medical condition will be given an appropriate MSE ... the MSE will be performed by a QMP ... St. Charles will maintain in the electronic medical records system a central log on each individual who comes to the emergency department seeking assistance. The log will contain the patient's:
* Name
* Identification number
* Chief complaint
*Arrival date and time
* Disposition date and time
* Disposition type (e.g. refused treatment, was refused treatment, transferred, admitted and treated, stabilized and transferred or discharged)."

2. During interviews with the FBCM and the CNO on 02/06/2018 at 1715, the FBCM stated Patient 9 "was not registered into the computer system because the patient was here less than 2 minutes before being sent to Bend in his/her own vehicle."

3. Review of the ED and OB Central Logs revealed that Patient 9, who presented to the hospital seeking emergency services, was not identified on the log as having been registered for emergency services on 11/23/2018. Refer to Tag A2406 for the detailed findings related to Patient 9.

4. The medical record of Patient 4 reflected that he/she presented to the FBC on 10/03/2018 at 1940 with a disposition of " Left AMA"and there was no chief complaint recorded in the OB Event log. Refer to Tag A2406 for the detailed findings related to Patient 4.

Based on interview, review of medical record and other documentation for 4 of 20 patients who presented to the hospital for emergency services (Patients 4, 9, 14, and 18) 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 hospital policy and procedure titled "EMTALA Rights and Responsibilities," with "Effective Date: 06/29/2016," was reviewed. It reflected:

* "The purpose of this policy is to describe how St. Charles Health System, Inc. (St. Charles) and its hospitals will comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) ... (1) providing, through a qualified medical professional, an appropriate, nondiscriminatory medical screening examination (MSE) within its capabilities to each patient who comes onto the hospital property seeking examination or treatment of what may be an emergency medical condition (EMC); (2) providing necessary stabilizing treatment or an appropriate transfer to each patient determined to have an EMC ... All caregivers and physicians will be oriented to EMTALA and receive ongoing education."

* "Definitions ... Dedicated Emergency Department - Any department of facility of the hospital that is licensed by the state as an emergency room or emergency department, that is held out to the public as a place that provides care for EMCs on an urgent basis without requiring appointments, or provides at least 1/3 of all of its outpatient visits for the treatment of EMCs on an urgent basis without requiring appointments. Dedicated emergency departments of St. Charles include, without limitation, the following ... The Family Birthing Units at St. Charles Bend, St. Charles Redmond, and St. Charles Madras."

* "Emergency Medical Condition (EMC) - A medical condition manifested 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 ... In addition, a pregnant woman who is having contractions is deemed to have an EMC if: There is inadequate time to effect a safe transfer to another hospital before delivery; or Transfer may pose a threat to the health or safety of the woman or the unborn child. A physician or qualified medical professional will be responsible for determining if an EMC exists."

* "Medical Screening Examination (MSE) - A medical evaluation conducted by a qualified medical professional that is designed to identify the presence of an EMC. A MSE is different from and, in most cases, additional to a medical triage."

* "Qualified Medical Professional (QMP) - A medical professional who has been determined qualified, in the applicable hospital's medical staff bylaws or rules and regulations, to conduct MSE's. QMPs at St. Charles include, without limitation, the following: Physicians (MDs and DOs) and advanced practice providers (NPs and PAs), who may perform MSEs in the dedicated emergency departments of St. Charles Bend, St. Charles Redmond, St. Charles Prineville, and St. Charles Madras, and Advance practice providers (NPs, PAs, and SNWs) and nurses in the Family Birthing Units, who may perform MSEs for pregnant women in the Family Birthing Unit under the direction of the on-call, obstetric physician."

* "Stabilizing Treatment - Such medical treatment as is necessary to assure, within reasonable medical probability, that no material deterioration of the patient's EMC is likely to result from or occur during the transfer of the patient from a facility. A pregnant woman is considered stabilized with respect to her pregnancy when she has delivered the child and the placenta."

* "Each person who comes to the emergency department seeking treatment of a medical condition will be given an appropriate MSE ... the MSE will be performed by a QMP ... If, after performing the MSE, a QMP determines that a patient is suffering from an EMC, then St. Charles shall provide stabilizing treatment to the patient."

* "On-Call Physicians. Each St. Charles hospital shall maintain an on-call list of physicians who are on its medical staff and who are available to provide stabilizing treatment."

