HospitalInspections.org

Based on interview, review of central log and medical record documentation for 7 of 20 individuals who presented to the hospital for emergency services (Patients 2, 5, 7, 15, 16, 19 and 20), review of an audio recording call, review of scope of service documentation, review of informational practice documentation, review of policies and procedures, and review of other documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured it met its EMTALA obligations in the following areas:
* Physician on-call responsibilities.
* Further examination and stabilizing treatment.
* MSEs.
* To obtain or attempt to obtain written and informed refusal of MSEs, and to ensure medical records contained required documentation per hospital policies and procedures.

Findings include:

1. The policy and procedure titled "Emergency Medical Screening Examination, Treatment, and Transfer (EMTALA) - National Policy" dated effective 04/12/2023 was reviewed. It reflected:
* "The hospital will provide a MSE by a QMP to any individual who comes to the hospital seeking emergency medical treatment (or requested on their behalf) to determine if the individual seeking care has an EMC; and, if an EMC exists, provide the individual with further medical examination and treatment as required to stabilize the EMC or arrange for transfer ..."
* "Patients Who Leave Without Being Seen (LWBS), Elope, or Leave Against Medical Advice (AMA) All reasonable efforts should be made to conduct a MSE before the individual leaves, with documentation of the discussions and efforts made to prevent the individual from leaving."
* "If an individual (or legal representative) refuses to consent to a medical evaluation or certain stabilizing treatment or transfer to another facility ... The individual (or legal representative) will be offered further medical examination, stabilizing treatment, or transfer to another facility, as appropriate for the individual, and ... The individual will be informed of the benefits and risks of refusing the medical examination, stabilizing treatment or transfer to another facility, which should be documented in KPHC ... Staff will take all reasonable steps to secure written informed refusal from the individual (or legal representative) of the examination, stabilizing treatment and /or transfer. If written refusal cannot be obtained, staff will document attempts and reasons, if known, in KPHC ... KPHC will contain a description of the proposed treatment and/or transfer that was refused by or on behalf of the individual."
* "Department or unit staff will complete the LWBS and AMA sections in KPHC, as appropriate, and/or complete the appropriate sections of the hospital's designated form(s) to document the details of the individual's departure from the hospital ... An individual who leaves the hospital after being triaged but before receiving an MSE should be noted in KPHC as LWBS. Any details about the reason the individual provided for leaving without being seen should be documented in KPHC."
* "An individual for whom an MSE has been initiated or completed who then leaves the hospital without notifying anyone should be noted in KPHC as having eloped. Details about what screening (and treatment, if any) had been completed up to point of the elopement should be documented in KPHC."
* "An individual who receives an MSE but then declines treatment and insists on leaving after a QMP determines they have an EMC that requires stabilizing treatment should be documented as having left AMA. The details of the discussion with the individual, including the risks and benefits of treatment and leaving without receiving treatment, should be documented in KPHC."
* "Staff will attempt to obtain the individual's signature on the form documenting that the individual refused an MSE and/or stabilizing treatment (when possible). If the individual refuses to sign the form, a notation to such should be made by the ED or L&D staff (e.g. 'individual refused to sign')."

2. The policy and procedure titled "AMA (Against Medical Advice), Elopement and Left Without Being Seen (LWBS)" dated effective 02/25/2020 was reviewed. It reflected:
* "Patients (or their legal representatives) shall be advised of their rights and given adequate information to make informed decisions prior to refusing medical care and treatment when at all possible including the risks in leaving, benefits of further examination and/or treatment, and any alternatives."
* "The purpose of this policy is to provide guidelines for appropriate steps to take when an individual seeking services in the ... Emergency Department, leaves or makes demand to leave prior to the completion of treatment of against the advice of the treating physician/clinician."
* "Staff Responsibility ... Left without being seen - ED ... If a patient leaves without being seen by a physician so that an MSE may be completed (i.e., is not in the waiting room when his/her name is called) then staff will ... Call the patient and conduct a reasonable search for the patient in the immediate area of the waiting room in an attempt to locate the patient. Document in nursing note."
* "Leaving against medical advice ... AMA is in the event a patient verbalizes the intent to leave, any staff member shall ... Take all reasonable steps to encourage the patient to remain for further medical care and treatment ... Direct the patient to an RN and/or physician ... The RN and /or physician shall ... Take all reasonable steps to encourage the patient to remain for further medical care and treatment ... Explain the risks and consequences of leaving the facility, including the benefits of continued treatment or hospitalization and any alternatives to treatment ... Assess the patient's cognitive and decision-making capacity ... "
* "If the patient still desires to leave AMA, the RN and/or physician shall make all reasonable attempts to obtain the patient's (or legal representative's) written signature on the Leaving Hospital Against Medical Advice form ... If the patient or legal representative refuses to sign the form a notation "refuses to sign" will be made in the signature space ... The physician or RN will sign the form and note the date, time and patient disposition ... The original form must become part of the patient's permanent medical record even if the patient or legal representative refused to sign ..."
* "If patient elopes from ED ... Conduct a reasonable search for the patient in the immediate area ... Notify the physician immediately if patient presented with an acuity of "1", "2", or "3" ... The physician shall determine whether further action is required (i.e., phone call to patient with follow up instructions, notification of local police) ... Document all efforts to locate patient, condition when last seen and any additional actions taken.
* "Emergency Department-document according to elements already covered in this policy as well as ... AMA is documented on Leaving Hospital Against Medical Advice form ... A hospital representative must witness the signing of the release form. This form is part of the permanent part of the medical record ..."

3. Regarding physician on-call responsibilities, refer to the findings identified under Tag A2404, CFR 489.20(r)(2) and 489.24(i)(1-2). The findings cited at Tag A2404 were determined to represent an IJ situation.

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

5. Regarding stabilizing treatment, refer to the findings identified under Tag A2407, CFR 489.24(d)(1-3).

6.a. The central log for Patient 7 reflected that they presented to the ED on 02/18/2023 at 2045 with a chief complaint of "Chest Pain." The ED disposition on the log was "AMA."

6.b. The medical record for Patient 7's 02/18/2023 ED encounter was reviewed and included:
* At 2052 RN triage notes reflected "Pt BIBA for CP from home. Pt started cardizem today per ems. Pt c/o back pain. Pt given zofran by ems. Bp 162/100 hr 102. 99% on RA. Pt is A&O. Pts breathing is even and unlabored."
* At 2052 vital signs were recorded.
* At 2054 an EKG was done.
* At 2234 an RN "Addendum" note reflected "Patient on call bell stating [they want] to leave AMA. Explained risks, not limited to death - patient verbalizes [their] understanding. Doctor notified. IV removed. Patient dressed [themselves] independently and left department."
* MD Provider notes electronically signed by the MD and dated 02/19/2023 at "12:20 AM" reflected "Patient left after being seen. We did not have an AMA discussion. [Patient] abruptly reported that [they] wanted [their] IV removed and left the hospital ... Patient left of [their] own accord after being seen."

