HospitalInspections.org

Based on observation, interview, review of documentation of a request from another hospital to transfer a patient to ARRMC for specialty services (Patient 18), review of documentation in 7 of 21 medical records of patients who presented to the hospital for emergency services (Patients 1, 2, 13, 14, 15, 20 and 22), review of central log documentation, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure compliance in the following areas:
* Recipient hospital responsibilities.
* On-call physician responsibilities.
* Provision of MSEs.
* Appropriate transfers of patients.
* Maintenance of a central ED log.
* Required posting of EMTALA signs.

Findings included:

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

2. Regarding on-call physician responsibilities refer to the findings identified under Tag A2404, CFR 489.20(r)(2) and CFR 489.24(j)(1-2).

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

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

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

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





















40575

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

Findings include:

1. a. A tour of the ED was conducted with the ED NM and the VPN on 10/24/2018 beginning at approximately 1640. The following observations were made:
* There were no EMTALA signs posted at or near the main ED entrance or at or near the ED entrance from within the hospital.
* There was one EMTALA sign posted on the wall above the doorway at the entrance to the ED from the waiting room. The sign was posted two to three feet above the top of the doorway towards the ceiling. There were no other signs posted in the large ED waiting room and the sign above the doorway could not be seen from all areas within the room.

b. During interview at that time the ED NM stated that the ED included four triage rooms, 29 treatment rooms/bays and four psychiatric beds. He/she stated that there were no EMTALA signs posted in any of those areas.

c. A second tour of the ED was conducted with the ED NM on 10/25/2018 at 1045 in response to information provided by the ED NM that there were signs posted in treatment rooms and areas inside the ED. The following observations were made:
*There was no EMTALA signage posted in exam/treatment rooms 4, 13, 22, 30 and 31.
*There was no EMTALA signage in the overflow medical/psychiatric rooms 24, 25, 26, and 27.
*There was no EMTALA signage posted in the ambulance entry.

2. a. A tour of the FBC was conducted with the FBC NM and the FBCD on 10/24/2018 beginning at 1655. The following observations were made:
* One EMTALA sign was observed posted on the wall next to the door between the FBC waiting area and the secure FBC. It was not readable from the waiting room chairs and was not visible when the doors to the unit were were opened to enter or exit.
* There were no EMTALA signs posted at or near the main FBC entrance, nor in the FBC triage and treatment rooms.

b. During interview with the FBC NM and the FBCD at that they they stated that the only EMTALA sign in the FBC was the one observed outside the secure FBC door.













40575

Based on interview, review of documentation of a request from another hospital to transfer a patient to ARRMC for specialty services (Patient 18), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure its on-call physicians fulfilled their on-call duties and obligations to provide consultation, to come into the hospital, and to accept patients for whom the hospital had capability and capacity to treat.

Findings include:

1. Refer to the findings identified under Tag A2411, CFR 489.24(f) that reflects Orthopedic on-call specialty Physician E failed to respond to a call from ARRMC in a prompt and timely manner and failed to accept Patient 18 in transfer from another hospital's ED for whom ARRMC had capability and capacity to treat.















40575

Based on interview, review of documentation in 5 of 21 medical records of patients who presented to the hospital for emergency services (Patients 1, 2, 15, 20 and 22), review of ED central log documentation and review of policies and procedures, it was determined the hospital failed to develop and enforce EMTALA and related policies and procedures to ensure maintenance of a central log that contained clear and accurate information about the disposition of each patient who came to the hospital seeking emergency services,

Findings include:

1. a. The p/p titled "EMTALA (ARRMC)" dated as last approved 05/27/2016 lacked reference to ARRMC's EMTALA obligation to maintain the required Central Log.

