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Based on observation, interview, review of medical record documentation for 22 of 27 individuals who presented to the CGH off-campus Brookings ED satellite location for emergency services (Patients 1, 2, 3, 4, 6, 7, 9, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25 and 27) review of the ED central log 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 that ensured it met its EMTALA obligations in the following areas:
* To develop policies and procedures and scope of service documents that clearly described the hospital's capability and capacity at its main campus location and its off-site Brookings satellite location, and that described how emergency services operations at the off-site Brookings ED satellite were integrated with the operations at CGH and its main campus ED.
* To conspicuously post signs in all areas individuals wait for examination and treatment that specify individual's rights under EMTALA.
* To maintain a central log.
* To provide MSEs without delay, within the hospital's capability and capacity at the CGH off-campus Brookings satellite and the CGH main campus, for all individuals who presented for emergency services.
* To affect appropriate transfers to other hospitals for further exam and stabilizing treatment not within CGH's capability and capacity that included physician certification of patient specific risks of transfer, provision of copies of medical records, and use of appropriate medical transportation with qualified personnel.
* To not dissuade patients from staying for MSEs or stabilizing treatment, including for reasons related to inquiries about payment, finances and insurance obtained prior to MSEs.
* To not dissuade patients from use of medical transportation with qualified personnel between the Brookings ED satellite and the CGH main campus, and for transfers to other hospitals, including for reasons related to inquiries about payment, finances and insurance for medical transportation.
* To obtain or attempt to obtain written and informed refusal of MSEs, treatment or an appropriate transfer in the cases of individuals who refused examination, treatment or transfer.

Findings included:

1. Refer to the findings identified under Tag C2402, CFR 489.20(q) that reflects the hospital's failure to conspicuously post required EMTALA signs in all areas individuals wait for examination and treatment.

2. Refer to the findings identified under Tag C2405, CFR 489.20(r)(3) that reflects the hospital's failure to develop P&Ps related to maintenance of a central log.

3. Refer to the findings identified under Tag C2406, CFR 489.24(a)&(c), that reflects the hospital's failure to ensure all individuals who presented for emergency services received MSEs and stabilizing treatment within the hospital's capability and capacity, without delay.

4. Refer to the findings identified under Tag C2409, CFR 489.24(e) that reflects the hospital's failure to affect appropriate EMTALA transfers to other hospitals with the necessary capability and capacity for patients for whom an EMC had not been ruled out, removed or resolved.

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

Findings include:

1. The P&P titled "Emergency Medical Treatment & Active Labor Act (EMTALA)" dated as revised on 11/30/2017 was reviewed and reflected the following reference related to the posting of signs: "CHN shall have current EMTALA signage present and visible from every public entrance of the hospital and clinic. These signs shall be posted conspicuously in places likely to be noticed by all individuals entering the emergency department as well as those individuals waiting for examination and treatment in other areas besides the emergency department such as entrances, admitting, waiting and treatment areas."



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2. During a tour of the ED with the HS on 07/21/2020 at 1120 the following observations were made:
* An ED waiting area located to the left of the ED check in and registration desk, where four chairs were located revealed there was no EMTALA signage posted in that waiting area or the ED check in and registration desk. In addition, from that ED waiting area, a large red sign was observed on a metal stand that read "EMERGENCY" with an arrow pointing away from the ED and ED waiting area in the direction of a clinic that was located in the same building. The "EMERGENCY" sign inaccurately directed individuals away from the ED and created the possibility that individuals presenting for emergency services could inadvertently wait for exam and treatment in clinic areas where EMTALA signage may not be posted.
* Another ED waiting area to the right of the outside of the ED entrance where approximately 14 chairs were located was observed. The waiting area was rectangle shaped and had one EMTALA sign posted near one end of the room. The sign was partially covered by a blue sign that read "Blue Waiting Room" and was not readable from the chairs at the other end of the room located across from the "Financial Counselor Scheduling" door as a result of glare on the sign from a window.

3. During an interview with the HS on 07/21/2020 at 1130, he/she confirmed that some individuals who presented for emergency services waited to enter the ED department in the waiting area to the left of the ED check in and registration desk, and there was no EMTALA sign posted or visible from that waiting area.

Based on interview and review of hospital policies and procedures it was determined that the hospital failed to develop EMTALA policies and procedures that ensured a central log was maintained for completeness, and accurately reflected all individuals who presented for emergency services, the reasons they presented and their dispositions including whether they refused treatment or they were refused treatment.

Findings include:

1. The P&P titled "Emergency Medical Treatment & Active Labor Act (EMTALA)" dated as revised on 11/30/2017 was reviewed and reflected the following reference related to maintenance of a central log: "Medical Screening Exams must include, at a minimum, the following: 1. Patient Log entry including disposition and condition of patient."

There were no other P&Ps or information related to maintenance of a central log.

Based on interview, review of medical record documentation for 12 of 27 individuals who presented to the CGH off-campus Brookings ED satellite location for emergency services (Patients 4, 11, 12, 13, 15, 16, 18, 19, 20, 21, 22 and 24), review of policies and procedures and the hospital's scope of services document, review of staff training materials, review of incident documentation, review of imaging operations documentation and other documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured that every individual who presented to the hospital for emergency services received a MSE within the hospital's capability and capacity, provided without delay and that hospital staff did nothing to dissuade patients from staying at the hospital for the provision of a MSE as follows:
* Patients 18 and 20 experienced delay in the provision of an MSE or stabilizing treatment at the Brookings ED satellite as result of hospital staff attempts to have those patients transported to the CGH main campus prior to the MSE or stabilizing treatment.
* Patients 4, 12, 21 and 22 did not receive MSEs or stabilizing treatment within the capability and capacity of CGH at the time of those encounters that included IV antibiotics, imaging such as CT and ultrasound, and laboratory testing.
* Patients 15 and 16, for whom EMCs had not been ruled out, removed or resolved were transported from the Brookings ED satellite to the CGH main campus in another town for further examination and stabilizing treatment in POVs by family members. Appropriate medical transportation with qualified personnel was not used for transport and hospital staff written training materials reflected that staff were informed to consider that CGH was responsible for payment of all ambulance transport between the Brookings ED satellite and the CGH main campus.
* Patients 11, 13, 19 and 24 left the Brookings ED satellite before receiving a MSE or before the MSE was completed for reasons that were unclear or unexplained, or after insurance information had been obtained, and there was no evidence that hospital staff said or did nothing to dissuade patients from staying.

Findings include:

1. According to Internet distance information, the CGH off-campus Brookings ED satellite location in coastal Brookings, Oregon is approximately 28 miles and 38 minutes drive-time on a rural coastal highway from the Curry General Hospital main campus in Gold Beach, Oregon.