There was no documentation that reflected the RN and/or physician encouraged the patient to remain for further medical care and treatment in accordance with hospital policy.

The record contained no AMA form and there was no documentation that the RN and/or physician attempted to have the patient sign an AMA form in accordance with hospital policy. In addition, there was no documentation that staff attempted to obtain the patient's signature and the patient refused.

There was no documentation that the RN and/or physician explained the benefits of continued exam and/or treatment in accordance with hospital policy.

6.c. During interview and review of Patient 7's medical record on 06/07/2023 at 1245 the ED QC confirmed there was no AMA form.

7.a. The OB log for Patient 15 reflected that they presented to the OB department on 05/02/2023 at 2221 with a chief complaint of "dizzy and high BP." The disposition was "Transferred" and the "Departure" date and time was 05/02/2023 at 2303.

7.b. The medical record for Patient 15's 05/02/2023 OB encounter was reviewed. An OB MD note dated 05/02/2023 at 2323 included "Referred patient to [the] Emergency Department for evaluation of cardiac symptoms ..."

7.c. The medical record for Patient 15's 05/02/2023 ED encounter was reviewed and reflected the patient arrived to the ED at 2311 and included:
* At 2335 vital signs were recorded.
* At 2338 RN triage notes reflected "Pt was at work when [they] got dizzy and couldn't see the computer screen. Pt stood up and fell back into [their] chair. Pt reports that [they] had two episodes and palpitations this week and is scheduled for a holter monitor and echo outpatient. Pt denies CP or feelings of palpitations. Pt nauseous and dizzy in triage, states [they feel] like [they are] spinning ... 15 [weeks] 5 [days] pregnant ..."
* At 2345 an EKG was done.
* At 0135 on 05/03/2023 an RN recorded "Called in lobby, no answer x1."
* At 0153 an RN recorded "Called in lobby, no answer x2."
* At 0218 an RN recorded "Called in lobby, no answer x3. PAR reported to this RN that pt left."
* At 0218 "Discharge Information" reflected "Disposition: Left Against Medical Advice Or Discontinued Care."

There was no documentation that reflected the details about the reason the patient left the ED before an MSE in accordance with hospital policy. There was no documentation that reflected staff attempted to discourage or dissuade the patient from leaving prior to having an MSE.

7.d. During interview and review of Patient 15's ED medical record on 06/07/2023 at 1600 the ED QC confirmed the record reflected the patient left the ED before receiving an MSE.

8.a. The central log for Patient 16 reflected that they presented to the ED on 05/12/2023 at 1756 with a chief complaint of "Motor Vehicle Accident." The ED disposition on the log was "AMA."

8.b. The medical record for Patient 16's 05/12/2023 ED encounter was reviewed and included:
* At 1756 the patient arrived to the ED.
* At 1759 vital signs were recorded.
* At 1759 RN triage notes reflected "Pt was a restrained driver of MVA. Pt reports left lateral neck pain that radiates up into his head. Pt does take blood thinner for a-fib."
* At 1911 labs were collected.
* At 1945 CTA Brain and Neck was completed.
* At 2034 an RN recorded "Pt to RN triage booth. Pt would like to leave [MD name] was notified and pt assume [sic] risk of leaving without ct results being red [sic]."
* MD Provider notes electronically signed by the MD and dated 05/12/2023 2035 reflected "... informed by nurse that patient had [their] CT scan. Radiologist had not yet reviewed. Patient does not want to wait in the ED for results. Patient is leaving AMA ..."

There was no AMA form in the medical record and no documentation that the patient was asked to sign an AMA form by the RN and/or physician or that the patient refused to sign the form, in accordance with hospital policy.

8.c. During interview and review of Patient 16's medical record on 06/07/2023 at 1150 the ED QC confirmed there was no AMA form and no documentation that reflected the patient refused to sign an AMA form. The ED QC stated, "I would expect to see it [AMA form]."

9.a. The central log for Patient 20 reflected that they presented to the ED on 06/02/2023 at 1420 with a chief complaint of "Chest Pain." The ED disposition on the log was "AMA."

9.b. The medical record for Patient 20's 06/02/2023 ED encounter was reviewed and included:
* At 1420 the patient arrived to the ED.
* At 1423 vital signs were recorded.
* At 1426 an EKG was done.
* An RTMC MD Note from 06/02/2023 1356 was copied and pasted into ED triage notes by an ED RN that reflected "68 yo [patient] with h/o HTN, afib, CP, dizziness, worse with exertion, SOB. Symptoms started about 3 weeks ago while working in yard, felt heaviness, lightheadedness, CP and shortness of breath. Worse today while digging hole at farm. Advised asa and SMC ED."
* At 1430 labs were collected.
* At 1704 an RN recorded "No answer x1 for reeval."
* At 1721 an RN recorded "No answer x2 for reeval."
* At 1745, an MD recorded "ED Disposition AMA/Refused Treatment."
* An MD Provider note electronically signed by the MD and dated 06/05/2023 at 2258 reflected "Patient was called repeatedly from the waiting room and appears to have eloped before we could discuss result."

There was no documentation that reflected the details about the reason the patient left the ED in accordance with hospital policy, including whether the patient told staff they were leaving or whether staff saw the patient leave. There was no documentation that the patient was asked to sign an AMA form by the RN and/or physician or that the patient refused to sign the form in accordance with hospital policy.


40575

Based on interviews, review of medical record documentation for 1 of 2 encounters of individuals who presented to the hospital for emergency services and experienced aortic dissection (Patient 19), review of an audio recording call, review of scope of service documentation, review of informational practice documentation, review of policies and procedures and review of other documentation, it was determined that the hospital failed to enforce it's EMTALA policies and procedures and failed to ensure it met its EMTALA obligations in the following areas:
* The hospital failed to ensure on-call specialty physicians came to the ED when requested by ED physicians for further exam and/or stabilizing treatment.
* Patient 19 presented to the ED 05/22/2023, and it was identified by CT scan that the patient had an EMC, an aortic dissection. The ED physician called the on-call cardiothoracic surgeon who was on-call for specialty cardiothoracic services, and requested they come to the patient's bedside to evaluate and possibly provide stabilizing treatment because the patient was in extremis. The cardiothoracic surgeon declined, did not come in, and advised the ED physician to transfer the patient to another hospital. The patient was transferred to another hospital, and expired on 05/22/2023 shortly after arrival. The survey findings further reflected that hospital leadership had "reviewed" the case, but had not conducted corrective actions to mitigate the possibility of recurrence for other patients.

These findings were determined to represent an IJ situation under this tag, Tag A2404. Refer to Tag A000 at the beginning of this 2567 SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal.