* "... Discharge Against Medical Advice or Without Being Seen. If a patient decides to leave the hospital against medical advice (AMA) and/or to leave the hospital before receiving the MSE, then the patient should be asked to complete the Against Medical Advice (A.M.A) and Refusal form before leaving. If possible, the patient should be advised to return to the emergency department immediately if his or her symptoms persist or get worse. St. Charles should try at least two (2) times to follow-up by phone or other appropriate method with patients who leave AMA."

2. The "SCHS Plan for the Provision of Patient Care" dated as effective 08/30/2017 was reviewed, it reflected:

* "... At the point of first contact with a person, a process is undertaken to obtain the appropriate and necessary information to match the individual need with the level of care required and to the appropriate setting. Patients who require services not provided by a SCHS hospital are referred to other facilities using established guidelines ... Scope of Service ... St. Charles Redmond is a 48-bed, acute care, non-profit community hospital. The hospital serves patients from the Redmond community and referral area who need emergency, critical, acute, and obstetrical care."

3. The electronic "ST. Charles Redmond Medical Staff Rules and Regulations," dated as approved 06/15/2016 was reviewed. It reflected "Compliance: the emergency room staff will be in compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) and all other applicable federal and state statute and laws, and all patients presenting to the emergency room will be evaluated as per hospital policy titled EMTALA Rights and Responsibilities."

4. The electronic "ST. Charles Health System, INC. ST. Charles Redmond Medical Staff Bylaws," dated as approved 11/16/2017 was reviewed. It reflected "Basic Responsibilities and Requirements: As a condition of consideration for appointment or reappointment, and as a condition of continued appointment, every applicant and member specifically agrees to the following ... to provide continuous and timely care to all patients for whom the individual has responsibility ... to abide by all Bylaws and Rules and Regulations of the Medical Staff and all Hospital policies that pertain to the Medical Staff that have been provided and made known to the Medical Staff through a mechanism established by the Hospital and approved by the Medical Executive Committee ... within the scope of his or her privileges, to provide emergency service call coverage, consultations, and care for unassigned patients ... to comply with clinical practice protocols and guidelines pertinent to his or her medical specialty, national patient safety initiatives, and core measures, as may be adopted by the Medical Staff, the Medical Executive Committee, or the division or section of which he/she is a member or maintains privileges, or clearly document the clinical reasons for variance."
* The bylaws contained no specific references to EMTALA requirements.

5. The printed, undated electronic "Medical Staff Roster" reflected Physician G's status as "Active Staff" at SCR and his/her specialty was OB/GYN.

6. The "ObGyn" on-call schedule for November 2018 reflected Physician G was scheduled for OB/Gyn call on 11/14/2018, 11/15/2018, 11/20/2018, 11/21/2018, 11/23/2018, 11/28/2018, and 11/29/2018 from 7a - 7a.

7. During interviews with the FBCM and the CNO on 02/06/2018 at 1715, they reported that Patient 9 did not have an MSE and that the patient was sent in [his/her] own vehicle to SCB. The FBCM stated Patient 9 "was not registered into the computer system because the patient was here less than 2 minutes before being sent to Bend in his/her own vehicle."

8. A written summary of Patient 9's encounter at SCR on 11/23/2018 was reviewed. It included the following documentation by Physician G: "I was called by FBC nursing staff at 10pm on 11/23 stating a patient had presented with c/o preterm labor. This is a patient I had transferred to Bend due to PTL on Wed. 11/21 ... According to the nurse [he/she] had just been discharged from the Bend FBC unit and was on [his/her] way home when ctx started again so [he/she] had [his/her] [parent] drive [him/her] to Redmond. I told the nurse over the phone to have patient return to Bend as this patient might require NICU services. I felt the patient would be safer driving back to Bend vs undergo admission and ambulance transfer due to the recent delays I have had in getting timely ambulance transfers due to the lack of transport teams available for laboring mothers. I did not want this patient's care to be delayed and assumed [he/she] was stable as [he/she] had just recently been discharged from the Bend facility. The nurse contacted Bend FBC and let them know [he/she] the patient was on [his/her] way back to their facility. The patient safely made it to Bend FBC. [He/she] was never admitted to the Redmond facility."

