HospitalInspections.org

Based on observation, interview, review of PHS Transfer Center audio recordings, review of Transfer Center documentation of a request from another hospital to transfer a patient to PPMC for specialty services (Patient 4), review of documentation in 1 of 7 medical records of patients who were transferred from PPMC to another hospital for specialty services not available at PPMC at that time (Patient 22), review of central log documentation, 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:
* Recipient hospital responsibilities.
* On-call physician responsibilities.
* Appropriate transfers of patients.
* Maintenance of a central ED log.
* Required posting of EMTALA signs.

Findings included:

1. Regarding recipient hospital responsibilities refer to the findings identified under Tag A2411, CFR 489.24(f).

2. Regarding on-call physician responsibilities refer to the findings identified under Tag A2404, CFR 489.20(r)(2) and CFR 489.24(j).

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

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

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

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

Findings include:

1. The PPMC policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated as last revised "03/2018" contained the following reference to EMTALA signage:
* "Signage means the signs posted by the Hospital in its dedicated emergency department(s) and in a place or places likely to be noticed by all individuals entering the dedicated emergency department(s) that inform individual (sic) of their rights under EMTALA...Each Hospital will post signage in the dedicated emergency department specifying the rights of individuals with emergency medical conditions and women in labor who come to the dedicated ED for health care services, and indicate on the signs whether the hospital participates in the Medicaid program."

The policy and procedure explicitly referred to the "dedicated emergency department" and thereby failed to address EMTALA signage in the Maternity Department where women in labor, or with other possible EMCs related to pregnancy, presented.

2. A tour of the ED department was conducted at 1035 on 07/17/2018 with the ED manager. It was observed that the department had one primary ambulatory entrance from outside the hospital, along with access to the ED registration area from 2 other internal hallway access points and one separate ambulance entrance. The main waiting area and the three triage rooms did not have any EMTALA signage posted. In addition, although there was an EMTALA sign observed on a wall behind the glass-enclosed registration desk, it was not readable as a result of glare from the glass barrier and its location behind the registration desk. These observations were confirmed during interviews with staff present during the ED tour.














40575

Based on interview, review of PHS Transfer Center audio recordings, review of Transfer Center documentation of a request from another hospital to transfer a patient to PPMC for specialty services (Patient 4), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure its on-call physicians fulfilled their on-call duties and obligations to provide consultation, to come into the hospital, and to accept patients for whom the hospital had capability and capacity to treat.

Findings include:

1. Refer to the findings identified under Tag A2411, CFR 489.24(f) that reflects on-call ENT Physician L refused to accept Patient 4 from another hospital's ED for whom PPMC had capability and capacity to treat.

Based on 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 included:

1. The PPMC policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated as last revised "03/2018" contained the following references to a central log:
* "Central log - Central log is a log maintained by the Hospital on each individual who comes to its dedicated emergency department...Central log. Each dedicated emergency department of the Hospital will maintain a central log recording the names of individuals who came to the dedicated emergency department seeking treatment and indicate whether these individuals refused treatment, were denied treatment, or were treated, admitted, stabilized, and/or transferred or were discharged."

The policy and procedure explicitly referred to the "dedicated emergency department" and thereby failed to ensure that women who presented to the Maternity Department in labor, or to rule out labor or other possible EMCs related to pregnancy, were included in the central log.

In addition, the PPMC policy and procedure titled "Perinatal Triage and Medical Screening Examination" dated as last revised "04/2017" lacked any references to the central log. An indirect reference was at the end of the policy and procedure under "Cross References" where the "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" policy and procedure was listed.

2. The hospital's Maternity Department log was reviewed. The log was hand written and contained fifteen columns of for recording of information that included, but was not limited to: Date In; Time In; Patient Name; MD/CNM; Reason For Visit; Disposition; Date Out; Time out.

A seventy-four-page sample of the log was reviewed that contained 1,024 patient entries between 06/01/2018 through 07/17/2018. Of the 1,024 entries 298 entries had multiple incomplete dates, blank spaces, omissions, alterations and inaccuracies. Examples included but were not limited to the following:
*One entry on the log dated "6/18" reflected blank spaces for date out and time out; and entries in the spaces for reason for visit and disposition had been altered and the original entry had been scribbled over and was not readable.
*One entry on the log dated "6/19" reflected five blank spaces including date out and time out; and entries in the spaces for patient name, MD/CNM, and birthdate had been altered with "White-out" and a write-over. .
*Three entries all dated "7/2" that had patient names and the majority of spaces completed for those patients had been entirely crossed out.