Findings include:

1. Refer to the findings identified under Tag A2407, CFR 489.24(d)(1-3). Those findings reflect the hospital's failure to enforce it's EMTALA policies and procedures and failed to ensure it met its EMTALA obligations related to on-call specialty cardiothoracic physicians. Patient 19 presented to the ED on 05/22/2023, and it was identified by CT scan that the patient had an EMC, an aortic dissection. The ED physician called the on-call cardiothoracic surgeon who was on-call for specialty cardiothoracic services, and requested they come to the patient's bedside to evaluate and possibly provide stabilizing treatment because the patient was in extremis. The on-call cardiothoracic surgeon "declined" the ED physician's request, did not come in, and advised the ED physician to transfer the patient to another hospital. The patient was transferred to another hospital, and expired on 05/22/2023 shortly after arrival to the receiving hospital. These findings were determined to represent an IJ situation under this tag, Tag A2404.

2. The policy and procedure titled "Emergency Medical Screening Examination, Treatment, and Transfer (EMTALA) - National Policy," dated effective 04/12/2023, was reviewed. It reflected:
* "Stabilizing Treatment, If, after the MSE, it is determined that the individual has an EMC, the hospital must: Within its capability and capacity, provide further medical examination and treatment required to stabilize the EMC."
* "If the individual requires services of a consultant to provide stabilizing treatment, an on-call physician will be contacted and will be available to evaluate and treat the individual within a reasonable period of time to meet the medical needs of the individual, in accordance with the physician's obligations under EMTALA, Professional Staff Bylaws, rules and regulations, and medical center policies."
* "Once the EMC is stabilized, the individual may be discharged, admitted to the hospital for further care, or transferred to another facility."
* "If the individual is not or cannot be stabilized within the hospital's capability and capacity, the hospital will not discharge or transfer the individual to another medical facility ..."
* "The hospital may not transfer any individual with an unstable EMC unless (i) the individual or their legal representative makes an informed request for the transfer; or (ii) a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the individual from the transfer ... Subject to patient consent and without unreasonably delaying transfer, the hospital should provide additional treatment within its capability as may be required to minimize risks during the transfer to the individual's health ... until the individual leaves the hospital."
* "On-Call Physician Absence ... The hospital should have policies and/or procedures for ED and L&D staff to follow if an on-call physician is unable or unwilling to respond, including, but not limited to, steps to verify that the individual is appropriately assessed and stabilized as requested by the ED or L&D, if possible, before transferring."
* "On-Call Physicians - List and Responsibilities ... A list of physicians who are on-call to come to the emergency or labor and delivery departments to consult or to provide treatment necessary to stabilize an individual with an emergency medical condition will be maintained. On-call physician responsibilities to respond, examine, and treat emergency patients are defined in the Professional Staff Bylaws, rules and regulations, and/or written policies and procedures."
* "The on-call physician will be available via telephone or in person at the hospital within a reasonable period of time when it is determined by the emergency physician to be medically necessary."
* "The emergency physician and an on-call specialist may consult by telephone or in-person to determine the stabilizing or other treatment the individual may need."
* "Any disagreement between the emergency physician and on-call physician regarding the need for an on-call physician to come to the hospital to examine and/or stabilize the individual must be resolved by deferring to the medical judgment of the emergency physician who has personally examined and is currently treating the individual."

3. A document titled "Bylaws and Rules & Regulations of the Unified Professional Staff Kaiser Foundation Hospital - Westside and Kaiser Foundation Hospital - Sunnyside" dated 12/02/2020 was reviewed. It reflected:
* "SECTION I-H. ATTENDANCE OF PATIENTS IN EMERGENCY SITUATIONS An appropriate medical screening examination (MSE) within the capability of the hospital(s) (including routinely available ancillary services) shall be provided to all individuals who come to the emergency department and request (or on whose behalf a request is made) examination or treatment ..."
* "Emergency services and care shall be provided to any person in danger of loss of life or serious injury or illness or to prevent serious permanent disfigurement, or to provide care of a woman in [their] labor where delivery is imminent whenever there are appropriate facilities and qualified personnel available to provide such services or care. Such emergency services and care shall be provided without regard to the patient's race, color, ethnicity, sexual orientation, religion, national origin, citizenship, age, sex, preexisting medical condition, physical or mental disability, insurance status, economic status, or ability to pay for medical services, except to the extent such circumstances are medically significant to the provision of appropriate care to the patient."
* "The Chief of each service shall establish policies and duty rosters of physicians, including physicians who serve on an 'on call' basis, to provide coverage in emergency cases. In emergency situations, Professional Staff members are required to attend patients until appropriately relieved."

4. The policy and procedure titled "On-Call Specialty Consultation," dated as last reviewed 02/25/2020, was reviewed. It reflected:
* "The chief of each service shall establish rosters of clinicians, including physicians who serve on-call, to provide coverage in emergency cases. The on-call physician will be available within 30-minutes by telephone. The on-call physician will be available at the hospital within 60-minutes if he/she is required to examine and/or stabilize the patient with emergency or other medical conditions."
* "Purpose ... To ensure timely, specialty consultation for patients in an emergency who require further examination and/or admission."
* "As a requirement for participation in the Medicare program, hospitals must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition."
* "If a physician or specialist is required for consultation or to stabilize a patient with an emergency medical condition, the emergency department staff will contact the operator, page directly through Staff Availability page, or contact directly through Cortext."






40575

Based on interview, review of central log and medical record documentation for 2 of 2 encounters of an individual who presented to the hospital for emergency services and was escorted out of the hospital by security staff before an MSE (Patient 2), and review of policies and procedures, it was determined that the hospital failed to fully develop and enforce it's EMTALA policies and procedures as it failed to ensure that every individual who presented to the hospital for emergency services received a MSE within the hospital's capabilities and capacity.

Findings include:

1. The policy and procedure titled "Emergency Medical Screening Examination, Treatment, and Transfer (EMTALA) - National Policy" dated effective 04/12/2023 was reviewed. It reflected:
* "The hospital will provide a MSE by a QMP to any individual who comes to the hospital seeking emergency medical treatment (or requested on their behalf) to determine if the individual seeking care has an EMC; and, if an EMC exists, provide the individual with further medical examination and treatment as required to stabilize the EMC or arrange for transfer ..."
* "As soon as practical after arrival, all individuals who come to the emergency department ... for medical treatment will be triaged to determine the order in which they will receive an MSE."
* "Medical Screening Examination (MSE) All hospitals operated by Kaiser Foundation Hospitals and Kaiser Foundation Health Plan, Inc. ... will provide an appropriate MSE to any individual who comes to the ED to determine if an EMC exists. A MSE will be provided: In a non-discriminatory manner to all individuals with similar signs and symptoms regardless of ability to pay. Within the capability and capacity of the emergency department ... including on-call physicians and ancillary services routinely available to the hospital ... The scope of the MSE is tailored to the presenting symptoms and medical history of the individual. It may range from a simple examination (such as a brief history and physical) to a complex examination that may include diagnostic testing ... or diagnostic imaging ... The extent of the necessary examination to determine whether an EMC exists is within the judgment and discretion of the physician or other QMP performing the examination."
* "Patients Who Leave Without Being Seen (LWBS), Elope, or Leave Against Medical Advice (AMA) All reasonable efforts should be made to conduct a MSE before the individual leaves, with documentation of the discussions and efforts made to prevent the individual from leaving."
* "An individual who leaves the hospital after being triaged but before receiving an MSE should be noted in KPHC as LWBS. Any details about the reason the individual provided for leaving without being seen should be documented in KPHC.
* "Staff will attempt to obtain the individual's signature on the form documenting that the individual refused an MSE and/or stabilizing treatment (when possible). If the individual refuses to sign the form, a notation to such should be made by the ED ..."