b. The p/p titled "Against Medical Advice (AMA), Left Without Treatment (LWT), and Elopement. (Asante)" dated as last reviewed 09/29/2015 included the following direction:
* "...the policy describes protocols to follow to ensure the event is sufficiently documented and that the patient is aware of their rights and the consequences of his/her choice...It is the policy of Asante to provide a patient desiring to leave the hospital AMA with all necessary information that will allow them or the legal designated representative to make a meaningful and informed decision on whether to leave or not. Every adult has the legal right to accept or reject medical treatment as long as the individual is mentally competent. A patient's competency is determined and documented by the physician."
* "Definitions.
- Against Medical Advice - The patient has been seen by provider and the patient or legal representative refuses medical care and chooses to leave.
- Left Without Treatment - The patient has not yet been seen by a provider but has been triaged and/or care has been initiated by department standing orders/protocols.
- Elopement - The patient has left without the knowledge of the staff and provider.
- Decision Making Capacity - An assessment of the patient or legal representative's ability to understand and communicate a decision; specifically the individual's ability to understand, appreciate the information, process the information, and express their decision as a choice."
* "Documentation in the medical record by nursing should include, but is not limited to: The provider's (sic) capacity to make an informed AMA decision. Discussion of the risks of AMA discharge with the patient or legal representative. Discharge Instructions."
* "Documentation in the medical record by the provider should include but is not limited to: The patient's capacity to make an informed AMA decision. Discussion of risks of AMA discharge with the patient or legal representative. Alternatives offered to AMA discharge. Any pending or outstanding diagnostic tests."
* "Document on the AMA Form: Patient's reason for leaving AMA. Names of relatives or others notified of the patient's decision and the dates and times of the notifications. Explanations of the risks and consequences of the AMA discharge, as told to the patient, including the name of the person who provided the explanation. List of those accompanying the patient at discharge and instructions given to them."

2. The medical record of Patient 22 reflected he/she was brought to the ED by EMS ambulance on 10/27/2018 and received services in the ED. However, the ED log did not contain an entry for Patient 22 on 10/27/2018. Refer to Tag A2406 for the detailed findings related to Patient 22.

3. The ED log reflected that the disposition of Patient 1 from the ED on 06/11/2018 was "AMA." However, the medical record of Patient 1 reflected he/she was discharged from the ED before a MSE was completed and there was no evidence that the patient had been advised of the risks of leaving the ED prior to the completion of the MSE as stipulated in the hospital's AMA policy and procedure. Refer to Tag A2406 for the detailed findings related to Patient 1.

4. The ED log reflected that the disposition of Patient 2 from the ED on 06/30/2018 was both "Sent to L&D" and "ED Dismiss Never Arrived." However, the a notation in the EPIC EHR system for Patient 2 reflected that he/she was transported from the ED to L&D in a wheelchair.

5. The ED log reflected that the disposition of Patient 15 from the ED on 09/21/2018 was "LWBS after Triage." However, documentation in Patient 15's medical record by the NP reflected "I saw this patient in my role as the ED provider at triage. As such I did limited history and physical exam to confirm the patient's triage level and order appropriate studies (if any) to begin the patient's workup. The patient understands that further evaluation will be done when they are brought back to an ED room...Patient was unavailable when called twice. Patient presented back to the window and I reviewed all the results with [him/her]." The NP's documentation reflected that a MSE had been initiated and therefore the disposition that the patient "left without being seen" was inaccurate. Refer to Tag A2406 for the detailed findings related to Patient 15.

6. The ED log unclearly reflected that the disposition of Patient 20 from the ED on 10/17/2018 was both "LWBS after Triage" and "LWBS before Triage." Refer to Tag A2406 for the detailed findings related to Patient 20.

7. The findings for Patients 1, 2, 15, 20 and 22 were discussed during interviews with staff at the time of the record reviews on 10/25/2018, 10/26/2018 and 12/03/2018 and no additional information was provided.

8, The AMA policy and procedure referenced in finding 1.b. above did not include the categories of "LWBS before triage" and "LWBS after triage" that were used extensively to record dispositions in the ED log and the EHR. The category of "LWT" described in the policy and procedure was not observed to be used in the ED log.







40575

Based on interview, review of documentation in 4 of 21 medical records of patients who presented to the hospital for emergency services (Patients 1, 15, 20 and 22), and review of policies and procedures and other documents it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that all patients were provided a complete and appropriate MSE.

1. a. The policy and procedure "EMTALA (ARRMC)" dated as last revised 05/27/2016 included the following requirements:
* "In order to be compliant with the Federal Law -Emergency Medical Treatment & Active Labor Act (EMTALA): The hospital will provide an appropriate medical screening examination (MSE) within the capability of the Hospital's dedicated emergency department (ED) or obstetrical department (OB), including ancillary services routinely available to the dedicated ED/OB, to determine whether or not an emergency medical condition (EMC) exists. The examination will be conducted by an individual(s) determined qualified by Hospital Bylaws or Rules and Regulations; and The Hospital will provide all patients that present to the dedicated emergency department and/or OB with an EMC, a MSE and the treatment which is required to stabilize the EMC, within the capability of the Hospital, or will arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below...Once the MSE has been performed, including performing necessary tests/exams and it has been determined that an EMC does not exist, the patient may be discharged from the ED."
* "A physician or a QMP...shall perform the MSE. The physician or QMP shall determine within reasonable clinical confidence whether the individual has an EMC, utilizing the services within the capability of the ED/OB, and using ancillary services and resources routinely available in the ED/OB for individuals with similar symptoms. The MSE may be an ongoing process and the medical record must reflect this assessment of the patient's condition. Monitoring must continue until it is deemed the individual is stable, and it is deemed they have no emergent medical condition..."