40575

Based on interview, review of documentation in 1 of 7 medical records of patients who were transferred from PPMC to another hospital for specialty services not available at PPMC at that time (Patient 22), and review of hospital policies and procedures and other documents, 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:
* Physician certification of medical benefits vs risks was not documented.
* There was no documentation that available medical records were sent or transmitted to the receiving hospital.

Findings include:

1. The policy and procedure "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated as last reviewed "03/2018" included the following definitions and "Procedures:"
* "For the purpose of this policy, an EMTALA patient is defined as any patient present in a facility's emergency department who has been stabilized within the limits of that facility's current capabilities or a patient present in a facility's emergency department who has not been stabilized and the patient is requesting the transfer, after being informed of the hospital's EMTALA obligations and the risks of transfer. The sending hospital takes precedence in determining if the patient is an EMTALA patient. Transfers of these patients are subject to EMTALA provisions."
* "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 facility...if physician or qualified care provider certifies in writing that the benefits of transferring the patient to another facility outweigh the risk (See Attachment A - 'Patient Transfer Form.')."
* "Accompanying records sent with patient...[ED] treatment record...Flow sheet(s)...Laboratory results...X-rays...Progress notes..."
* "Documentation to occur on patient's chart...Records that accompanied patient...Explanation of benefits and risks are explained to patient/family."

2. The ED record of Patient 22 was reviewed and reflected that the pregnant patient presented to the hospital on 06/21/2018 at 1111 following a MVA. The "Obstetric Admission Note" dated 06/21/2018 at 1632 by the CNM reflected that the patient received a MSE and "Irregular uterine contractions...Plan transfer to LEMC for observation due to PTL symptoms/ ? Abruption at 34w4d and PPMC NICU on divert (pt elects transfer to avoid postpartum neonatal transfer if [he/she] delivers). [Discussed with LEMC Physician], who accepts pt transfer and agrees w/ plan of care. LEMC L&D notified...[Physician] recommended transfer and counseling upon arrival due to gestation [greater than] 34wk and dilation 3cm."

The "Patient Transfer" form dated and timed next to the physician's signature as 06/21/2018 at 1605 lacked individualized information about the reason for, and risks and benefits of transfer. The only documentation was in the form of a checkmark in a box next to "Reason for Transfer:...Medically indicated" and another checkmark in a box next to "Summary of transfer benefits:...Obtain level of care/service not available at the facility." Under the section for "Summary of transfer risks" there was no documentation. As required by this CFR and the PPMC policy referenced above there was no clear documentation of "...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."

In addition, the section for "Records sent with patient" was blank. There was no documentation to reflect that the patient's available medical records were sent with the patient or were otherwise transmitted to the receiving hospital.

3. During interview with the Maternity Department NM and L&D CN at the time of the record review on 07/18/2018 at 1110 they confirmed the lack of documentation in Patient 22's record.

Based on interview, review of PHS Transfer Center audio recordings, review of Transfer Center documentation of a request from another hospital to transfer a patient to PPMC for specialty services (Patient 4), 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 its compliance with recipient hospital responsibilities to accept patients from referring hospital EDs, without delay, for whom it had capability and capacity to treat.

Findings include:

1. The document provided to reflect the hospital's scope of services was titled "Patient Placement Guidelines" and was "Updated 4/3/17." It reflected that the hospital had ENT surgical capability and capacity where it denoted "ENT" under the heading of "4th Floor Surgical."