2. The policy and procedure titled "AMA (Against Medical Advice), Elopement and Left Without Being Seen (LWBS)" dated effective 02/25/2020 was reviewed. It reflected:
* "Left without being seen - ED: If a patient leaves without being seen by a physician so that an MSE may be completed (i.e., is not in the waiting room when his/her name is called) then staff will: Call the patient and conduct a reasonable search for the patient in the immediate area of the waiting room in an attempt to locate the patient. Document in nursing note."
* "If this patient appeared to have had a psychological emergency and leaves before an MSE, the Hospital Administrative Supervisor (HAS)/Nursing Supervisor will be called to notify authorities (Sheriffs' department) to do welfare check."

3. The medical staff "Bylaws and Rules & Regulations of the Unified Professional Staff," dated 12/02/2020 were reviewed. Section I-H, "Attendance of Patients in Emergency Situations" reflected "An appropriate medical screening examination (MSE) within the capability of the hospital(s) (including routinely available ancillary services) shall be provided to all individuals who come to the emergency department and request (or on whose behalf a request is made) examination or treatment."

4.a. Review of the central log for Patient 2 reflected they arrived to the ED on 12/25/2022 at 1553 with a chief complaint of "Chest Pain." The log reflected the patient's "EMTALA Disposition" was "LWBS."

4.b. Review of medical record documentation for Patient 2's 12/25/2022 ED encounter included the following:
* The patient presented to the ED by ambulance on 12/25/2022 at 1553.
* At 1613 an RN recorded "Vitals" that included Temp 98.9, Pulse 100, Resp 20, BP 139/86 and SpO2 98%.
* At 1613 an RN recorded an ED triage note "Pt BIBA for report of chest discomfort. EMS reports that a passerby saw patient lying on sidewalk and called 911. EMS reports pt c/o chest discomfort. Negative 12 Lead by EMS. Pt poor historian about sx onset and subjective information. Pt appears sleepy at triage, but arousable to voice. Pupils appear to be approximately 3-4 mm bilat and round/reactive."
* At 1615 an EKG was completed.
* At 1620 a chest xray was done.
* At 1812 an RN recorded "Pt asked to put on mask by this RN, Pt started cussing and yelling at staff. Refusing to put on a mask. Pt escorted out by security."
* At 1813 an RN recorded "ED Disposition" was "Left Without Being Seen."
There were no physician notes and no documentation that the patient received an MSE. There was no documentation regarding what happened to the patient after being escorted out by security. There was no documentation that an attempt was made to deescalate the situation or that a physician attempted to evaluate the patient and conduct an MSE, which is what their stated process included in finding 4.d.

4.c. Review of medical record documentation for Patient 2 reflected they returned to the ED by ambulance on 12/25/2022 at 1914 with a chief complaint of SI.
An AMR Patient Care Report reflected the patient was picked up by EMS at 1851, and was transported to the hospital. The report further reflected "pt is [48 years old] alert and oriented having suicidal ideation. Pt had recently been kicked out of Kaiser Sunnyside. Pt states [they] also tried to overdose a couple of days ago but denies any drug use today ... Pt states [they want] to kill [themselves] and [have] no reason to live anymore ... Patient remained calm and cooperative during transport ... Arrived at Kaiser Sunnyside, pt assigned to quiet room, once in room pt started to get confrontational and aggressive toward EMS and nurses. Security was called and pt was escorted from the property ... Primary Impression: Behavioral/Psychiatric - Suicidal ..."
* At 1953 an RN recorded "This RN went in to assist with triaging patient and entered the room to patient yelling and cursing at staff. Patient being verbally aggressive and assaultive, making threats to staff members. Patient raising [their] hands, making fists and pointing [their] finger in staff members' faces. Patient lays [themselves] on the ground and refuses to cooperate with triage or assessment. Security called for assistance due to patient's agitation and aggression. Patient escorted out at this time as [they are] refusing to cooperate with care/triage. Patient states 'I will just keep coming back. You ... better
watch out." Charge RN notified.'"
* At 1954 an RN recorded "ED Disposition" was "Left Without Being Seen."
There were no physician notes and no documentation that reflected the patient received an MSE. There was no documentation that reflected staff attempted to obtain the patient's signature indicating that they refused an MSE and/or stabilizing treatment, or documentation that reflected the patient refused to sign in accordance with hospital policies and procedures.

There was no documentation that an attempt was made to deescalate the situation or that a physician attempted to evaluate the patient, which is what their stated process included in finding 4.d.

4.d. During an interview and review of the medical record documentation for Patient 2's 12/25/2022 1553 and 1914 ED encounters with the ED QC and other hospital staff on 06/07/2023 at 1440, the ED QC stated the process for managing disruptive patients presenting for emergency services was that security staff would be contacted, and an ED MD would attempt to provide care and an MSE "in the moment." Patients attempting to harm themselves would get an NMI (mental illness hold) initiated and hospital staff would try to deescalate the situation in real time.


40575

Based on interview, review of documentation in medical records of 2 of 2 patients with aortic dissection who were transferred to other hospitals (Patients 5 and 19), review of an audio recording call, review of scope of service documentation, review of informational practice documentation, review of hospital policies and procedures and review of other documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that within the capabilities and capacity of the hospital, it provided stabilizing treatment necessary for the patients' condition.
* In addition the hospital failed to develop policies and procedures and scope of service documents that clearly delineated the hospital's capabilities and capacity to provide further examination, and stabilizing treatment for patients with aortic dissections.

Findings include:

1. During an interview with the CHO on 06/06/2023 at 1040, they provided the following information:
* KSMC received a call from PSVMC with concerns involving Patient 19.
* The patient presented to KSMC by ambulance "in pretty bad shape."
* The patient had an aortic dissection and and needed cardiac and vascular surgery.
* KSMC's on-call cardiothoracic surgeon, KSMC CT MD C and on-call vascular surgeon, KSMC Vascular MD B made the decision to transfer the patient to OHSU.
* There were no beds available at OHSU so KSMC staff called PSVMC. PSVMC accepted the patient for transfer and expressed concerns related to the patient's stability.
* The patient was transferred to PSVMC.
* The "patient's clinical status was deteriorating" at the time of transfer.
* The patient passed away shortly after arrival at PSVMC.