b. The "[ARRMC] Medical Staff Rules and Regulations" dated at last approved by the ARRMC Board on 08/06/2018 included the following articles:
* "Article IV Content and Timeliness of Medical Record Documentation" included a section "Emergency Care" that stipulated "Medical records of patients who have received emergency care will contain the information outlined in this section...This documentation will be the joint responsibility of the responsible practitioners and the Hospital: ...Record of care prior to arrival; Known long-term medications, including current medication, over-the-counter drugs, and herbal preparations; Pertinent history of the injury or illness, including details relative to first aid or emergency care given to the patient prior to his or her arrival at the Emergency Department; Results of the medical screening examination, including significant clinical, laboratory, and radiographic findings; Treatment given, if any; Conclusions at termination of treatment, including final disposition, condition, and instructions for follow-up care..."
* "Article VII Surgical Services" included a section "Pre-Procedural Requirement" that stipulated "The physician responsible for the patient's care shall document in the medical record a history and physical in compliance with the History and Physical Requirements Policy...Informed consent is required in compliance with the Consent, Informed Consent (Asante) Policy..."
* Article VII included a section "Post-Procedural Procedures" that stipulated "An operative procedure report must be dictated immediately after an operative procedure and entered into the record. The operative procedure report shall include...the type of anesthesia/sedation used and name of the practitioner providing anesthesia..."

2. a. Although the ED central log for 10/27/2018 did not include an entry that reflected Patient 22 presented to the hospital for emergency services, the EPIC EHR system did contain documentation that reflected Patient 22 was brought to the hospital from PMMC, a nearby hospital, by EMS ambulance on 10/27/2018 at 2206. The record reflected the patient's course through the ED was as follows:
* At 2206 an ED RN entry reflected "Triage Started."
* At 2208 an ED RN recorded "Brought in by EMS from Providence ER to have a bolt placed in [his/her] skull for ICP. Patient is [on a ventilator] and to go to Portland after."
* At 2208 an ED RN recorded "Suicide Risk Assessment...Unable to Assess...On a vent."
* At 2209 an ED RN recorded "Have you had a fever in the last few days? No;" and "Was the patient educated that weapons are not allowed per policy? Yes." However, one minute prior the RN had recorded inability to assess because the patient was "on a vent."
* At 2210 an ED RN entry reflected "Triage Completed" however there was no documentation of assessment of the patient's physical presentation and condition nor that a triage acuity had been assigned.
* At 2210 an ED RN recorded that cefazolin (Ancef) 2g in D5W IVPB was administered in accordance with a physician's order that was written at 2157, prior to the time of Patient 22's arrival to the ED.
* At 2212 an ED RN recorded only "MD at bedside."
* At 2215 an ED RN recorded only "[Neurosurgeon Physician M] at bedside for procedure. Patient head shaved. Site marked by provider."
* At 2225 an ED RN recorded only "ICP drain placed clear fluid in drain coming out of drain."
* At 2236 an ED RN entry reflected that the RN initiated a "New Bag" of nicardipine (Cardene) in accordance with a physician's order written at 2236, and in another entry at that same time the RN recorded that the nicardipine was infusing "per continuous drip while in procedure."
* At 2239 an ED RN recorded only "Patient has Cardene, Versed and Fentanyl infusing with transfer from Providence. Patient hooked up to ICP monitor, ICP of 8." However, there was no MAR nor readings from the ICP monitor.
* At 2241 an ED RN recorded only "Patient to leave ER to fly to Portland with flight crew."
* At 2250 an ED RN recorded only "Patient discharged with Mercy Flights to transport to [PSVMC in Portland]."
* At 2347 an ED MD recorded only "I was not involved with care of this patient. Patient was transferred from [PMMC] for the neurosurgical service." However, there was no transfer form or other transfer documentation.
* There was no other documentation by an ED MD to reflect that the patient received a MSE.
* The only other physician documentation in the record was an "Operative Note" dictated on 10/27/2018 at 2300 and electronically signed by Physician M four days later on 10/31/2018 at 1758.
* The "Operative Note" included the following:
- "Preoperative Diagnosis: Aneurysmal subarachnoid hemorrhage and hydrocephalus and Glasgow coma score 3T."
- "Postoperative Diagnosis: Aneurysmal subarachnoid hemorrhage and hydrocephalus and Glasgow coma score 3T."
- "Procedure: Right frontal twist drill bur hole for placement of right frontal external ventricular drain with antibiotic impregnated catheter."
- "Description of Procedure: The patient was maintained on the [EMS ambulance transport stretcher] with [his/her] head of the bed elevated...midline/sagittal suture was then palpated and marked...an incision line marked...prepped x2 with ChloraPrep...sterilely draped...skin was incised with a 15 blade and a self-retaining retractor was placed. A twist drill bur hole was then fashioned...dura was then penetrated with a spinal needle and then by a Cushing needle. The ventricular drain was then passed...crystal clear CSF on the first pass. Estimated ICP was less than 10...incision was then closed...sterilely connected to the drainage bag and confirmed to be draining..." The last statement recorded under the "Description of Procedure" was "[Waveform brain activity] was difficult to assess on the [EMS ambulance transport monitor]."
- "Complications: None."
* There was no other documentation in the record of Patient 22 by Physician M or by an ED Physician.