2. The policy and procedure "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated as last reviewed "03/2018" included the following definitions and "General Policies:"
* "For the purpose of this policy, an EMTALA patient is defined as any patient present in a facility's emergency department who has been stabilized within the limits of that facility's current capabilities or a patient present in a facility's emergency department who has not been stabilized and the patient is requesting the transfer, after being informed of the hospital's EMTALA obligations and the risks of transfer. The sending hospital takes precedence in determining if the patient is an EMTALA patient. Transfers of these patients are subject to EMTALA provisions."
* "On-call list means the list of physicians who are 'on-call' after the initial medical screening examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition."
* "On-call coverage. The hospital will maintain a list of physicians who are on-call to come to the hospital to consult or provide treatment necessary to stabilize an individual with an emergency medical condition. If a physician is listed as on-call and requested to make an in-person appearance to evaluate and treat an individual, that physician must respond in person in a reasonable amount of time. If the physician is on the hospital's on-call list; has been requested by the treating physician to appear at the hospital; and fails or refuses to appear within a reasonable period of time; then the hospital and the on-call physician may be subject to sanctions for violation of the EMTALA statutory requirements."
* "Receiving a patient who is present in another facility's emergency department who has been stabilized within the limits of that facility's current capabilities to a Providence hospital...Any hospital department receiving a request to transfer a patient to a Portland Service Area hospital transfers the call to the Providence Transfer Center...Transfer Center determines whether the situation involved an EMTALA-related patient by asking the requesting facility if the patient is currently in their emergency department...If yes, the Transfer Center collects appropriate information from appropriate personnel in the requesting facility's emergency department. This information includes patient demographics, nature of emergency, type of interventions required, type of hospital bed required, and type of physician required. Transfer Center determines the receiving hospital capacity...If...the...facility has capacity, Transfer Center contacts the appropriate on call physician on a recorded phone line using the Emergency Department call list. Transfer Center personnel communicate details of the transfer to the physician on call using a common script. These details include name of requesting facility and physician, patient information, nature of emergency, and specifies that the transfer is an EMTALA-related patient. Transfer Center connects on call physician to emergency physician at the requesting facility...If transfer is not accepted by on call physician, Transfer Center documents details of transfer request, including physician's reason for refusing to accept the transfer...A patient transfer to a Providence Health & Services Department that does not comply with EMTALA guidelines for an appropriate transfer must be reported to the [CMS SA, OHA] within 72 hours of receiving the patient or risk termination of its provider agreement with Medicare.

3. The PPMC "Policies and Procedures Professional Staff" dated as "revised" 05/28/2018 stipulated "Emergency Call...All Active and Active Provisional Physician members of the Professional Staff who hold core privileges in their specialty areas are required to take emergency hospital call...Members must be available to respond by phone, and when clinically indicated in person, to the Hospital(s) within thirty (30) minutes when on the published emergency call schedule."

4. The printed, undated and untitled electronic PPMC medical staff roster reflected that Physician L had been on staff at PPMC since 09/14/2006, was "Active" status, and Physician L's specialty was Otolaryngology, also referred to as ENT.

5. The "ENT" on-call list for July 2018 reflected Physician L was scheduled for ENT call on 07/03/2018, 07/04/2018, 07/06/2018, 07/07/2018, and 07/08/2018.

6. Review of the printed electronic Transfer Center call record titled "Hospital/Pt. Transfer" for a call about Patient 4 reflected a call was received on 07/07/2018 at 2307 from an ED Physician at PHRMC, who requested ENT specialty services. Notes for two calls were recorded:
* A note dated 07/07/2018 at 2313 reflected "PPMC can take transfer per [PPMC HS]. Connected [Physician L, PPMC ENT on-call] to [Physician K, PHRMC ED Physician]. Pt was seen in clinic 4 days ago w/ asymmetric tonsils. pt was started on prednisone, clindamycin and augmentin but swelling has worsened. has very large left sided tonsil, afebrile. [Physician L] does not feel this is a medical necessary transfer. [Physician L] suggests hospitalist at [PHRMC] admit to their hospital, get iv antibiotics, and be monitored. [Physician L] does not feel that this is a medically necessary transfer. [Physician L] is not willing to accept a transfer that has not been assessed by local ENT. [PHRMC ED Physician K] said [he/she] would speak to hospitalist at [PHRMC] to see if they would admit there."
* A note dated 07/07/2018 at 2355 reflected "Received call from [PPMC HS], who wanted to speak to [Physician L, PPMC ENT on-call]. Connected [Physician L] says that [he/she] does not feel that it is [his/her] responsibility to cover the ER in Hood River. [He/she] is upset that there are ENTs in Hood River that will not see the pt. [PPMC HS] informed [Physician L] that the ENTs are not available in Hood River for tonight. [Physician L] keeps repeating that there are ENTs in Hood River that will not see their patient. [PPMC HS] states that ENT is not available in Hood River tonight and that this may become an EMTALA violation because the patient needs to be transferred for a higher level of care to [PPMC]."