1.a. During an interview on 06/06/2023 at 1300, the QIC stated KSMC did not conduct an investigation of the events reported in finding 1.

2. An audio recording call between KSMC ED MD A and PSVMC CT MD E was recorded on 05/22/2023 beginning at 1740 and was 8 minutes and 34 seconds in duration. During play of the audio recording the following was heard:
Providence Transfer Center staff: "Providence Transfer center, this is [Transfer Center staff name]."
PSVMC CT MD E: "Yes, it's [PSVMC CT MD E]."
Providence Transfer Center staff: "Hi there, I will connect you to [KSMC ED MD A]."
PSVMC CT MD E: "So where is KSMC, where is that?"
Providence Transfer Center staff: "Kaiser Sunnyside Medical Center."
PSVMC CT MD E: "Kaiser, okay."
Providence Transfer Center staff: "Excellent, let me connect you. [PSVMC CT MD E] and [KSMC ED MD A], I have you both on the line and I will stay connected on the line as well."
KSMC ED MD A: "Hello [PSVMC CT MD E], this is [KSMC ED MD A], I am an ER doc here at Kaiser Sunnyside who um, I have a patient here 76-year-old [patient] takes no medications who arrived as a possible stroke alert sudden onset of chest pain at 4 o'clock then subsequently the ambulance developed right upper extremity right lower extremity weakness. [Patient] was talking to us, oriented and has pulses in [their] distal extremities. Arrived hypotensive in the 80's, found to have a Type A dissection. We do have a vascular surgeon thoracic surgery here who um given the malperfusion our vascular surgery can not, does not deal with, I guess these types of um dissections. And so, uh, this is a higher level of care uh transfer that we can't take care of this patient here."
PSVMC CT MD E: "Um, can I just back track for a second?"
KSMC ED MD A: "Yes, please."
PSVMC CT MD E: "So, cardiothoracic surgery said what?"
KSMC ED MD A: "So, it's not the cardiothoracic surgeon as much although it sounds like there are some concerns there but our vascular surgeon uh is can't take care of uh the vascular surgery part of this patient given the malperfusion to [their] left lower leg."
PSVMC CT MD E: "Yeah, but I mean it doesn't matter though. So I - this is a type A aortic dissection involving the ascending aorta, right?"
KSMC ED MD A: "Correct."
PSVMC CT MD E: "Okay, so the treatment for this is emergency cardiothoracic surgery where we replace the aorta and reestablish flow to the left leg, it doesn't involve the vascular surgeons at all and the initial steps and usually just, usually fixing the dissection, fixes the perfusion to the leg. So, what, cause Kaiser Sunnyside you guys have cardiothoracic surgeons, right?"
KSMC ED MD A: "Yes, yes and I have talked to my cardiothoracic surgeon [unintelligible] we cannot manage this here, please transfer to another hospital."
PSVMC CT MD E: "Okay, sounds good so [they're] hypotensive right now in the 80's?"
KSMC ED MD A: "[Patient] was in the 80's bilateral arms but I was just recently told [they] went to the 60's so [they're] getting 2 units of PRBC's let me see [their] last one just a second. Alright, 67/41 getting 2 units of blood."
PSVMC CT MD E: "I ... so I mean [they're] probably in tamponade, so I mean the hard part that I'm having here is that we're transferring a patient who's in extremis, into an ambulance, outside of a hospital to another hospital, and [they're] leaving a hospital that has a cardiac surgeon."
KSMC ED MD A: "It's the worst."
PSVMC CT MD E: "Right, that just seems that doesn't seems incomp [unintelligible], I don't like, I mean this [patient] is hypotensive and going to die and stuff in transport cause [they're] in tamponade so I mean were going to put [them] in the ambulance and bring [them] over here and stuff when [they're] in a hospital and stuff in which there is available staff like in the hospital right?"
KSMC ED MD A: "Yes ... I I I talked to multiple, I've had multiple phone calls with the cardiac [unintelligible] cardiothoracic surgeon and vascular surgeon and it's been rough, yes, um, yes, I agree that this is frustrating, yes."
PSVMC CT MD E: "I mean [they need] to be stable though to come to me because we're putting [them] you're going to call an ambulance now and they are going to come and pick that [patient] up and then [they're] going to transport here and show up with a blood pressure of 60 and I don't have an OR staff here and so that I mean I just it's very hard for me to accept this patient outside of a hospital and stuff when there's an operating room and stuff that's upstairs from you guys to go try to help this [patient], [they're] dying, right, I mean, [their] blood pressure is 60."
KSMC ED MD A: "yes, yes."
PSVMC CT MD E: "I'm happy to accept the patient and stuff but I mean when [they get] here and stuff."
KSMC ED MD A: "We would transfer [patient] like code 3 to get to you guys."
PSVMC CT MD E: "Right, but I don't have an operating room staff here so [they're] going to show up and I need 45 minutes. So were moving [them] out of a hospital that has an available operating room. So, by all means and stuff I'm happy to help you and stuff. You know like this is going to be a thing afterwards and stuff that we have to address. Transfer center by all means and stuff accept this patient here [they] may very much die in route."
KSMC ED MD A: "Of course."
PSVMC CT MD E: "So, make sure this is recording and stuff because we are going to have to circle back on this."
KSMC ED MD A: "Most Definitely"
PSVMC CT MD E: "yeah, it's being recorded."
Providence Transfer Center staff: "And [KSMC ED MD A] I hope that you can involve your administrator on call to escalate care."
PSVMC CT MD E: "I mean, [their] blood pressure is 60/40 right now, we are moving a patient out and stuff who is dying to another hospital and stuff. It just doesn't seem to be the best way to approach it, but we can, we're here to help you in whatever means possible. So, I'll try to activate a team here and stuff it's just a good possibility and stuff that the patient may not make it here, unfortunately, because [they're] in tamponade, [they have] blood around [their] heart so ..."
KSMC ED MD A: "Yes, [they] definitely [have] blood around [their] heart."
PSVMC CT MD E: "Yeah, [they have] ruptured and stuff that's why [their] vascular structure is out, so I mean."
KSMC ED MD A: "Yes, [they have] moderate hemopericardium."
PSVMC CT MD E: "Right, I mean [they're] not going to make it here, I mean, you know. This needs an emergency person to come down and stick a needle in or take [them] to the operating room and make a pericardial window to try to get [them] to live. I mean, you know."
KSMC ED MD A: "Um, I will talk again to our vascular surgeon but if you go ahead and accept [them] we can activate, I will take one last effort to talk to our cardiothoracic surgeon, but, um."
PSVMC CT MD E: "Yeah, I have no team in the hospital here, so I have to call everyone in, they are at least an hour away. You know this is an hour and stuff and this [patient] is going to show up 60 over 70 and I'm going to probably pronounce [them] dead. This you know, unfortunately and stuff it doesn't make this is a challenging problem for you and I'm sorry you're in the middle of it."
KSMC ED MD A: "Yes, ok."
PSVMC CT MD E: "So, transfer center, bring [patient] to the ICU because if [they're] truly hypotensive like this, when [they arrive] and stuff, I will make [them] comfort measures and we will walk away, unfortunately."
KSMC ED MD A: "Understood."
PSVMC CT MD E: "Because that unfortunately what's going to happen here."
KSMC ED MD A: "And so are you the accepting doctor."
Providence Transfer Center staff: "[They are]."
PSVMC CT MD E: "I guess so, it sounds like I may be the only person who's taking responsibility here, outside of you, so. You and I have taken responsibility for this patient."
KSMC ED MD A: "Ok, thank you very much, I appreciate it."
Providence Transfer Center staff: "I highly encourage an administrator on call, whoever your administrator, your AOC is needs to be immediately involved."
PSVMC CT MD E: "Yes."
KSMC ED MD A: "OK, thank you very much."
Providence Transfer Center staff: "Thank you."