The summary included the following documentation by the FBCM: "I spoke to both [Physician G] and night charge nurse yesterday ... [Physician G] was not in house when the patient presented to FBC. [Charge RN] called [Physician G] to come in for another term labor patient and at the same time advised [him/her] that there was a 33 wk contracting patient that had just arrived after being discharged home from Bend FBC. According to [Charge RN], [Physician G] asked if the patient was Patient 9 and when [Charge RN] replied yes, [Physician G] told [him/her] to tell the patient to get back in [his/her] car and go back to Bend. (Both [Physician G] and [Charge RN] were under the impression the patient had left Bend and come directly to Redmond but in actuality a few hours had elapsed). [Charge RN] clarified the instructions with [Physician G], and [he/she] was clear-send the patient back to Bend in [his/her] own car ... [Physician G] did not believe the patient could be that far advanced into labor if Patient 9 had just been discharged from Bend, but by the time Patient 9 arrived back in Bend [he/she] was contracting regularly and ruptured while in triage."

9. Review of the OB Central log revealed that Patient 9 who presented to the hospital seeking emergency services was not identified on the log as having been registered on 11/23/2018.

10. The medical record of Patient 4 reflected that he/she presented to the FBC on 10/03/2018 at 1940, and there was no chief complaint recorded in the OB Event log. The record reflected:
* At 1941 an entry by an FBC RN was recorded as "Left Against Medical Advice."
* There was no documentation in the record to reflect the patient's chief complaint or that the patient had been made aware of the possible risks of leaving the hospital before being seen by a QMP. The CRM confirmed at the time of the record review that there was no other documentation for this encounter in the patient's medical record.

11. The medical record of Patient 18 reflected that he/she presented to the ED on 01/21/2019 at 1100. The record reflected:
* The chief complaint noted in the medical record was "hand and stomach wound."
* At 1103 vital signs and a pain scale was documented.
* At 1316 the record reflected: "Dismissed. Not seen, LWBS by healthcare provider."
* There was no documentation in the medical record to reflect what happened to the patient, the severity of the wounds or that the ED staff made any attempt to make the patient aware of the possible risks of leaving the hospital before being seen by a QMP. The CRM confirmed at the time of the record review that there was no other documentation for this encounter in the patient's medical record.

12. The medical record of Patient 14 reflected that he/she presented to the ED on 01/05/2019 at 2227 with a chief complaint of "hematuria." The record reflected:
* At 2229 the patient "LWBS."
* There was no other documentation in the medical record to reflect that ED staff made attempts to make the patient aware of the possible risks of leaving the hospital before being seen by a QMP. The CRM confirmed at the time of the medical record review that there was no other documentation for this encounter in the patient's medical record.

Based on interview, review of documentation in 6 of 6 medical records of patients who were transferred from SCR to another hospital for services SCR did not have capability to provide at that time (Patients 1, 3, 8, 11, 16, and 17), and review of hospital policies and procedures, it was determined that the hospital failed to enforce its EMTALA policies and procedures to ensure that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved as the physician certification that the benefits of transfer outweighed the risks of transfer did not reflect that patient specific, individualized risks of transfer had been identified.

Findings include:

1. The hospital policy and procedure titled "EMTALA Rights and Responsibilities," dated "Effective Date: 06/29/2016" was reviewed. It reflected "The purpose of this policy is to describe how St. Charles Health System, Inc. (St. Charles) and its hospitals will comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) ... (2) providing necessary stabilizing treatment or an appropriate transfer to each patient determined to have an EMC ... All caregivers and physicians will be oriented to EMTALA and receive ongoing education."

"Emergency Medical Condition (EMC) - A medical condition manifested 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 ... In addition, a pregnant woman who is having contractions is deemed to have an EMC if: There is inadequate time to effect a safe transfer to another hospital before delivery; or Transfer may pose a threat to the health or safety of the woman or the unborn child. A physician or qualified medical professional will be responsible for determining if an EMC exists."

"Stabilizing Treatment - Such medical treatment as is necessary to assure, within reasonable medical probability, that no material deterioration of the patient's EMC is likely to result from or occur during the transfer of the patient from a facility. A pregnant woman is considered stabilized with respect to her pregnancy when she has delivered the child and the placenta."