7. An audio recording of the first call between Physician L, PPMC ENT on-call and Physician K, PHRMC ED Physician was recorded on 07/07/2018 beginning at 2313 and was 8 minutes and 26 seconds in duration. During play of the audio recording the following was heard:
Transfer Center staff connected PHRMC ED Physician K and PPMC ENT on-call Physician L and indicated he/she would record the outcome.
PHRMC ED physician: "PHRMC ED physician at Hood River, I have [Patient 4] seen in clinic 4 days ago with asymmetrical tonsils and was thought to have peritonsillar cellulitis or early abscess put on prednisone, clindamycin and Augmentin and has progressed and gotten worse. Tonight, [he/she] came into ED complaining of increasing pain, increasingly difficult to swallow and feels SOB if [he/she] lies flat."
PHRMC ED physician: "Large Left tonsil that sort of merges into the uvula on beefy red, left side of neck is tender but not swollen. Afebrile, not tachycardic, I ran [him/her] through the CT scanner and radiologist is reporting 3.1 x 2.5cm lesion within the left palitide tonsil. [Patient 4] is failing outpatient management and we don't have ENT on call out here anymore."
PPMC ENT on-call: "You have ENTs who are out there but not taking call?"
PHRMC ED physician: "Yah, there were 3 they are down to 2 in the hospital. I just called one earlier and [he/she] goes well they're not on call, the hospital is not paying for call coverage, they are stretched too thin, yah so they are not on call."
PPMC ENT on-call: "Uh."
PHRMC ED physician: "Well you know I'd say maybe IV antibiotics here, but [his/her] airway makes me nervous."
PPMC ENT on-call: "This is uhm been a chronic problem with your ENT coverage and I don't feel like this is a medically appropriate transfer. Last time I ran into this uh the patient was transferred to-had been inappropriately assessed by the local ENT there and didn't have insurance and I actually had to call medical staff affairs to say this was a medically inappropriate transfer and that's kind of how I feel now. Uhmmm."
02:44 PHRMC ED physician: "What do you suggest I do with this [patient]?"
PPMC ENT on-call: "Admit [him/her] to the hospital service and put [him/her] on IV antibiotics and steroids and observe [him/her], and try to get your ENTs involved. I mean I think your medical staff affairs at your hospital needs to be involved in this because I am not the-we should not be the default for patients that are not covered by your ENT service."
PHRMC ED physician: "So, if this [patient] needs a surgical airway in the middle of the night?"
PPMC ENT on-call: "I am not sure [he/she] needs a surgical airway." (both speaking at the same time)
PHRMC ED physician: "Well I'm not either but if [he/she] gets worse."
PPMC ENT on-call: "Has [he/she] been-has [he/she] been adequately medically managed."
PHRMC ED physician: "[He/she's] on adequate outpatient antibiotics that are failing."
PPMC ENT on-call: "For how long?"
PHRMC ED physician: "[He/she's] been on prednisone, [he/she's] been on clindamycin and Augmentin for 4 days and [he/she's] getting worse."
PPMC ENT on-call: "And why do we feel like [he/she] is a surgical airway?"
PHRMC ED physician: "Well I look at this CT and [his/her] airway is narrowed, and [he/she] has an abscess that is not going to be drained by the hospitalist. I don't know whether this is an abscess that mandates drainage because I am not an ENT surgeon, but [he/she] has an abscess."
PPMC ENT on-call: "Right."
PHRMC ED physician: "And it's fairly large."
04:33 PPMC ENT on-call: "You have ENT surgeons at your hospital."
PHRMC ED physician: "I know, but I don't have access to them and I am not going to be able to change that tonight. Right, I have already talked to ENT and they have an issue."
PPMC ENT on-call: "And what did they say?"
PHRMC ED physician: "[He/she] said that they don't [unintelligible]. The hospital is not willing to pay them for call coverage and have locums so that they are not on call every other night. That's between them and the hospital; I can't control that."
PPMC ENT on-call: "Well, no, I understand that, but this has been a chronic problem for years, inappropriate transfers to our hospital because your ENTs are not willing or able to assess the patient. So, is the patient in distress?"
PHRMC ED physician: "[He/she] doesn't want to lie flat because [he/she] feels like [he/she] can't breathe."
PPMC ENT on-call: "Uh huh"
PHRMC ED physician: "[He/she's] sitting up."
PPMC ENT on-call: "Uh huh"
PHRMC ED physician: "But [he/she's] not drooling but I don't (unintelligible)."
PPMC ENT on-call: "Is [he/she] taking PO?"
PHRMC ED physician: "I don't know I can give [him/her] dexamethasone, [he/she's] been on prednisone I can give [him/her] dexamethasone and see if that will keep [him/her] out of trouble but we ..."
05:42 PPMC ENT on-call: "Yah I think 20 of Decadron continue IV antibiotics and try and get your ENTs involved. I don't think this is a medically appropriate transfer. You have ENTs locally that are not willing to cover their patients in their region."
PHRMC ED physician: "I know but [he/she's] not an established patient with them."
PPMC ENT on-call: "Uh No"
PHRMC ED physician: "[He/she] was seen at one of the local clinics, [he/she] was not."
06:29 PPMC ENT on-call: "[He/she] is a patient that is appropriate for ENT coverage locally and not appropriate for a medical transfer to Portland if [he/she] is not in airway distress."
PHRMC ED physician: "Ok I will talk to the hospitalist."
PPMC ENT on-call: "And [he/she] has not been on IV antibiotics and steroids then this is something you need to address at your level, at your local ENT level because we are not willing to-we are not willing to accept patients from ENT patients that have not been assessed by the local ENT. The only way we will accept uh accept patients is if your ENTs call us and say we have assessed this patient and are unable ..."
PHRMC ED physician: "That would be great there is no ENT on call I mean so I can't ..."
07:33 PPMC ENT on-call: "[Physician K, Physician K], you know what [Physician K], that needs to be taken up at your level."
PHRMC ED physician: "Ok Saturday night, I will talk to the hospitalist and ask them if they will accept this patient and if they won't than I will be back on the phone trying to call some other hospital. You know I can't admit ..."
PPMC ENT on-call: "What I would do is call the medical staff affairs at your own hospital and say our ENTs are not providing adequate [unintelligible]."
PHRMC ED physician: "Right, I will talk to the on-call administrator I'm not sure what they are going to be able to accomplish tonight but thank you I will talk to the hospitalist and see if they will take the patient."
PPMC ENT on-call: "Ok."
PHRMC ED physician: "All right thanks."
End of call, length 08:26