3.a. Review of the central log for Patient 19 reflected they arrived to the ED on 05/22/2023 at 1625 with a chief complaint of "Chest Pain." The log reflected the ED Disposition was "Transfer" and discharge date and time were 05/22/2023 at 1821.

3.b. The medical record for Patient 19's 05/22/2023 ED encounter was reviewed and included the following documentation:
* At 1625, KSMC ED MD A documented "76 yrs ... was BIBA as stoke [sic] alert for sudden onset chest pain around 4 PM, shortly after subsequently developed right upper extremity and left lower extremity weakness and numbness which prompted [patient] to call EMS. Last known normal at 1600. On EMS arrival, [patient] was found hypotensive, and with decreased O2 sats and was given x3 24mg aspirin. No cardiac history. No medication use. No history of stroke. [Patient] denies a headache. [Patient] has never experienced these symptoms before. Not anticoagulated ... ED Course ... Patient brought in for Stroke alert in setting of sudden chest and subsequent neuro deficits RUE and RLE weakness. Hypotensive. Will continue stroke alert but combination of symptoms very concerning. Performing CTA neck/chest/abd/pelvis in addition to CTA brain/neck.
Review of Systems
Constitutional: Negative for chills and fever.
HENT: Negative for congestion, rhinorrhea and sore throat.
Eyes: Negative for visual disturbance.
Respiratory: Negative for cough, chest tightness and shortness of breath.
Cardiovascular: Positive for chest pain. Negative for palpitations and leg swelling.
Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting.
Genitourinary: Negative for dysuria and flank pain.
Skin: Negative for rash.
Neurological: Positive for weakness and numbness. Negative for syncope.
BP 112/78 ... Pulse 60 ... Resp 16 ... SpO2 94% ..."
* KSMC ED MD A documented the following:
1635 - "[KSMC ED MD A] discussed the case with neurology, [Neurology MD] will come evaluate the patient."
1654 - "Was informed by CT [imaging] staff that the patient is having a dissection."
1704 - "Need to keep patients [sic] blood pressure wnl, and HR less than 110, cardio and vascular surgery will further communicate if the patient will need to be transferred to OHSU or not."
1707 - "[KSMC ED MD A] notified the patient of [their] ongoing dissection, [KSMC ED MD A] discussed the possible transfer to OHSU, [patient] and [significant other] were in agreement."
1727 - "[KSMC ED MD A] spoke with thoracic and cardio thoracic surgery and they cannot perform the operation here. So, patient will need to be transferred."
1728 - "Calling OHSU transfer center, and was informed that they have no current beds."
1735 - "[KSMC ED MD A] was notified by nursing staff that [Patient's] blood pressure is dropping to the 50's-60's, HR in the 60's, will plan to transfuse the patient 2 units of blood."
1740 - "Will call Providence transfer center for available beds."
1745 - "HR 60 ideal and blood pressure less than 100, will place [Patient] on beta-blockers for blood pressure control."

* At 1744, an RN documented "Rapid emergent transfusion of un crossmatched unit of RBCs ..."

* KSMC ED MD A documented the following:
1752 - "Providence is requesting for imaging and will get back to me whether they have available beds to [sic] not. [Patient] is stabilized as much as possible within the capability of this facility but has a condition (Type A aortic dissection) with malperfusion and we are unable to take this person to our operating rooms per [KSMC Vascular MD B] and [KSMC CT MD C] which requires a higher level of care, or specialized care not available at this facility. I discussed the reason for transfer, the individualized risks and benefits of transfer for this patient (or the patient's surrogate decision-maker) and [they indicated] that [they understand] the risks and benefits. The pertinent risks of transfer specific to this patient include cardiac arrest. The benefits of transfer discussed include access to higher level of care and specialized services. The individualized benefits of transfer outweigh the risks of transfer. Patient unable to sign and [significant other] not at bedside currently. I personally discussed this case with [PSVMC CT MD E] who will arrange care of the patient at [PSVMC] ..."
1753 - "[Another ED MD] performing bedside US. Possible right ventricular collapse? Possible tamponade physiology. Considered bedside emergent pericardial drainage but BP maintaing [sic] SBP 70, unclear if this would improve patient's clinical condition at this time especially given unable to get patient immediately to OR. Could worsen [patient's] condition."

* At 1756, an RN documented "No available O2 sat, due to poor perfusion of extremities. Patient on 15L NRB at this time. Respirations even and unlabored."

* KSMC ED MD A documented the following:
1805 - "[KSMC ED MD A] discussed again with [KSMC CT MD C] and requested [they] come to bedside given patient in extremis. [KSMC CT MD C] declined as they are unable to intervene surgically here. Again advised transfer."
1821 - "EMS has arrived to transport the patient."

The record reflected the patient was transferred by EMS to PSVMC on 05/22/2023 at 1821.