2. a. The P&P titled "Emergency Medical Treatment & Active Labor Act (EMTALA)" dated as revised on 11/30/2017 was reviewed and included the following:
* "All patients presenting to an Emergency Department (ED) seeking care, or presenting elsewhere on the campuses of Curry General Hospital and Curry Medical Center, must be accepted and evaluated regardless of the
patient's ability to pay."
* "All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of Curry Health Network (CHN) to reach a diagnosis. Federal law requires that all necessary definitive treatment shall be given to the patient and only maintenance care can be referred to a physician office or clinic. Nursing triage is not acceptable as a medical screening exam under EMTALA."
* "A Medical Screening Exam is used to establish if an emergency medical condition exists."
* "Prior authorization may be obtained after medical screening and stabilization services are completed. This does not preclude qualified medical personnel from consulting with the patient's private physician if the consultation does not inappropriately delay required medical services."
* "Patients have the right to refuse care and treatment. Any patient who leaves prior to an evaluation by the provider is given the discharge status 'Left Without Being Seen' (LWBS). In this case, the nursing staff shall 'call' for the patient on three occasions and so document attempts to locate patient prior to noting final patient status as 'LWBS'."
* "Patients who decline recommended treatment and/or refuse all care, and who have been seen by the provider, must be requested to sign an 'Against Medical Advice' (AMA) Form, and the risks of such decision must be explained by the provider and so documented. If the patient refuses to sign such a form, two witnesses must attest to the declination."

The P&P did not clearly, completely and accurately describe the hospital's EMTALA obligations related to MSEs. For example:
* It did not define who was responsible to perform MSEs.
* It did not specify how MSE services in accordance with the full capabilities and capacity of CGH would be ensured and provided for all individuals who presented to the Brookings ED satellite, including provision of further examination or stabilizing treatment or admission at the CGH main campus.
* It was not clear what the "capability of Curry Health Network (CHN) to reach a diagnosis" meant in consideration that the CHN included non-hospital providers and services.
* It was not clear what "only maintenance care can be referred to a physician office or clinic" meant.
* It was not clear what "Prior authorization" referred to.
* It did not provide procedures to ensure that inquiries about "patient's ability to pay" did not delay the provision of MSEs and did not dissuade patients from staying for an MSE at any point during the ED encounter.
* It did not provide procedures for assurance that the circumstances that led to a patient leaving without a MSE or during an MSE would be clearly documented.

During interview with the CNO on 08/03/2020 at 1245 he/she stated there were no other P&Ps that contained additional direction or information related to management of patients who indicated to hospital registration or clinical staff that they wanted to leave before or during triage, before or during the MSE and before or during the provision of stabilizing treatment.

2. b. The P&P titled "Transport of Patients from Curry Medical Center Emergency Care" dated as last reviewed on 02/06/2020 was reviewed and included the following:
* "To define the process for patients requiring transportation from Curry Medical Center Emergency Care Satellite (CMC EC) to Curry General Hospital Main Campus for continued care ... To establish a policy that complies with EMTALA Requirements."
* "Patients requiring transportation from Curry Medical Center Emergency Care Satellite to Curry General Hospital Main Campus for continued care shall be transported via medical transport. The following steps shall be taken:
- The Provider shall notify the patient that medical transport shall be used to transport them to Curry General Hospital for continuing care.
- The patient must consent to receive this service.
- If the patient refuses medical transport, the following steps must be taken:
- The Provider must notify the patient of the risks associated with refusing medical transport
- The provider must document this conversation.
- The patient must sign an AMA form."

It was not clear whether the "AMA form," generally intended for patients who leave the hospital before examination or treatment at the hospital, contained language related to the use of a POV, against the medical advice of the physician, for transport from the off-campus Brookings ED satellite to the CGH main campus in another town for further exam or treatment of a potential EMC that had not been ruled out, removed or resolved.

2. c. The "Medical Staff Rules and Regulations" dated "March 2019" were reviewed and included the following:
* "In accordance with EMTALA, every emergency patient must sign an informed consent if capable of doing so ..."
* "Duties of the emergency physician on duty include ... In accordance with EMTALA, provide a medical screening exam for all patients who present to the Curry General Hospital Emergency Department or Curry General Hospital Emergency Medical Services Satellite including those to be seen by their private physician following stabilization."

2. d. The document titled "Scope of service" dated as last revised "10/2019" was reviewed and was not clear and complete in relation to the off-campus Brookings ED satellite. For example:
* The pharmacy, laboratory, radiology and cardiopulmonary sections of the document lacked information related to the scope and hours of those services at the off-campus Brookings satellite location to inform the provision of the MSE at the Brookings ED satellite. For example:
- The "Radiology Services" section reflected that "CT, MRI, and X-ray are available 24/7/365." However, it did not specify whether those were at the main campus or at the Brookings satellite and whether hours of service varied at the two locations.
- The "Radiology Services" section reflected "Mammo, Fluoroscopy, Echocardiography, Ultrasound, Nuclear Medicine*" (sic). It was not evident what the "*" referred to. There were no days and hours of services, it did not indicate whether those were at the main campus or at the Brooking satellite and whether hours of services varied at the two locations.
- The "Cardiopulmonary Services" section reflected "Registered Respiratory Therapist services 24 hours a day, seven days a week through inpatient, outpatient and outreach modalities. Services Provided: Inpatient and
outpatient pulmonary therapy. Inpatient and outpatient EKG and cardiac monitoring." However, it did not specify whether those were at the main campus or at the Brookings satellite and whether hours of service varied at the two locations.
* The "Appendix A Type & Scope of Emergency Services" included a table of emergency services available at the "CMC Emergency Care" or off-campus Brookings ED satellite location. For three "Emergency Situations" described as "Pregnancy-related emergencies," "Trauma: Meets OHA Exhibit 2 Guidelines" and "Mental Health/Suicidal-related emergencies" the table reflected for the off-campus Brookings ED satellite, "Preferentially Divert." It was not clear what that meant.

2. e. Review of the CGH "Organizational Chart" dated 07/16/2020 revealed that it included no reference to the off-campus Brookings satellite location and services provided at that location. As the Brookings satellite location services were not incorporated into the organizational chart, it was unclear how oversight and management of those services was provided to ensure integration with CGH's main campus operations.