The record of Patient 22 was incomplete and did not conform with ARRMC policies and procedures, including those that required a MSE:
* There was a lack of documentation to reflect that triage and nursing assessment had been completed, including related to the patient's physical condition, to tubes and lines present, and LOC.
* There was no documentation that an MSE had been conducted that included a physical exam and labwork, imaging or other diagnostic testing as appropriate.
* There was no documentation to reflect that the Neurosurgeon Physician M had conducted or consulted on a MSE for Patient 22, or that a H&P had been conducted prior to the operative procedure.
* There were no physician orders or incomplete physician orders for care and services provided including for the ventilator and the "Cardene, Versed and Fentanyl infusing."
* There was no documentation of ventilator care, and management/monitoring of the Cardene, Versed and Fentanyl IV medications infusing during the ED encounter.
* There was no ARRMC consent for care and services, or informed consent for the invasive operative procedure performed.
* There was no documentation of anesthesia or sedation administered to Patient 22 during the operative procedure.
* Further, the documentation in Physician M's Operative Note revealed that the patient was not moved off of the EMS ambulance gurney during the ED encounter; and that care and services were rendered using equipment that did not belong to ARRMC and that had not been subject to ARRMC preventive maintenance to ensure equipment functionality, accuracy and integrity. In fact, Physician M's last notation was that Patient 22's brain activity was difficult to assess on the ambulance monitor. There was no follow-up or verification of Patient 22's brain activity on ARRMC equipment to provide a clear and accurate assessment prior to the patient's discharge from the ED.

b. A written statement in memo/letter form Physician M was dated 11/02/2018. The document contained the following information from Physician M about the care and services rendered to Patient 22 from the time he/she presented to the ARRMC ED:
* "Patient arrival in ED - [Patient 22] arrived approximately 1-1/2 hours after transfer arrangements were initiated. [He/she] was not removed from the transport stretcher and Mercy flights monitors remained in place throughout [his/her] care. Mercy Flight managed [his/her] medications, ventilator, etc. except for antibiotics that were necessary for the procedure. Mercy Flights confirmed no allergies. A right frontal ventriculostomy was placed after the administration of prophylactic antibiotics with a very low intracranial pressure identified upon placement and confirmed with a measurement of 8 after connecting to the transducer. [He/she] was then prepared to return on [his/her] course to Portland and I specifically asked both the Mercy Flights crew and the emergency department personnel if any further paperwork, phone calls were necessary and all stated 'no.' I did contact the [PSVMC] intensivist and informed [him/her] that the ventriculostomy went well with a low ICP and [Patient 22] was on route....I was then contacted by [PMMC ED physician]...Apparently, there was difficulty with the patient flying from Medford to Portland and [he/she] wished my certification the patient could go by ground transport. This would be at the discretion of the receiving facility. It had been my understanding we would not be assuming any direct patient care. I did not admit to the (sic) patient to our hospital and [Patient 22] remained under the care of the transport team throughout [his/her] visit to the emergency department. [PMMC ED physician] asked if I had filled out EMTALA paperwork for the patient transfer to [PSVMC]. Given I had not assumed care...this was not performed. Further paperwork was not requested by the transferring team/Mercy flights."

c. During interview with the VPMA and the ARRMC JD on 1/03/2018 at 1228 they stated that there were no hospital policies and procedures for holding EMS vehicles, equipment and personnel, and none for the provision of hospital care and services on EMS transport gurney/stretchers and monitors, nor for the provision of hospital care and services by EMS personnel.