4. The medical record for Patient 19's 05/22/2023 encounter at the receiving facility, PSVMC, was reviewed and included the following documentation:
* A "Cardiac Surgery Attending Death Note" documented by PSVMC CT MD E, dated 05/22/2023 at 1920 and electronically signed by the MD on 05/22/2023 at 1929 reflected:
- "I was contacted by our transfer center at 5:53 PM, returning a page to the transfer center at 5:55 PM regarding an emergent aortic dissection at Kaiser Sunnyside Medical Center. We were connected shortly thereafter to the emergency room physician who is managing the patient's care. In short, this was a 76-year-old patient who presented in extremis around 4 PM to the Kaiser Sunnyside emergency room. Per review of the outside notes, [they] presented right upper extremity weakness, left lower extremity paraplegia, and significant mental status change. Initially, a code stroke was called and [they] underwent imaging that demonstrated a type a dissection with clear rupture into the pericardium and hemopericardium. It was a complex aortic dissection that extended from the root of the aorta and involved the ostium of the innominate artery up into the right carotid and right axillary, left carotid to the bifurcation, left subclavian, and extended down to the root and into the left common iliac with obstruction of the left common iliac. There was malperfusion of the left renal artery but perfusion of the celiac, SMA and right renal which originated from the true lumen, although the true lumen was quite compressed."
- "I received a call from the managing emergency room physician at Kaiser Sunnyside regarding emergent transfer. The patient, at that time, had a blood pressure of 60/30 despite ongoing resuscitation and was, by report, seemingly in cardiac tamponade. [Patient] was minimally responsive. I accepted the patient in transfer to our ICU."
- "Upon arrival, [patient] was minimally responsive and could barely open [their] eyes upon transfer to our ICU bed. [Patient] then became completely unresponsive, developed agonal breathing patterns with evidence of posturing and then suffered complete hemodynamic collapse. There were no palpable pulses, no appreciable electrical cardiac activity, and [they were] diffusely cyanotic. We declared [them] dead."
* An MD "Cardiac Intensive Care Unit DEATH/DISCHARGE SUMMARY" dated 05/22/2023 at 1940 and electronically signed by the MD on 05/22/2023 at 1953 reflected "Pt was received in transfer from Kaiser Sunnyside. [Patient] admitted to their ER at 4pm with symptoms of right upper extremity weakness and left lower extremity paresis, altered mental status, and crushing chest pain. [Patient] was diagnosed with Type A dissection and with pericardial hemorrhage with tamponade physiology. Due to the extent of the dissection (to involve the innominate, right carotid, right axillary, left carotid, left subclavian, descending in to the left common iliac, left renal occluded to flow) our Cardiothoracic Surgeon was called with a request to transfer. The sending facility was aware of the tamponade physiology but felt that they could not intervene and rather sent the patient by ambulance to PSV. [Patient] was delivered directly to the CICU. [Patient] was initially moving [their] Right arm. [Patient] was not responsive to command. [Patient] was unable to regard or track. Within minutes [they] became flaccid of extremities, with agonal respirations, upward gaze, and slowed [their] heart rate from normal sinus to bradycardia to asystole, all within 12 minutes."

5. During a phone interview with KSMC ED MD A on 06/07/2023 starting at 1310, they provided the following information regarding Patient 19's ED encounter:
* KSMC ED MD A stated they were working their shift in the ED when they were notified that a "stroke alert" was coming in from the field. The patient was also having chest pain and they were not sure if the patient was having a heart attack.
* When the patient arrived to the ED, they were alert, talking, had low BP, and RUE and LLE numbness. The patient's symptoms were concerning for aortic dissection. The patient was taken directly from the ambulance bay to CT.
* KSMC ED MD A received a call from CT that Patient 19 had a "bad aortic dissection".
* KSMC ED MD A stated the patient was brought back to the ED and they immediately called on-call KSMC Vascular MD B who stated they wanted to review images, talk with "radiology and imaging", and would call them back.
* KSMC ED MD A stated KSMC Vascular MD B called them back and stated they were not able to handle this patient and it would be best to transfer the patient.
* KSMC ED MD A stated they talked to on-call KSMC CT MD C who confirmed they had spoken to KSMC Vascular MD B. KSMC CT MD C confirmed they could not see the patient and the patient should be transferred.
* KSMC ED MD A called OHSU for a bed, but they did not have any beds available.
* KSMC ED MD A called PSVMC next to see if they had an available bed.
* KSMC ED MD A stated they talked to PSVMC CT MD E who accepted the patient for transfer but had concerns about the patient surviving the transfer.
* KSMC ED MD A stated the patient began decompensating, was declining clinically, and had fluid surrounding their heart. KSMC ED MD A stated they began giving the patient blood products and requested another ED MD to come to the bedside and perform an ultrasound because they were concerned about the fluid around the patient's heart.
* KSMC ED MD A called KSMC CT MD C a second time and requested that they come to the bedside to see if any emergency procedures could be done for the patient "because [KSMC CT MD C] was the only one who could do an "emergent, temporizing procedure."
* KSMC ED MD A stated KSMC CT MD C told them it wouldn't help the patient for them to come in.
* KSMC ED MD A confirmed the patient's condition was declining, they requested KSMC CT MD C to come to the bedside to provide possible stabilizing treatment, and KSMC CT MD C did not come, as requested.

6. During interview with KSMC's on-call Vascular Surgeon, KSMC Vascular MD B on 06/07/2023 starting at 1040, they provided the following information regarding Patient 19's ED encounter::
* KSMC Vascular MD B stated they were a Vascular Surgeon with on-call responsibilities that included responding to calls and pages from the ED. KSMC Vascular MD B stated there were times when they went to the ED and performed an assessment on a patient and other times they would see the patient the next day.
* KSMC Vascular MD B stated they were paged by KSMC ED MD A around 5pm about a patient with a dissection. KSMC Vascular MD B stated they looked at Patient 19's CT images and told KSMC ED MD A that it was a complex dissection and offered to contact the cardiothoracic surgeon to save time.
* KSMC Vascular MD B stated they called KSMC CT MD C and explained the CT scans and discussed what the patient needed from a vascular perspective which would be complex and not done at KSMC. The patient needed complex intervention and extensive vascular resconstruction. KSMC Vascular MD B stated they agreed that extensive malperfusion from dissection was "best not managed here and better to go elsewhere."
* KSMC Vascular MD B stated "The patient needs cardiothoracic surgery as fast as possible" and "I explained that I didn't think delaying care would be best for the patient and they needed to transfer."