2. f. The "Medical Staff Orientation Manual" dated 10/21/2019 was reviewed and included the following:
* "Patients Requiring Surgery - CMC-EC: If a patient requires surgical services, the ED provider must consult with the necessary surgeon ... medical transport will be called ... the patient will be transported from CMC-ED to CGH ED."
* "Admission from CMC-EC: If, after medical screening exam, it is determined that the patient requires a higher level of care, the patient will be transported to the nearest appropriate facility for such care. If CHN has the capability of treating the patient, CHN must do so, without regard for the patient's insurance status or ability to pay ... Once a [CGH bed] is assigned, the Hospitalist writes admission orders in CPSI, medical transport may be called, and the ED RN may call report to the receiving nurse ... The ED physician retains responsibility and accountability for the patient until they arrive at CGH."
* "Patients Requiring Transfer - CMC-EC:
- Transfer to CGH: Notify House Supervisor. Follow process for admission. Complete transfer form.
- Transfer to Regional Hospital: Notify the House Supervisor ... The ED physician consults with the receiving physician and writes transport orders for EMS. A completed transfer form and complete medical record is sent with EMS ...
- Consideration: When medical transport is used to transfer the patient between CMC-EC and any hospital for admission, the patient's insurance is billed for that service. When medical transport is used to transfer a patient between CMC-EC and CGH ED, Curry Health Network is responsible for transport costs."

In regards to the service capabilities of CGH at the off-campus Brookings ED satellite the manual reflected only:
* "Radiology: ... In addition to the imaging services available at the hospital, CMC Brookings offers MRI, DEXA and nuclear medicine services."

The "Medical Staff Orientation Manual" was not clear, accurate or appropriate. For example:
* The information was not contained in P&Ps or not consistent with the P&Ps referenced in Findings 2.a, 2.b. and 2.d. above.
* Information provided about the hospital's obligation to cover transport costs for patients transported from the Brookings ED satellite to the CGH main campus for further examination or stabilizing treatment or admission provided incentive or motivation for hospital staff to offer, provide the option, or otherwise encourage patients to use their own vehicles for transport.
* There was no other information in the "Radiology" and "Laboratory" services sections of the manual that described or specified the hours and types of those services available at the off-campus Brookings ED satellite location and how those varied from, and were integrated with, the CGH main campus operations.

2. g. The undated "Curry Medical Center Emergency Care Orientation Module" was reviewed and included the following:
* "EMTALA Requirements ... Patients who indicate they are seeking care must be checked in to the ED and be provided a Medical Screening Exam ... There are Same Day Appointments available in the CMC Clinic. To comply with EMTALA: This option may only be offered after a patient reports clearly that they 'Do Not Wish To Be Seen In the ED'. It should be reiterated that we are happy to see them in the Emergency Department, if they wish. They may then be redirected to the clinic registration area, for possible same day appointment scheduling."

The emergency care orientation information was not clear and did not describe the circumstances that would prompt the patient to report they "Do Not Wish To Be Seen in the ED" or that would result in the patient being offered an option for a "Same Day Appointment." It did not specify whether registration staff or clinical staff would offer the "Same Day Appointment." It did not indicate whether that "option" would be offered before or after registration, or before or after triage, or before or after any inquiries initiated by the patient or hospital staff related to payment, finances and insurance.

During interview with the CNO during the afternoon of 07/21/2020 he/she stated that there were no "same day" or walk-in appointments at the two physician clinics located at the CGH satellite location.

2. h. A. The document titled "ER Registration Process:," dated as "Original" on 10/04/2019, was reviewed and included the following:
* "When patient presents to window ..." The information that followed that was two pages of instructions for data entry into the registration part of the EHR system.
* The document continued: "Once patient has been triaged, you may get remaining Registration information including signatures. You may NOT discuss payment/insurance until the patient has been triaged. Please verify or update patient information, to include name, SSN, address, phone number(s), Emergency Contacts and insurance cards/ID are scanned every six months ... Go back to the Systems Menu and Complete Registration. This includes:
- Add insurance to the account from the profile. Make sure to update the financial class field.
- Run eligibility for the patient's insurance.
- Review the eligibility report to ensure correct insurance is on the account in correct Billing order ( (sic) Primary (Y), Secondary (s).
- If patient does not have insurance, print Facesheet and place in Financial Counselor's inbox, and give patient the Presumptive Temporary OHP application, Information (sic) patient they should return the completed
application to the Financial Counselor within 72 hours."

2. h. B. The document titled "ER Registration - Adding a New Patient" dated 04/29/2020 was reviewed and included:
* "Once patient has been Triaged and paperwork is complete, go to Patient Profile and fill in all required information." The list that followed included insurance information.

2. h. C. The document titled "CMC EC Registration Process and Flow:" dated "December 2019" was reviewed and included:
* "All patients that present at the front desk will be quick reg'd, placed on tracking board ... Registration monitors when EIS (sic) score is added to the tracking board and determines where patient is in order to complete registration ... If patient is returned to lobby to wait on room availability after triage, staff will attempt to complete registration ... All patients that are brought to the ER by ambulance or police arrive through the back door of the ER. The Unit Secretary will quick reg the patient, place on tracking board ... Registration will monitor when EIS (sic) score is added to tracking board and coordinate with Unit Secretary as to when they can come in to complete registration ..."

The registration process documents reflected that inquiries about finances and insurance were initiated after triage and before the MSE. Those inquiries included providing patients with financial assistance and State Medicaid Agency application information. There were no P&Ps or other documents that provided instruction for staff related to how to initiate that discussion with patients or what to say to patients when providing that information in a way that would not dissuade the patient from staying for an MSE. There were no directions to staff for how to respond to patients' questions about payment and financial assistance at any time during the ED encounter.

During interview with the RegM on 08/03/2020 beginning at 1100 he/she confirmed that all patients who presented to the ED were "quick reg'd" at the time they presented and that after the patient was triaged by an ED nurse, and before the MSE, the registration process was completed. He/she stated that the registration completion process included inquiry about finances and insurance and that for patients that did not have insurance the financial assistance information and State Medicaid Agency application was provided to patients at that time.

3. During interview with the CNO on 07/21/2020 beginning at 1830 he/she stated that on 06/10/2020 EMS arrived to the Brookings ED satellite with Patient 18 who was experiencing rectal bleeding. The CNO stated that upon arrival the ED physician had attempted to redirect EMS to the CGH main campus before the patient was moved into the Brookings ED. Incident documentation provided in an email from the CNO dated 07/22/2020 at 1729 reflected that when EMS staff was preparing the patient to move him/her from the ambulance into the ED, the ED physician approached them and stated that he/she wanted to discuss with them where the patient should be taken, and that because the patient had not been transported through the ED door it would not be an EMTALA violation. The documentation reflected that the ED physician continued to persist that the patient be taken to the CGH main campus, including minimizing the patient's symptoms by indicating that Patient 18 likely had a hemorrhoid. However, EMS staff insisted that they were to move the patient into the ED and the physician eventually allowed them do so.

Review of the central log for Patient 18 reflected he/she presented to the Brookings ED satellite on 06/10/2020 at 2020 by ambulance with chief complaint of "Rectal Bleeding." The log reflected the patient's "Diagnosis" was "Lower GI Bleed," his/her "Disposition" was "Admit," and "Discharge" date and time from the ED were recorded as 06/10/2020 at 2251.