3. The ED record for Patient 1 reflected that he/she presented to the ED by private vehicle on 06/11/2018 at 1953 with a chief complaint of "Suicidal." The record reflected the patient's course through the ED included the following:
* At 1956 the ED TN recorded "PT states [he/she] feels suicidal. Has a plan to take all [his/her] pills. States [he/she] called psych this afternoon and instructed to come in."
* At 1958 the ED TN recorded "Patient Acuity: 2"
* Between 2026 and 2032 urine and blood were collected for multiple lab orders.
* At 2034 the ED physician placed an order for a "Psychiatric Nurse Consult."
* At 2142 an ED RN recorded "Patient threatens to leave, 'If I don't get my [expletive] anxiety meds!' Pt encouraged to stay, be patient w/ assessment. Reports, 'I believe I'll be safe w/ my fiance. [He/she'll] keep me safe, [he/she's] part of my safety plans. I'm just here to get my prescriptions filled' Patient provided w/belongings, provider notified."
* At 2150 an ED RN recorded "Patient discharged."
* At 2150 the ED physician recorded "ED Disposition set to AMA."
* At 2314 the ED physician's note was electronically signed and included the following:
- "Assessment and Plan: Chief Complaint: Suicidal. Differential Diagnosis includes: Diagnostic Plan: PCU evaluation and then confer with me, laboratory work"
- "ER Course:" was blank.
- "Medical Decision Making: [Patient 1]...presents to the emergency department for evaluation of suicidal ideations. TC nurse did not talk with me in (sic) the patient left. Apparently [first name], psychiatric nurse did an evaluation, felt the patient was safe to leave. I was notified via Dr. halo the patient was leaving and immediately asked [first name] PCU nurse not to let [Patient 1] go but they stated they are to let [Patient 1] leave. Apparently [first name] with PCU states patient contracted for safety with them. They left."
- "Consultations. PCU nurse evaluation."
- "Final MDM Summary. Left against medical device (sic)."
- "Clinical Impression. Left against medical advice."
- "Disposition: Ama."

There was no documentation in the record of a "Psychiatric Nurse Evaluation" ordered by the ED physician nor was there any documentation by the "PCU nurse" referred to in the ED physician's 2314 note.

There was no documentation in the record that the risks of leaving the hospital prior to the completion of the MSE had been reviewed with and understood by the patient on an AMA form or in any other narrative or format.

The ED record of Patient 1 reflected he/she presented to the ED because he/she was "Suicidal," did not receive a complete MSE to determine if a psychiatric EMC existed and had not been informed of the risks of leaving the hospital without one.

4. The ED record of Patient 15 reflected that he/she presented to the ED by private vehicle on 09/21/2018 at 0949 with chief complaint of "...blood in urine x 3 days. Frequency with voiding, back pain." The record reflected the patient's course through the ED included the following:
* At 0956 the ED TN recorded patent had a "history of bladder cancer."
* Between 1059 and 1250 urine and blood were collected for multiple lab orders and imaging testing was conducted.
* At 1215 the ED NP's note was electronically signed and reflected "Chief complaint: 1 week of intermittent hematuria, R flank pain and dysuria. Clots and lots of bleeding today. Pertinent findings: PMH bladder Ca 5 years ago. Has appt Tuesday with Kaiser MD in Ca with CT ordered (visiting here). Plan: rainbow draw, cbc, cmp, CT renal."
* The next entry by an RN was recorded at 1315 and was "No change in patient condition."
* At 1354 the ED NP's note was electronically signed and reflected "Patient was unavailable when called twice. Patient presented back to the window and I reviewed all the results with [him/her]. [He/she] does have an appointment on Tuesday in California with [his/her] doctor and will follow-up then. [He/she'll] return to the emergency room if [he/she] has any further concerns."
* At 1355 the ED NP recorded "Patient dismissed...Patient departed from ED."
* At 1534 the ED NP recorded "ED Disposition set to LWBS after Triage."