"If, after performing the MSE, a QMP determines that a patient is suffering from an EMC, then St. Charles shall provide stabilizing treatment to the patient ... If a St. Charles facility does not have the capacity fully to stabilize a patient, then it may transfer the patient to another facility with more specialized capabilities. "

"... Each transfer of a patient from a St. Charles facility shall occur only after ... The St. Charles has provided stabilizing treatment within its capacity ... The receiving facility has capacity to treat the patient and has agreed to accept the transfer ... A physician, or if there is no physician physically present in the dedicated emergency department at the time of transfer, a QMP shall complete and sign Patient Transfer Form to verify that, based on the information known as of the time of transfer, the benefits reasonably expected from appropriate treatment at the receiving facility outweigh the increased risks to the patient and/or her unborn child associated with the transfer ... Send or otherwise make accessible to the receiving facility all medical records (in paper or electronic form) related to the EMC for which the patient is being transferred, as well as the name and address of any on-call physician who had refused or failed to appear within a reasonable time to provide stabilizing treatment ... Ensure that the transfer is accomplished by qualified personnel and transportation equipment."

2. The ED record for Patient 1 reflected he/she presented to the ED on 08/04/2018 at 0611 with a chief complaint of "anxiety." The medical record reflected:
* At 0634 the patient was seen by an MD and the patient transferred to SCB BHU via "private vehicle-[spouse]."
* Although there was no evidence of the patient transfer form required by the hospitals policies and procedures, there was documentation that the receiving hospital, SCB BHU, accepted the patient. However, no documentation that medical records were sent and no documentation to reflect the risks and benefits of transfer had been evaluated and understood by the patient and his/her spouse, or if the patient made it to SCB BHU.
* Further, appropriate transportation with qualified personnel was not used to facilitate the transfer.

3. The ED record for Patient 3 reflected he/she presented to the ED on 09/13/2018 at 1757 with a chief complaint of "Paranoid/hallucinations." The medical record reflected the following:
* An MSE was done by an MD who determined the patient needed to be transferred for psychiatric/neuro services that were not available at SCR.
* On 09/14/2018 at 0150 the MD signed the "patient transfer form" that included the physician certification of risks and benefits under which the "benefit" was documented as "psych, neuro" and the "risks" were blank. There was no documentation of patient specific risks of transferring the patient.

4. The ED record for Patient 8 reflected he/she presented to the ED on 10/17/2018 at 1453 with a chief complaint of "Suicidal." The medical record reflected the following:
* The EMC that the individual was experiencing upon presentation to the emergency room has been stabilized and the patient may now be transferred for psych services that SCR was not able to provide at this time.
*At 2310 the MD signed the "patient transfer form" that included the physician certification of risks and benefits under which the "benefit" was documented as "psych" and the "risks" were blank. There was no documentation of patient specific risks of transferring the patient.

5. The ED record for Patient 11 reflected he/she presented to the ED on 11/29/2018 at 1320 with a chief complaint of "abd/chest pain." The medical record reflected the following:
* The MSE was done by an MD who determined the patient needed to be transferred for cardiology services that were not available at SCR at that time.
* At 1535 the MD signed the "patient transfer form" that included the physician certification of risks and benefits under which the "benefit" was documented as "cardiology" and the "risks" were blank. There was no documentation of patient specific risks of transferring the patient.

6. The ED record for Patient 16 reflected he/she presented to the ED on 01/13/2019 at 1602 with a chief complaint of "CP, Suicidal." The medical record reflected:
* The patient was seen by an MD and a MSE was completed. It was determined the patient needed to be transferred by secure transport for "psych bed" as this service was not available at SCR at that time.
* At 2320 the physician signed the "patient transfer form" that included the physician certification of risks and benefits under which the "benefit" was documented as "no psych beds here" and the "risks" were "The individual's condition could worsen during transport and "The vehicle transporting the individual could be involved in an accident." There was no documentation of patient specific risks of transferring the patient.

7. The ED record for Patient 17 reflected he/she presented to the ED on 01/18/2019 at 2222 with a chief complaint of "cough; fever." The medical record reflected:
* The patient was seen by an MD and a MSE was completed at 2216. It was determined the patient needed to be transferred for inpatient pediatric services that were not available at SCR at that time.
* At 2311 the physician signed the "patient transfer form" that included the physician certification of risks and benefits under which the "benefit" was documented as "pediatrics" and the "risks" were "The vehicle transporting the individual could be involved in an accident." There was no documentation of patient specific risks of transferring the patient.