The medical record for Patient 18's 06/10/2020 encounter was reviewed and included the following:
* At 2019 the patient arrived to the ED.
* At 2026 the patient was triaged by an RN.
* The "Chief Complaint" was "frank blood from rectum x 1 day, colonoscopy end of may."
* At 2313 the ED physician signed the "ED Provider Note" that reflected "GU/Rectal: frank red blood in circling (sic) the anus and on the buttocks. Rectal exam was not peformed. Due (sic) to obvious rectal bleeding ... After initial evaluation patient went to the CT suite. [He/she] does not have perforation but [he/she] does have extensive metastatic disease in the pelvis the liver and the lungs. [He/she] is on Eliquis and therefore with [his/her] GI bleed will be sent to Gold Beach or other facility for admission ... Patient was diagnosed on 04/30/2020 by [CGH physician] having rectal verge metastatic cancer. Due to the cancer and bleeding I feel this needs to be re-evaluated by [CGH physician]."
* The "ED Departure Date/Time" was recorded at 06/10/2020 at 2310.
* A "Patient Transfer Form" reflected that patient was transferred to CGH main campus for admission.

Although the delay that occurred when the physician attempted to redirect the patient to another facility may have been a matter of a few minutes and may not have significantly impacted this patient's condition, the potential for delay in exam and treatment for other patients additionally existed. The ED physician's actions were not in compliance with EMTALA which requires that all individuals who present to the hospital, including its premises, property and parking lot receive a MSE within the hospital's capability and capacity. The physician's assertion that redirection to another facility would not be an EMTALA violation because the patient was not through the ED door yet was not accurate and reflected that the hospital's policies and procedures and training had not been effective.

4. Review of the central log for Patient 20, a 14-year-old, reflected he/she presented to the Brookings ED satellite on 06/22/2020 at 1014 by POV with chief complaint of "Chest Tube Issue." The log reflected the patient's "Diagnosis" was "Spontaneous Pneumothorax, Chest Tube," his/her "Disposition" was "[Transfer]," and "Discharge" date and time were recorded as 06/22/2020 at 1705.

The medical record for Patient 20's 06/22/2020 encounter was reviewed and included the following:
* At 1013 the patient arrived to the ED.
* At 1022 the patient was triaged by an RN.
* The "Chief Complaint" was recorded as "Pt seen at Curry Medical Center ED on Saturday for a spontaneous pneumothorax. Chest tube was inserted and pt's parent to follow up. Attempts to follow up with provider were unsuccessful; pt returned to the ED."
* The "ED Provider Note" reflected that patient was seen by the ED physician at 1025. The physician documented that Patient 20 had presented to the ED two days prior with a pneumothorax and had a chest tube placed at that time. The note reflected that the ED physician on the 06/20/2020 visit was "unable to put in a conventional a (sic) chest tube." The 06/22/2020 note continued and reflected that the ED physician called the [CGH surgeon] who "agrees of (sic) doing a two view chest and [he/she] will evaluate x-ray at that time and we will make a decision As (sic) for the patient's care."
* A "Radiology Report" reflected that the radiologist notified the ED physician of the result of "XR Chest 2 view." The report reflected that "The current pneumothorax is large in size and is more prominent than any of the comparison studies. There is some mild shift of the heart and mediastinal structures to the left compatible with a tension component ... There is a possible right-sided chest tube but there is a large right-sided pneumothorax. There is some mild shift of the heart and mediastinal structures to the left."
* At 1040 the ED Physician documented "I discussed the case with [CGH surgeon] in Gold Beach. [He/she] reviewed x-ray. [He/she] feels that patient would be better served placing the chest tube here in Brookings and then transferring to a thoracic surgeon. I then discussed the findings with the radiologist. [He/she] is now indicating that there is a midline shift. I returned the call to [CGH ED physician] and discussed the findings per radiologist. I then discussed the cased with [CGH surgeon] who then accepted the patient. But [CGH ED physician] then told me to perform the chest tube insertion here. I will proceed with insertion of chest tube and transfer of patient."
* An untimed "Nursing Note" reflected that the previously inserted "Chest tube removed from the right upper chest w/o complication."
* At 1230 the ED Physician documented the chest tube placement procedure.
* At 1315 the ED Physician documented contact with two hospitals in Medford, Oregon who both were unable to accept the patient.
* At 1329 and 1358 the ED Physician documented contact with two hospitals in Portland, Oregon who did not accept the patient.
* At 1416 a "General Surgery Telephone Consultation Note" was electronically signed by the CGH surgeon. The note reflected "I was called prior to repeat imaging while the patient was in triage. I discussed with the ER physician regarding obtaining an x-ray and to call me back as soon as the x-rays were completed. X-rays today showed a significant pneumothorax with tracheal and mediastinal deviation. I had a long discussion with the ER physician regarding the need for chest tube placement ... ER physician inquired about transferring [Patient 20] to Gold Beach where I was doing procedures. We discussed the the patient should be stabilized with a chest tube in the Brookings Emergency Department before a 40 minutes (sic) transfer to Gold Beach. We also discussed further that the patient could not be admitted at the hospital in Gold Beach. [He/she] is a pediatric patient. We also discussed that [he/she] likely needs pleurodesis/VATS procedure. We discussed [he/she] needs to be transferred to a facility that has a thoracic surgeon present such as Medford or Eugene. We discussed that this is now [his/her] 3rd encounter to our system with the spontaneous pneumothorax. We do not have the facility or the hospital resources to care for this patient. I never refused transfer of this patient. We discussed that if the ER physician is incapable of performing a chest tube placement or does not have the equipment or supplies [he/she] could transferred (sic) the patient to the Gold Beach ER and I would place a chest tube. We then discussed once I placed the chest tube in Gold Beach I would then transfer the patient to Medford or Eugene for further admission and treatment. Both [CGH ED physician] and myself discussed this with the ER physician at length. Multiple phone conversations were had over this patient."
* At 1436 the ED Physician documented contact with a hospital in Springfield, Oregon and final acceptance of the patient by that hospital at 1455.
* The "ED Departure Date/Time" was recorded as 06/22/2020 at 1705, approximately six and one-half hours after the initial communications between the ED physician at the off-campus Brookings ED satellite and the surgeon at the CGH main campus.

The record of Patient 20 reflected that communications between the ED physician at the off-campus Brookings ED satellite and the surgeon and ED physician at the CGH main campus created a delay in the provision of
stabilizing treatment and transfer. Although the delay may not have significantly impacted this patient's condition, the potential for delay in exam and treatment for other patients additionally existed. The record of the "discussions" and "multiple phone conversations" reflected a lack of clear procedures and coordination between the satellite and the main campus for provision of further exam and stabilizing treatment, including where the record reflected the ED physician "discussed the case with [CGH surgeon] who then accepted the patient. But [CGH ED physician] then told me to perform the chest tube insertion here."