8. An audio recording of the second call between PPMC HS and Physician L, PPMC ENT on-call was recorded on 07/07/2018 beginning at 2355 and was 16 minutes and 5 second in duration. During play of the audio recording the following was heard:
Transfer Center staff connected PPMC ENT on-call Physician L and PPMC HS and says "go ahead."
PPMC HS: "Hey [Physician L]."
PPMC ENT on-call: "Hi, what's your-"
PPMC HS: "Can you hear me?"
PPMC ENT on-call: "Uh Yes, what's your name?"
PPMC HS: "My name is [PPMC HS], I am a nursing administrator at Providence Portland and I am calling because I got a call from the nursing executive over at Hood River regarding [Patient 4] with the peritonsillar abscess."
PPMC ENT on-call: "Yah."
PPMC HS: "Um So, I guess from their point of view not having an ENT available they don't feel comfortable or safe admitting the patient upstairs and I think they are actually going to cite this as an EMTALA issue in terms of transferring to a higher level of care. So, I am trying to figure out what we can do, and I so wanted to connect with you about what your thoughts were and what we might be able to work out."
PPMC ENT on-call: "Well my initial thoughts are that we have several inappropriate transfers from Hood River over the last several years."
PPMC HS: "OK."
01:41 PPMC ENT on-call: "Where ENT were not willing to assess the patient in Hood River and just say transfer."
PPMC HS: "Ok, it's my understanding that they don't even have an ENT available tonight to do an assessment."
PPMC ENT on-call: "Umm, they have ENTs in the town."
PPMC HS: "Well, all I know from the nursing executive for however their administrative set up is organized and I can't really speak to it for all intents and purposes I guess do not have access to an ENT even if there is one in town, I don't know if they don't have contracts with them or what not. [He/she] is telling me they do not have one available which is why they are seeking a higher level of care."
PPMC ENT on-call: "Yah, So, uh I don't feel that that's our problem, I feel that that's their problem."
02:34 PPMC HS: "It's all in the Providence system though so I can't isolate it to one specific you know Providence area and say that this is their problem especially if this goes beyond me because the upper level people are not going to look at it that way at all."
PPMC ENT on-call: "So, they have ENTs in Hood River who are not willing to assess the patient."
PPMC HS: "Or they just haven't set up things to have an ENT at night or on the weekends, I don't really know."
02:58 PPMC ENT on-call: "I don't feel it's appropriate for us to cover Hood River, but they have ENTs in Hood River."
PPMC HS: "So, the reason I am calling you is because if we can't figure out a way to bring this patient over this is going to get escalated and it's going to get all sorts of administrative people involved tonight and I would really like to avoid that situation."
04:05 PPMC ENT on-call: "Uh yes but there have been several medical medically inappropriate transfers from Hood River because the ENTs from Hood River are not willing to cover the ER and I don't feel, I don't feel it's appropriate that I have to cover the ER in Hood River."
PPMC HS: "Well so, I guess I am just confused because this is sort of the purpose of the transfer center within Providence is we transfer patients all the time for, you know, care that is not able to be met at one specific facility for whatever the reason is."
PPMC ENT on-call: "Right so why is it that there are ENTs in Hood River who are not able to assess the patient."
PPMC HS: "I can't answer that, I don't know."
PPMC ENT on-call: "That's, that's the issue."
PPMC HS: "And I agree with you and I am happy to, you know raise that question and have it get investigated."
04:34 PPMC ENT on-call: "You know what ... I had a patient [unintelligible] transferred to me from Hood River for an inappropriate diagnosis and the patient did not have insurance and I actually had to call medical staff affairs at Hood River and say this patient should not be billed because they were not assessed and inappropriately transferred."
05:08 PPMC HS: "Right, I-I totally hear your frustration with that and I do think it's an issue that needs to get-."
PPMC ENT on-call: "No, it's not a frustration, it's an inappropriate medical transfer so you have ENTs in Hood River who are not ..."