7. During a phone interview with KSMC's on-call cardiothoracic surgeon, KSMC CT MD C on 06/07/2023 starting at 0945, they provided the following information regarding Patient 19's ED encounter:
* KSMC CT MD C stated they were a cardiothoracic surgeon and had been in practice for 22 years.
* KSMC CT MD C stated they had on-call responsibilities that included responding to pages and getting to the hospital within 40 minutes if requested to come in.
* KSMC CT MD C stated they were on-call for cardiothoracic surgery when they received a phone call around 1700 from KSMC Vascular MD B about Patient 19. The patient had dissection involving cold upper extremities, evidence of malperfusion, [and] "kidneys dead." KSMC CT MD C stated they discussed CT results with KSMC Vascular MD B who stated they were not capable of performing the vascular component of the dissection. KSMC CT MD C stated "Since I didn't have appropriate back-up, I agreed with vascular's decision to transfer the patient."
* KSMC CT MD C stated they received a call from KSMC ED MD A who wanted to confirm that KSMC CT MD C had talked to vascular [KSMC Vascular MD B]. KSMC CT MD C told KSMC ED MD A they had talked to KSMC Vascular MD B and "agreed with vascular's decision to transfer the patient."
* KSMC CT MD C stated that fifteen to twenty minutes later, KSMC ED MD A called KSMC CT MD C again and wanted them to perform a "pericardial window because the patient was becoming hypotensive." KSMC CT MD C stated the patient had been accepted for transfer at another hospital and an ambulance was "on the way." KSMC CT MD C stated that since an ambulance was already on the way, it would be best to transfer the patient. KSMC CT MD C stated "I would have to take the patient to the OR, intubate them, canulate the groin like they are going on bypass. If you go on bypass, you are committed to the surgery that can't be completed. It takes hospital staff one hour to get the OR set up and the patient might sanguinate. It's multifactorial, dead leg, dead arm, occluded renal artery."
* KSMC CT MD C stated that a pericardial window may or may not help, that they are unable to know. PSVMC had already accepted the patient and it was best to get the patient to the other facility as soon as possible.
* KSMC CT MD C stated "after reflection, I didn't see the echo done. From discussion there is a suggestion of tamponade, but not confirmed. Window may not have helped anyway, could be fluid, could be acidotic. [Patient] may not have survived anyway."
* KSMC CT MD C confirmed they received two calls from KSMC ED MD A. The first call confirming they spoke to KSMC Vascular MD B and the second call about performing a [pericardial] window.
* KSMC CT MD C was asked if they were requested by KSMC ED MD A to come into the hospital and KSMC CT MD C stated "[KSMC ED MD A] said 'I wish you were here.'" KSMC CT MD C stated "I think [KSMC ED MD A] needed help .. I said I could come in but it's going to take me about 25 minutes to get there ... it's probably safer for [them] to get transferred ... my impression was, the ambulance was there or almost there."
* KSMC CT MD C was asked if they came into the hospital to stabilize or attempt to stabilize the patient, and they stated, "No."

It was not clear why KSMC CT MD C, who was on-call for cardiothoracic services, did not come to the hospital as requested by KSMC ED MD A, and provide or attempt to provide stabilizing treatment. For example,
* KSMC CT MD C stated the patient should be transferred "since [KSMC Vascular MD B] was unable to complete surgical repair." However, according to PSVMC CT MD E, "emergency cardiothoracic surgery where we replace the aorta and reestablish flow to the left leg ... doesn't involve the vascular surgeons at all ... usually fixing the dissection, fixes the perfusion to the leg."
* KSMC CT MD C stated there was "a suggestion of tamponade" but it was not confirmed, and a pericardial window may or may not have helped. However, according to PSVMC CT MD E the patient was in tamponade, was in extremis, and needed "... an emergency person to ... stick a needle in or take [them] to the operating room and make a pericardial window to try to get [them] to live."

8. During an interview on 06/07/2023 at 1730, the CHO stated the hospital had bed capacity on 05/22/2023 when Patient 19 was transferred to PSVMC.

9. The policy and procedure titled "Emergency Medical Screening Examination, Treatment, and Transfer (EMTALA) - National Policy" dated effective 04/12/2023 was reviewed. It reflected:
* "If, after the MSE, it is determined that the individual has an EMC, the hospital must: Within its capability and capacity, provide further medical examination and treatment required to stabilize the EMC."
* "If the individual requires services of a consultant to provide stabilizing treatment, an on-call physician will be contacted and will be available to evaluate and treat the individual within a reasonable period of time to meet the medical needs of the individual ..."
* "Once the EMC is stabilized, the individual may be discharged, admitted to the hospital for further care, or transferred to another facility."
* "If the individual is to be transferred, then the hospital must transfer the stabilized individual according to hospital and department transfer policies and procedures."
* "Patient transfer decisions will include all relevant factors, including but not limited to: consideration of the individual's welfare; the risks and benefits of the transfer; and the availability of equipment and/or services at the sending and receiving facilities."
* "Unstable Patient. The hospital may not transfer any individual with an unstable EMC unless (i) the individual or their legal representative makes an informed request for the transfer; or (ii) a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the individual from the transfer. Subject to patient consent and without unreasonably delaying transfer, the hospital should provide additional treatment within its capability as may be required to minimize risks during the transfer to the individual's health ... until the individual leaves the hospital."
* "On-Call Physicians - List and Responsibilities. A list of physicians who are on-call to come to the emergency or labor and delivery departments to consult or to provide treatment necessary to stabilize an individual with an emergency medical condition will be maintained. On-call physician responsibilities to respond, examine, and treat emergency patients are defined in the Professional Staff Bylaws, rules and regulations, and/or written policies and procedures."
* "The on-call physician will be available via telephone or in person at the hospital within a reasonable period of time when it is determined by the emergency physician to be medically necessary."
* "Any disagreement between the emergency physician and on-call physician regarding the need for an on-call physician to come to the hospital to examine and/or stabilize the individual must be resolved by deferring to the medical judgment of the emergency physician who has personally examined and is currently treating the individual."
The policies and procedures lacked any clear description of the hospital's cardiothoracic capability, capacity and stabilizing treatment for patients with aortic dissections.

10. A document titled "Bylaws and Rules & Regulations of the Unified Professional Staff Kaiser Foundation Hospital - Westside and Kaiser Foundation Hospital - Sunnyside" dated 12/02/2020 was reviewed. It reflected:
* "The Board of Directors recognizes that the standards and effectiveness of hospital services and medical care and treatment depend largely upon the Professional Staff, and desires active Professional Staff assistance and cooperation for maintaining acceptable standards of medical care, treatment, safety and hospital services for all persons admitted to or treated in the Hospitals. The Professional Staff and the Board of Directors each recognize that the interests of hospital patients will be best served and protected by concerted and cooperative effort on the part of all the Professional Staff practicing at the Hospitals, acting with the support and cooperation of the Board of Directors."
* "Transfer of Patients - A patient shall be transferred to another facility only when such transfer is authorized by the attending physician and has been agreed upon by an accepting physician and facility. The patient or the patient's legal representative, when he or she is reasonably available, shall consent to the transfer. Before transferring a patient who has been diagnosed with an emergency medical condition ... the physician shall provide emergency services and care to prevent, to the extent possible, a material deterioration of, or jeopardy to, the patient's medical condition or expected chances of recovery during transfer."
* "Clinically unstable patients shall not be transferred unless: a) the patient is being transferred to a higher level of care and the risks of transferring the patient are outweighed by the benefits of the transfer, or b) the patient insists on such transfer after being fully informed of the risks associated with the transfer."
The bylaws, rules and regulations lacked any clear description of the hospital's cardiothoracic capability, capacity and stabilizing treatment for patients with aortic dissections.

11. The document titled "2023 Plan for Provision of Patient Care Kaiser Foundation Hospital-Sunnyside" dated approved "February 8, 2023" was reviewed. It reflected:
* "Scope of Service - As a full service licensed acute care facility, KSMC provides the following services: General Acute Care ... Surgical Service, including Cardiovascular Surgery, Cardiovascular Intensive Care and Step-down units."
* "The Medical Center provides general care to adult patients who require either acute medical and/or surgical interventions (i.e., adult medical-surgical care, adult critical care services ... KSMC is the regional site for neurosurgery, elective, and emergency inpatient surgery from East,