Further, it was unclear what was meant by "... this is now [Patient 20's] 3rd encounter to our system with the spontaneous pneumothorax. We do not have the facility or the hospital resources to care for this patient." The EDs at both of the hospital's locations are obligated to provide examination and stabilizing treatment within the hospital's capability and capacity and without delay regardless of how many times a particular patient presents.

Refer also to the findings for Patient 20 under Tag C2409 related to the hospital's failure to affect an appropriate transfer.

5. Review of the central log for Patient 4 reflected he/she presented to the Brookings ED satellite on 03/02/2020 at 1602 by POV with chief complaint of "F/U Right Middle Finger Injury." The log reflected the patient's "Diagnosis" was "Cellulitis of Finger," his/her "Disposition" was "[Transfer]," and "Discharge" date and time were recorded as 03/02/2020 at 1941.

The medical record for Patient 4's 03/02/2020 encounter was reviewed and included the following:
* At 1602 the patient arrived to the ED.
* At 1607 the patient was triaged by an RN.
* The "Chief Complaint" was recorded as "infected right middle finger."
* At 1923 the ED physician electronically signed the "ED Provider Note" that reflected "Patient crushed [his/her] hand 9 days ago in between metal and was seen in the ED with an x-ray negative for fracture. Patient has had increased swelling, redness, tenderness and complains of pain in [his/her] palm intermittently. [He/she] noted pus coming from the hand and poked a hole in [his/her] skin to drain it and (sic) 3 days ago. Symptoms have since worsened ... Right hand middle finger with swelling mostly around the PIP joint and the soft tissue inbetween (sic) the MCP and PIP. patient (sic) has mild tenderness on passive extension, [he/she] has pale distal finger tips of all fingers in [his/her] right hand. Sensation is intact [his/her] (sic) patient has mild tenderness of the palm to palpation however, is not reproducible ... differential diagnosis includes: tenosynovitis, cellulitis."
- Under "ED Course" the physician recorded "Patient was given IV vancomycin while in the ED. I discussed the case with plastic surgeon in Eugene [physician name] who reviewed pictures of [his/her] hand and previous x-rays. [He/she] does not feel this is a tenosynovitis at this time but suggests that the patient be admitted for IV antibiotics and follow up with the hand surgeon as an outpatient. [Second physician name] in Crescent city accepts patient ... transfer to Sutter Coast Hospital."
* The patient's "ED Departure Date/Time" was recorded as "19:25" however, it was unclear whether the patient's condition had been assessed, or what the patient's condition was, at the time of departure as the nursing entries in the record were untimed. Further, the patient signed an acknowledgment of receipt of discharge instructions at 1942, after the recorded departure time. Therefore it was unclear what the accurate departure time was.

There was no documentation to reflect that the ED physician contacted the ED physician or Hospitalist at the CGH main campus to inquire about the provision of further exam and stabilizing treatment and admission at CGH prior to arranging transfer to another hospital.

During interview at the time of the record review with the CNO and SNO on 07/30/2020 beginning at 1400 the CNO stated that CGH had the capability to provide inpatient IV antibiotics and the CNO stated that CGH had inpatient bed and acuity capacity on the date and time of Patient 4's ED encounter. The CNO confirmed that it was unclear why Patient 4 was sent to another hospital when CGH had both capability and capacity.

"Mode of Transportation" for the transfer was recorded as "Private Car." Refer also to the findings for Patient 4 under Tag C2409 related to the hospital's failure to affect an appropriate transfer.

6. Review of the central log for Patient 12 reflected he/she presented to the Brookings ED satellite on 05/14/2020 at 0021 by ambulance with chief complaint of "[Ground Level Fall]." The log reflected the patient's "Diagnosis" was "Needs CT," his/her "Disposition" was "[Transfer]," and "Discharge" date and time were recorded as 05/14/2020 at 0321.

The medical record for Patient 12's 05/14/2020 ED encounter was reviewed and included the following:
* At 0022 the patient arrived to the ED.
* At 0030 the patient was triaged by an RN.
* The "Chief Complaint" was recorded as "Non witnessed fall at home. Has been drinking all day and hit [his/her] head (ear is cut). [He/she] also has an abrasion on [his/her] left knee."
* The patient's signature on the "Conditio

Based on interview, review of documentation in 15 of 17 medical records of patients who were transferred from the CGH off-campus Brookings ED satellite location and from the CGH on-campus ED to other hospitals for further examination and stabilizing treatment (Patients 1, 2, 3, 4, 6, 7, 9, 12, 14, 18, 20, 22, 23, 25 and 27 ) and review of hospital policies and procedures, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that it affected appropriate transfers to other hospitals for patients who required further examination and stabilizing treatment to rule out, remove or resolve potential EMCs as follows:
* Physician certifications of risks and benefits of transfer were lacking evidence that the physician certified and that the patient was informed of individualized and patient specific risks.
* Appropriate modes of transportation with qualified personnel were not used for transfers.
* Medical records were not sent to the receiving hospital.
* In the cases of Patients 4, 12 and 22, those patients were transferred to other hospitals for further examination and treatment that was confirmed to be within the capability and capacity of CGH at those times. Refer to the findings for those patients related to capability and capacity under Tag C2406 in this SOD.

Findings include:

1. a. The P&P titled "Emergency Medical Treatment & Active Labor Act (EMTALA)" dated as revised on 11/30/2017 was reviewed and reflected the following regarding "Patient Transfers:"
* "CHN may not transfer or discharge patients who are considered unstable, as long as the Network has the capability to provide treatment and care to the patient. Once Network service limits have been reached the patient may be transferred to a higher level of care, even if not identified as 'stable'."
* "If a patient is to be transferred the following must be followed:
- Physician certification that the risks of transferring the patient are outweighed by the benefits. The individual risks and benefits must be documented and the patient's medical record must support these, or
- The patient requests a transfer in writing."
* "In addition, ALL the following steps must be documented:
- The receiving hospital ... must accept the patient ..."
- The receiving Provider ... must accept the patient ..."
- Patient must give written consent for transfer (if patient unable to consent, this may be implied).
- The patient must be transferred by an appropriate medical transfer vehicle. A patient may not be transferred in a private passenger vehicle unless that patient refuses to be transported by ambulance. The patient's refusal must be in writing.
- The physician shall order appropriate medical personnel to attend the patient, maintain and/or initiate treatment or medications and manage known potential adverse effects. Appropriate life support equipment shall be ordered.
- Copy of the medical record, including physician documentation, nursing documentation, EKGs, Radiology images, and laboratory test results shall accompany the patient when transferred ..."
* "Prior authorization may be obtained after medical screening and stabilization services are completed ..."