PPMC HS: "I guess my point [Physician L] tonight I will not be able to solve that problem."
PPMC ENT on-call: "Who are not willing to assess the patient."
PPMC HS: "Right, I hear your, I guess what I am trying to relay is that issue is not going to get solved tonight so I am trying to find a way to deal with this particular issue, also realizing we need to also deal with a larger issue you know tomorrow or Monday."
PPMC ENT on-call: "So, is the patient in distress?"
PPMC HS: "I can call this [Physician K] in the ER, I don't really know, what I was told is that they are uncomfortable and unwilling to admit them upstairs."
PPMC ENT on-call: "When I spoke to [Physician K], I asked [him/her] to admit the patient for IV antibiotics and steroids."
06:11 PPMC HS: "For whatever reason [Physician L] they are not comfortable doing that there without an ENT evaluation, I don't know what else to say."
A PPMC ENT on-call: "And they have ENTs in Hood River."
PPMC HS: "Right, so I don't know what to say [Physician L] there's no I can't deal with the ENTs in Hood River tonight I understand that that's an issue but it's sort of irrelevant."
06:40 PPMC ENT on-call: "So why is that, why can't you call the ENTs from Hood River?"
PPMC HS: "Well one that's like ..."
PPMC ENT on-call: "Why do I have to be the default person?"
06:45 PPMC HS: "Because that is the way the system is set up right now, the Providence system."
PPMC ENT on-call: "Right, so there's a history of inappropriate medical transfer costing the patient thousands of dollars because the ENTs in Hood River would not assess the patient."
PPMC HS: "Yes, I agree with you, I also need to figure out this transfer tonight or I am going to have to wake up my own chief nursing executive and this whole thing is going to get really ugly."
PPMC ENT on-call: "Really ugly for whom?"
PPMC HS: "In terms of just the mess because they are going to cite this as an EMTALA issue."
PPMC ENT on-call: "EMTALA meaning ..."
PPMC HS: "Meaning transfer to a higher level of care that is being denied."
PPMC ENT on-call: "Um without being assessed by a local ENT I don't see what that's an EMTALA issue, you have ENTs locally who refuse to assess the patient."
PPMC HS: "You understand that we can't do anything about that right now?"
PPMC ENT on-call: "No, I don't understand that."
PPMC HS: "That's such a larger issue that's going to take a lot of meetings and people."
PPMC ENT on-call: "You have ENTs locally who are refusing to assess the patient, so why should the patient be transferred to Portland to be assessed when you have local ENTs that are refusing to address their patients."
PPMC HS: "Okay I feel like we are going in circles um I hear what you're saying I need to know what where doing here because I have to decide if we can either bring this patient over or if I need to start making phone calls."
08:40 PPMC ENT on-call: "Phone calls to whom?"
PPMC HS: "I've got to make a phone call to my chief nursing executive over the fact that I've got a call from the chief nursing executive over at Hood River over this issue. I guess what I'm saying is it would be a lot easier to bring this patient over here tonight and then deal with the larger issue on Monday."
PPMC ENT on-call: "Sure, bring your patient to your hospital and treat them medically and get your ENTs involved and if they are not comfortable with that level of care than I mean an ENT should be able to manage a peritonsillar abscess. That is not a medically appropriate transfer, the patient has not been assessed by another otolaryngologist."
PPMC HS: "Well and that's the whole point, they can't be tonight which is of great concern."
PPMC ENT on-call: "They can't be assessed tonight because your otolaryngologist refuses patients."
PPMC HS: "Well not me, I'm the nursing sup at PPMC so I'm over seeing PPMC tonight and trying to help solve this situation."
PPMC ENT on-call: "[unintelligible] .... comfort level"
PPMC HS: "Okay so I guess at this point I just I'm hearing what you're saying I just want to let you know I have to start making calls up and I would expect that you're going to be getting calls from some of these people too."
PPMC ENT on-call: "I think that there are otolaryngologists in Hood River who should be able to manage a peritonsillar abscess."
PPMC HS: "I understand but we are being told at the time that there are not."