The P&P was unclear and incomplete. For example:
* It was not clear what was meant by the "CHN may not transfer or discharge patients ... as long as the Network has the capability ..." and whether "CHN" and "the Network" referred to CGH and its capabilities.
* There was no direction related to how or where to obtain "The patient's refusal ... in writing." It did not include procedures to manage those situations and ensure that hospital staff did or said nothing to dissuade the patient from transfer by appropriate mode of transport with qualified medical personnel who could respond should the patient's condition change during transfer.
* It was unclear how "appropriate medical personnel" and "life support equipment" would be provided if a patient refused transport by ambulance.
* It was unclear what was meant by "Prior authorization," including what type of authorization and for what.

1. b. The P&P titled "Transport of Patients from Curry Medical Center Emergency Care" dated as last reviewed on 02/06/2020 was reviewed and included the following:
* "To define the process for patients requiring transportation from CMC EC Satellite to other receiving hospitals, with capability and capacity to provide care for patients who cannot be provided a definitive level of care within Curry Medical Center Emergency Care Satellite or Curry General Hospital Main Campus ... To establish a policy that complies with EMTALA Requirements."
* "Patients requiring transportation from CMC EC Satellite to another hospital for stabilizing treatment not available at Curry General Hospital Main Campus shall be transported with qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. The following steps shall be taken:
- The Provider shall notify the patient that medical transport shall be used to transport them to the receiving hospital for continuing care.
- The patient must consent to receive this service.
- If the patient refuses medical transport, the following steps must be taken:
- The Provider must notify the patient of the risks associated with refusing medical transport
- The provider must document this conversation.
- The patient must sign an AMA form

It was not clear whether the "AMA form," generally intended for patients who leave the hospital before examination or treatment at the hospital, contained language related to the use of a POV, against the medical advice of the physician, for transfer to another hospital in another town or city for further exam or treatment of a potential EMC that had not been ruled out, removed or resolved.

1. c. The "Medical Staff Orientation Manual" dated 10/21/2019 was reviewed and included the following:
* "Patients Requiring Transfer - CMC-EC:
- Transfer to Regional Hospital: Notify the House Supervisor ... The ED physician consults with the receiving physician and writes transport orders for EMS. A completed transfer form and complete medical record is sent with EMS ...

2. The medical record for Patient 2 reflected that he/she presented to the Brookings ED satellite for emergency services on 01/04/2020 at 1414 with a chief complaint of "Right Foot Pain." The patient received an MSE for "erythema/swelling ... 2+ pitting: R foot" and "elevated D-dimer." Patient 2 was subsequently transferred to SCH by POV for further examination by "ultrasound" for "possible DVT" as ultrasound was not available on Saturdays at the off-campus Brookings satellite or at the CGH main campus.

The record did not contain a "transfer form" required under Finding 1. c. above.

There was no documentation elsewhere in the record of the elements of an appropriate EMTALA transfer. The record lacked the following:
* That SCH and the SCH provider accepted the patient in transfer. The "ED Provider Note" electronically signed on 01/04/2020 at 2132 reflected "Called Sutter Coast Hospital and spoke with [SCH ED physician] to inform [him/her] that [Patient 2] would be going there where ultrasound was available." The note did not reflect whether SCH accepted the patient, only that the Brookings ED provider informed SCH that the patient was going there.
* Physician certification that the benefits of transfer to another hospital outweighed the risks of transfer and that reflected that the patient had been informed of the specific risks to him/her.
* Patient 2's written consent for transfer.
* That medical records were sent to the receiving hospital at the time of the transfer.

Further, the record reflected that appropriate transportation with qualified personnel was not utilized for the transfer and that the patient was transferred by POV. Documentation related to transfer by POV was not clear or complete:
* The "ED Provider Note" reflected "Offered [Patient 2] an ambulance ride but [he/she] declined stating [his/her spouse] would drive [him/her]." There was no other related documentation in the note.
* A printed hospital form in the record was altered, and the majority of the original printed verbiage on the form had been replaced with handwritten verbiage. With a combination of printed and handwritten language the form read "Leaving Hospital in Private Car instead of Ambulance. This is to certify that I, [Patient 2], am leaving Curry General Hospital by private car instead of Ambulance because [spouse] is available to take me." It was signed by Patient 2 only. There were no staff signatures. There was no other information on the form, including about risks of the transfer and about risks of transfer by POV.

In addition, there was no documentation related to the patient's condition at the time of departure from the ED which was documented as at 1711 and as "Discharged to: Home." The last "Nursing Note" in the record prior to discharge to "home" was on 01/04/2020 at 1523 and reflected "To xray via WC."

There was no documentation in the record that reflected that the specific risks to the patient associated with transport by private vehicle while the patient experienced an acute medical condition that required transfer to another hospital were described. There was no documentation to reflect how the information about transportation was presented and what prompted the patient to "decline" an ambulance. There was no documentation to reflect that hospital staff said or did nothing to dissuade the patient from accepting safe transport with qualified personnel who could respond if his/her condition changed.

According to Internet distance information, Sutter Coast Hospital in Crescent City, California is approximately 25 miles and 32 minutes drive-time on rural coastal highway from the CGH off-campus Brookings ED satellite location in coastal Brookings, Oregon.

3. The medical record for Patient 4 reflected that he/she presented to the Brookings ED satellite for emergency services on 03/02/2020 at 1602 with a chief complaint of "F/U Right Middle Finger Injury." The patient received an MSE for "Cellulitus of Finger." Patient 4 was subsequently transferred to SCH by POV for "IV antibiotics."

* The "Patient Transfer Form" included the following:
- "Benefits of transfer" was recorded as "Admission."
- "Risks of Transfer" was recorded as "Death & Debilitation."
- "Reason for Transfer" was recorded as "Hand Cellulitis."
- A paragraph that reflected "All Transfers have the inherent risks of traffic delays, accident during transport, inclement weather, rough terrain or turbulence pain or discomfort during movement, and the limitation of personnel present during transport."
- "Transfer Consent of Patient/Representative" was not completed and signed by Patient 4.

In regards to "risks" it was not clear what "debilitation" meant for Patient 4. There was no other documentation in the record, including in the ED Provider Note, that the physician had informed the patient of his/her specific risks of transfer, what those were and that the benefits of the transfer outweighed those risks.

* The "Patient Transfer Form" included the following:
- "The patient will be transferred by qualified personnel and transport equipment as required, including the use of necessary and appropriate life support measures."
- "Mode of Transport" was recorded as "POV."
- "Transport Personnel" was not completed.
- A paragraph preceded by a blank checkbox that reflected "Patient hereby refuses transfer by physician recommended mode of transport and wishes to go by private vehicle. Patient/representative understands and accepts the risks associated with this decision. Initials of patient/representative [Two initials]."
- "Transfer orders: Following orders for support and treatment during transfer" was recorded as "POV."