PPMC ENT on-call: "Medically inappropriate transfers."
PPMC HS: "Okay, can I just ask you point blank, are you refusing to accept this patient?"
11:15 PPMC ENT on-call: "Uh without assessment by the local otolaryngologist, I will not accept the patient."
PPMC HS: "Okay."
11:00 PPMC ENT on-call: "If the local ENT comes in and examines the patient and says I am not comfortable with this level of acuity and calls me and discusses it, I will accept the patient, but I have only talked to an ER physician who has not had the patient evaluated by an otolaryngologist, which you have locally."
PPMC HS: "So, just one final question."
PPMC ENT on-call: "This has been a recurrent problem for years!"
PPMC HS: "Okay I hear you, I just have one ..."
11:49 PPMC ENT on-call: "I feel like I need to cover all of Portland and Hood River when there are otolaryngologists in Hood River who are unwilling to come into the ER and evaluate the patient."
PPMC HS: "So just one final question for you, if I call Hood River and they tell me that it's not a matter of them refusing to come in, it's a matter that the hospital has not set up the ability for them to come in yet so that its actually impossible, will that make a difference?"
PPMC ENT on-call: "Wait, Whoa, whoa why would it be impossible for an otolaryngologist with staff privileges at the hospital to evaluate the patient."
12:13 PPMC HS: "Well I don't know yet, I'm going to call and find out I'm just asking if that would make a difference?"
PPMC ENT on-call: "Right, so that's not my problem you have ENTs in Hood River who apparently do not want to evaluate patients."
PPMC HS: "Okay the last thing I just want to say is you are aware that in the Providence system they look at it at a system level and not at an individual level at all."
PPMC ENT on-call: "Than does not, I..."
PPMC HS: "I'm just telling you the way this is going to get evaluated."
12:46 PPMC ENT on-call: "Can you explain that a little more?"
PPMC HS: "Sure, Providence is a system of, as you know, of many different hospitals and so when one transfer occurs as long as within the Providence system they don't mind transferring, whatever the reason is so when a person who is working for Providence doesn't view it from the system level, I'm just telling you that's going to be interpreted as problematic."
PPMC ENT on-call: "Uhm ..."
PPMC HS: "So, even though its Hood River its still a Providence facility it's not like it's their problem, it's our problem because we are Providence."
PPMC ENT on-call: "There are still Hood River otolaryngologists who are refusing to see the patients."
PPMC HS: "Okay I ..."
PPMC ENT on-call: "So ..."
PPMC HS: "I think the problem is they don't have ENTs under contract over the weekend."
13:54 PPMC ENT on-call: "Well you know what, that is not my problem."
PPMC HS: "It is your problem [Physician L], it is your problem."
PPMC ENT on-call: "I should not have to cover Hood River."
PPMC HS: "I understand that, but you do."
PPMC ENT on-call: "And there are ..."
14:08 PPMC HS: "You do, because it's a Providence facility, this needs to happen, and I am just asking you if you are refusing because I basically need to say that a Providence physician is not willing to accept a Providence patient because they are at a different facility."
PPMC ENT on-call: "Uh no, that's not the issue."
PPMC HS: "Well the other facility doesn't have contract ENTs on the weekend."
14:37 PPMC ENT on-call: "I am not obligated to cover Providence Hood River."
PPMC HS: "Right, that's why we're transferring the patient here."
PPMC ENT on-call: "Right ... There are otolaryngologists in Hood River who are not willing to see patients."
PPMC HS: "Okay so I'm going to go ahead and get off the phone now I've got to make some phone calls because this is just isn't going anywhere."
PPMC ENT on-call: "No, because It's been a chronic problem that we frequently get calls from Providence Hood River to accept inappropriate transfers, and that needs to be addressed at the executive level."
PPMC HS: "It does, but it's not going to solve this particular issue tonight."
PPMC ENT on-call: "No, but the patient apparently from what I hear, is stable."
PPMC HS: "Okay, uhm ..."
PPMC ENT on-call: "And has not been medically managed with IV antibiotics and steroids."
PPMC HS: "Okay, I appreciate your time [Physician L], I'll call you back if I need to...thanks."
End of call, length 16:05