There was no documentation in the ED Provider Note or elsewhere in the record that reflected what the "physician recommended mode of transport" was or that the specific risks to the patient associated with transport by private vehicle while the patient experienced an acute medical condition that required transfer to another hospital were described. There was no documentation to reflect how the information about transportation was presented and what led to the decision for transfer by "POV." There was no documentation to reflect that hospital staff said or did nothing to dissuade the patient from accepting safe transport with qualified personnel who could respond if his/her condition changed.

* An "ED Provider DC Instructions" form contained an unauthenticated and untimed entry that reflected "Patient is being discharged and transferred to Sutter Coast Emergency room for admission."

* According to Internet distance information, Sutter Coast Hospital in Crescent City, California is approximately 25 miles and 32 minutes drive-time on rural coastal highway from the CGH off-campus Brookings ED satellite location in coastal Brookings, Oregon.

* During interview at the time of the record review with the CNO and SNO on 07/30/2020 beginning at 1400 the CNO stated that CGH has the capability to provide inpatient IV antibiotics and the CNO stated that CGH had inpatient bed and acuity capacity on the date and time of Patient 4's ED encounter. The CNO confirmed that it was unclear why Patient 4 was sent to another hospital when CGH had both capability and capacity.

4. The medical record for Patient 9 reflected that he/she presented to the Brookings ED satellite for emergency services on 04/14/2020 at 1343 with a chief complaint of "Possible Overdose." The patient received initial exam and treatment at the Brookings ED satellite from where he/she was transported by ambulance to the CGH main campus ED for further exam, including mental health evaluation, and stabilizing treatment for "Benadryl Overdose, Suicidal Attempt." Patient 9 was subsequently transferred by "secure transport" to Cedar Hills Hospital for "psychiatric services" not available at CGH.

* The "Patient Transfer Form" for the transfer from the CGH main campus ED to Cedar Hills Hospital included the following:
- "Benefits of transfer" was recorded as "Psychiatric Services."
- "Risks of Transfer" was recorded as "Transportation Risks."
- "Reason for Transfer" was recorded as "Suicidal Ideation."
- A paragraph that reflected "All Transfers have the inherent risks of traffic delays, accident during transport, inclement weather, rough terrain or turbulence pain or discomfort during movement, and the limitation of personnel present during transport."
- "Transfer Consent of Patient/Representative" was not completed and signed.

The "risks" of transfer identified were not patient specific and were redundant to those transportation risks pre-printed on the transfer form. There was no other documentation in the record, including in the ED Provider Note, of physician certification that the benefits of transfer outweighed patient specific risks, and that the physician had informed the patient of his/her specific risks of transfer, what those were and that the benefits of the transfer outweighed those risks.

* The "Patient Transfer Form" did not include a section related to sending available medical records to the receiving hospital at the time of the transfer. There was no other documentation anywhere else in Patient 9's medical record that reflected medical records were sent to the receiving hospital at the time of the transfer.

* According to Internet distance information, Cedar Hills Hospital in Portland, Oregon is approximately 340 miles and more than five and one-half hours drive-time from the CGH off-campus Brookings ED satellite location in coastal Brookings, Oregon.

* During interview at the time of the record review with the CNO and SNO on 08/03/2020 beginning at 1315 no additional information was provided related to the lacking appropriate transfer elements described for Patient 9.

5. The medical record for Patient 12 reflected he/she presented to the Brookings ED satellite for emergency services on 05/14/2020 at 0021 by ambulance with chief complaint of "[Ground Level Fall]." The patient received initial exam and was then transferred by ground ambulance to the Crescent City, California airport from where he/she was flown to SHRB for "emergent [CT imaging] to r/o ICH."

* The "Patient Transfer Form" for the transfer to SHRB included the following:
- "Benefits of transfer" was recorded as "HLOC, CT imaging."
- "Risks of Transfer" was recorded as "worsening of condition, death, disability."
- "Reason for Transfer" was recorded as "HLOC, intoxication, head injury, no CT available."
- "Transfer Consent of Patient/Representative" was not completed and signed although the patient had signed the "Conditions of Access" form.

The "risks" of transfer identified were not patient specific. There was no other documentation in the record, including in the ED Provider Note, of physician certification that the benefits of transfer outweighed patient specific risks, and that the physician had informed the patient of his/her specific risks of transfer, what those were and that the benefits of the transfer outweighed those risks.

* The "Patient Transfer Form" did not include a section related to sending available medical records to the receiving hospital at the time of the transfer. There was no other documentation on the transfer form or anywhere else in Patient 12's medical record that reflected medical records were sent to the receiving hospital at the time of the transfer.

* In addition, the patient's condition and the time of departure from the ED were not recorded.

* According to Internet distance information, Crescent City airport is approximately 29 miles and 38 minutes drive time from the Brookings ED satellite, and SHRB in Springfield, Oregon is approximately 230 ground miles from the Crescent City airport.

6. The Brookings ED medical record for Patient 14, 79 years-old, reflected that he/she presented to the Brookings ED satellite for emergency services on 05/20/2020 at 1656 with a chief complaint of "Right Leg Pain and Swelling." The patient received a physical exam by the ED provider and findings reflected "2+ lower leg edema below the knee of right leg." Patient 14 was subsequently transferred to SCH by POV for further examination by "Ultrasound to rule out DVT of the right lower extremity" and for "finishing a DVT workup" as ultrasound was not available on weekdays after 1700 at the off-campus Brookings satellite or at the CGH main campus.

* The "Patient Transfer Form" included the following:
- "Benefits of transfer" was recorded as "Higher Level of Care."
- "Risks of Transfer" was recorded as "Death."
- "Reason for Transfer" was recorded as "US R/O DVT."
- A paragraph that reflected "All Transfers have the inherent risks of traffic delays, accident during transport, inclement weather, rough terrain or turbulence pain or discomfort during movement, and the limitation of personnel present during transport."

There was no other documentation in the record, including in the ED Provider Note, that the physician had informed the patient of his/her specific risks of transfer in addition to "death," what those were and that the benefits of the transfer outweighed those risks.

* The "Patient Transfer Form" included the following:
- "The patient will be transferred by qualified personnel and transport equipment as required, including the use of necessary and appropriate life support measures."
- "Mode of Transport" was recorded as "Ground" and had been crossed out with a line drawn across the word.
- "Transport Personnel" was recorded as "EMT basic."
- A paragraph preceded by a checkbox that reflected "Patient hereby refuses transfer by physician recommended mode of transport and wishes to go by private vehicle. Patient/representative understands and accepts the risks associated with this decision. Initials of patient/representative ____." The initials space was blank.
- In the section "Transfer orders: Following orders for support and treatment during transfer" the words "ACLS Protocols" were circled and had been crossed out with a line drawn over those circled words.