9. Review of the printed, untitled electronic Transfer Center Log reflected it contained columns for specified information. An entry dated on 07/07/2018 reflected the following information in the those columns:
* "Requested Specialist Type - ENT/Otolaryngology"
* "Receiving Specialist Type - ENT/Otolaryngology"
* "Transaction Date - 7/7/2018 11:07:38 PM"
* "Disposition - Advice"
* "Receiving Facility - [PPMC]"
* "Transfer Reason - Higher Level of Care"
* "Diagnosis - left peritonsillar abscess"
* "Sending Facility - [PHRMC]"

The log was not accurate as it reflected the disposition of the call was "Advice." However, Physician L had clearly and repeatedly refused to accept the patient in transfer and no medical advice was given.

10. A PPMC "EMTALA Investigation Form" dated 07/09/2018 contained the following narrative: "[Physician L, PPMC ENT on-call] contacted by [Physician K, PHRMC ED Physician] to transfer patient to PPMC for ENT eval as no ENT on call at PHRMH. [PHRMC ED Physician K] concerned about patient's airway and needed to be assessed by ENT to determine if abscess requires drainage. [Physician L] refused to accept patient...felt it was a medically inappropriate transfer and patient needed to be assessed by local ENT before [he/she] would accept. Repeated attempts by [PHRMC ED Physician K], and later by [PPMC HS], to explain that there was not an ENT available to assess patient and that this could be an EMTALA violation. [Physician L] continued to refuse to accept patient stating it is Hood River's problem and not PPMC's problem that a local ENT was refusing to see the patient."

11. An undated and untitled document contained the following narrative: "[PPMC HS] attempted to escalate the denial of the PHRMH patient to the Administrator on call after speaking with [Physician L, PPMC ENT on-call] on July 8, 2018. Unfortunately, the Administrator on call did not respond to the pages until after the patient had been transferred to Legacy. [PPMC HS] also contacted the Surgery Department Chair who was not able to assist in accepting the patient."

12. During interview with QMC B on 07/17/2018 at 1110 he/she stated that on 07/17/2018 at the time of the Transfer Center call about Patient 4, PPMC did have an ENT bed available for the patient. QMC B reported that the PHRMC ED Physician requested transfer to PPMC for ENT specialty services due to Patient 4's worsening peritonsillar abscess condition that included SOB after four days of outpatient treatment. QMC B stated that Physician L, PPMC ENT on-call, believed that PHRMC had an ENT Physician available to them and therefore he/she refused to accept the patient. QMC B further stated that in discussion with Physician L since the event, Physician L stated the he/she wasn't aware of the hospital's EMTALA obligations.

13. During interview with Physician L, the PPMC ENT on-call, on 07/17/2018 beginning at 1635 he/she provided the following information:
* Physician L stated that he/she had been in practice as an ENT physician since 1998 and had started assuming on-call duties in 2009.
* Physician L stated he/she was on-call and received call from the PHRMC ED Physician about Patient 4 who presented with peritonsillar abscess that had been treated for the past 4 days with steroids and antibiotics; a CT scan showed 3 x 2.5 cc fluid collection; Patient 4 was managing secretions and had a "little SOB when lying down."
* Physician L stated that Patient 4 could be managed with IV antibiotics and steroids; he/she asked the PHRMC ED Physician to have the PHRMC Hospitalist observe and manage the patient; and call ENT "tomorrow" for further consult.
* Physician L stated that there was a history of inappropriate transfers from PHRMC and that he/she had to call the PHRMC medical staff affairs previously about another case of a transfer from PHRMC to PPMC for ENT services for a patient "who didn't have insurance."
* Physician L stated "I didn't see any justification for ambulance transfer of someone who'd been there for four days...could have resolved very well with IV antibiotics and steroids...I felt [Patient 4] had not been adequately managed after four days."
* Physician L stated that he/she did not recall another phone call with anyone at PPMC that night after the call with the PHRMC ED Physician.
* Physician L stated that QMC B called me after the event and told me the refusal was an EMTALA violation; "I'm not versed at all in EMTALA rules...[QMC B] made me see I made a mistake."
* Physician L stated that he/she had received "none, zero" EMTALA training.
* Physician L stated the he/she would have been able to respond in a timely manner the night of Patient 4's case if he/she had needed to come into the hospital.
* Physician L continued to demonstrate lack of understanding of EMTALA requirements as he/she stated further that he/she "understands now" that "if a physician says they're uncomfortable" with a patient's condition and the hospital has a bed "we must take [the patient]."

14. During interview with QMC B on 07/18/2018 at 1015 he/she confirmed that during the 07/17/2018 interview Physician L stated that he/she did not recall the phone call with the PPMC HS.

15. The only documentation of training or education for Physician L related to the hospital's EMTALA obligations was provided in the form of a printed "PULSE News for Oregon/SW Washington providers" electronic newsletter dated "September 2017." A short article in the newsletter was titled "Why it's important to follow EMTALA, the 'anti-dumpi