The last "Disposition" entry was recorded by an RN at 1938 and reflected "Transferred Via: Ambulance." A "Nursing Note" recorded at 2003 reflected "patient requested to be transferred by POV." There was no documentation in the ED Provider Note related to mode of transportation or discussions with the patient about that. There was no other documentation related to the patient's departure from the ED.

The original documentation on the transfer form reflected a determination that EMS transport and personnel were to affect the transfer for Patient 14. There was no documentation in the record that reflected that the specific risks to the patient associated with transport by private vehicle while the patient experienced an acute medical condition that required transfer to another hospital were described. There was no documentation to reflect how the information about transportation was presented and what prompted the patient to have "requested to be transferred by POV." There was no documentation to reflect that hospital staff said or did nothing to dissuade the patient from accepting safe transport with qualified personnel who could respond if his/her condition changed.

* The "Patient Transfer Form" did not include a section related to sending available medical records to the receiving hospital at the time of the transfer. There was no other documentation anywhere else in Patient 14's medical record that reflected medical records were sent to the receiving hospital.

* According to Internet distance information, Sutter Coast Hospital in Crescent City, California is approximately 25 miles and 32 minutes drive-time on rural coastal highway from the CGH off-campus Brookings ED satellite location in coastal Brookings, Oregon.

* During interview at the time of the record review with the CNO and SNO on 08/03/2020 beginning at 1315 the CNO confirmed that there was no other documentation related to mode of transportation used for the transfer of the patient. No additional information was provided related to the lacking appropriate transfer elements described for Patient 14.

7. The Brookings ED medical record for Patient 22, seven (7) years-old, reflected that he/she presented to the Brookings ED satellite for emergency services on 06/29/2020 at 0821 with a chief complaint of "Abdominal Pain, Vomiting." An MSE for "possible appendicitis" was initiated. Patient 22 was subsequently transferred by POV to Asante Rogue Regional Medical Center for ultrasound and further examination.

* The "Patient Transfer Form" included the following:
- "Benefits of transfer" was recorded as "pediatric diagnostic workup for appendicitis."
- "Risks of Transfer" was recorded as "ruptured appendix."
- "Reason for Transfer" was recorded as "workup for suspected appendicitis."
- A paragraph that reflected "All Transfers have the inherent risks of traffic delays, accident during transport, inclement weather, rough terrain or turbulence, pain or discomfort during movement, and the limitation of personnel present during transport."

There was no other documentation in the record, including in the ED Provider Note, that the physician had fully informed the patient's parent of all of the specific risks of transfer for this pediatric patient, including death, and that the benefits of the transfer outweighed those risks.

* The "Patient Transfer Form" included the following:
- "The patient will be transferred by qualified personnel and transport equipment as required, including the use of necessary and appropriate life support measures."
- "Mode of Transport" was blank.
- "Transport Personnel" was blank.
- A paragraph preceded by a checkbox that reflected "Patient hereby refuses transfer by physician recommended mode of transport and wishes to go by private vehicle. Patient/representative understands and accepts the risks associated with this decision. Initials of patient/representative ____." The space for the initials was blank.
- "Transfer orders: Following orders for support and treatment during transfer" was blank.

An untimed "Nursing Note" reflected "[ED physician] speaking with Asante RRMC for POV transfer ED to ED for possible appendicitis." An "ED Discharge Instructions" form dated 06/29/2020 at 1102 and signed by Patient 22's parent reflected "Instructions - Please go directly to Asante Rogue Regional ER for further workup. Do not let [Patient 22] eat or drink anything until cleared by the doctor at Asante Hospital."

There was no documentation in the record by nursing or medical staff to reflect why the patient was transported by POV. There was no documentation in the record that reflected what the "physician recommended mode of transport" was or that the specific risks to the patient associated with transport by private vehicle while the patient experienced an acute medical condition that required transfer to another hospital were described. There was no documentation to reflect how the information about transportation was presented and that hospital staff said or did nothing to dissuade the patient's parent from accepting safe transport with qualified personnel who could respond if the patient's condition changed.

* According to Internet distance information, ARRMC in Medford, Oregon is approximately 130 miles and two hours and 45 minutes drive-time over rural, coastal mountain highway from the Brookings ED satellite location in coastal Brookings, Oregon.

8. a. Similar findings related to the lack of individualized and patient specific transfer risks were identified in the medical records for the following patients who presented to the Brookings ED satellite:
* Patient 1 on 01/01/2020 transferred to Sutter Coast Hospital for further exam by pelvic ultrasound related to abdominal pain, ovarian cyst and possible torsion.
* Patient 3 on 02/10/2020 transferred to Salem Hospital for further exam and stabilizing treatment of pancreatic pseudocysts.
* Patient 6 on 03/09/2020 transferred to Sacred Heart Riverbend for further exam and stabilizing treatment of GI bleed.
* Patient 18 on 06/10/2020 transferred from CGH main campus to Bay Area Hospital for further exam and stabilizing treatment of GI bleed.
* Patient 20 on 06/22/2020 transferred to Sacred Heart Riverbend for further exam and stabilizing treatment of tension pneumothorax.
* Patient 23 on 07/01/2020 transferred to Sutter Coast Hospital for further exam by ultrasound to rule out RLE DVT.
* Patient 25 on 07/05/2020 transferred to Asante Three Rivers Medical Center for further exam and stabilizing treatment of fever and sepsis.
* Patient 27 on 07/09/2020 transferred to Sutter Coast Hospital for further exam by ultrasound to rule out RLE DVT.

8. b. Similar findings related to the use of POVs for transfer in lieu of appropriate medical transportation with qualified medical personnel were identified in the medical records for
* Patient 23 on 07/01/2020 transferred to Sutter Coast Hospital for ultrasound to rule out RLE DVT.
* Patient 27 on 07/09/2020 transferred to Sutter Coast Hospital for ultrasound to rule out RLE DVT.

8. c. Similar findings related to the lack of evidence that medical records were sent at the time of transfer were identified in the medical records for
* Patient 1 on 01/01/2020 transferred to Sutter Coast Hospital for a pelvic ultrasound related to abdominal pain, ovarian cyst and possible torsion.
* Patient 3 on 02/10/2020 transferred to Salem Hospital for further exam and stabilizing treatment of pancreatic pseudocysts.
* Patient 6 on 03/09/2020 transferred to Sacred Heart Riverbend for further exam and stabilizing treatment for GI bleed.
* Patient 7 on 03/14/2020 transferred to Sutter Coast Hospital for further exam and stabilizing treatment of pneumothorax and respiratory failure.
* Patient 27 on 07/09/2020 transferred to Sutter Coast Hospital for further exam by ultrasound to rule out RLE DVT.