There was no documentation in the record that the risks of leaving the hospital prior to the completion of the MSE had been reviewed with and understood by the patient on an AMA form or in any other narrative or format.

The ED record of Patient 15 reflected he/she did not receive a complete MSE to determine if an EMC existed and had not been informed of the risks of leaving the hospital without one.

5. The ED record of Patient 20 reflected that he/she presented to the ED by "Other" means of arrival on 10/17/2018 at 0058 with a chief complaint of "poison oak." The record reflected that the patient's course through the ED was:
* At 0102 the ED TN recorded "Triage Started."
* At 0105 the ED TN recorded "Patient dismissed."
* At 1509 the ED NP recorded "Patient left without being sen (sic) after triage. No studies were ordered" and "ED Disposition set to LWBS after Triage."
* The only other documentation in the EHR was an unsigned note that reflected "Patient's [spouse] is in L and D having a baby and patient doesn't want to wait to be seen."

The documentation by the ED TN and the ED NP inaccurately reflected that the patient left the ED "after" triage as there was no documentation that any aspect of triage had occurred. For example, there was no documentation of vital signs, no documentation of observation and assessment of the affected area on the patient's body, and no documentation of the triage priority assigned after triage has been completed.

There was no documentation in the record that the risks of leaving the hospital prior to an MSE had been reviewed with and understood by the patient on an AMA form or in any other narrative or format.

The ED record of Patient 20 reflected he/she did not receive an MSE to determine if an EMC existed and had not been informed of the risks of leaving the hospital without one.

Based on interview, review of documentation in 3 of 7 medical records of patients who were transferred from ARRMC to another hospital for specialty services ARRMC did not have capability or capacity to provide at that time (Patients 13, 14 and 22), and review of hospital policies and procedures, it was determined that the hospital failed to enforce its EMTALA policies and procedures to ensure that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved.

Findings include:

1. The policy and procedure "EMTALA (ARRMC)" dated as last revised 05/27/2016 contained the following requirements:
* "The Hospital will provide all patients that present to the dedicated emergency department and/or OB with an EMC, a MSE and the treatment which is required to stabilize the EMC, within the capability of the Hospital, or will arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below...Transfers Out: "A patient is identified for inter-hospital transfer...When patient care needs exceed the capabilities of the hospital and; A physician at the receiving facility, has agreed to accept the patient and; The receiving facility has agreed to accept the patient, has available bed space and resources necessary to care for the patient...The following will be completed by ARRMC staff...The patient's transferring physician or designee, or QMP, will call the receiving facility to confirm that both the physician and facility have agreed to accept the patient transfer. Upon decision to transfer the patient, informed consent for the transfer must be obtained from the patient (or patient's family) and documented on ER-32 'Transfer Form.' In the event that the patient cannot give consent because of injury or illness, the physician documents this fact and obtains informed consent form the patient's family if possible. If no one is available to consent for patient and the MD feels the welfare of the patient will be jeopardized if the transfer is delayed, the patient may be transferred without consent. The ARRMC MD must document the benefits vs. risks and clinical need for transfer. ED staff will call and arrange appropriate transportation, designated by the MD or QMP. Proper equipment and appropriately trained EMS personnel must be utilized to handle the problems specific to the patient's condition. The hospital shall, within its capability, provide medical transfers that minimize the risks to the individual's health...Transfers of unstabilized individuals are permitted only pursuant to individual/family request, or when a physician, or a QMP is consultation with a physician, certifies that the expected benefits to the transfer outweigh the risks of transfer. Copies of the following medical record information (relating to the patient's current visit) will be sent with the patient: Face sheet, current MD orders, signed transfer consent, MAR, vital signs, treatments interventions provided, progress notes, history and physical, admit assessment, laboratory reports, operative reports, code status/advanced directives, diagnostic imaging reports and any other pertinent documentation from relevant disciplines. Pending results/documentation shall be called or faxed to receiving hospital as soon as available. Prior to transfer the patient's nurse calls report to receiving facility and documents patient condition at time of transfer, name of transporting agency, method of transport and name of receiving facility and receiving nurse on ER-32 Transfer Form. A copy of this transfer form is also sent with the patient."

2. Refer to the findings for Patient 22 identified under Tag A2406 that reflects that ARRMC had not been responsible as the sending facility to affect an appropriate transfer to PSMVC.

The medical record of Patient 22's ED encounter on 10/27/2018 revealed that it did not contain the "ER - 32 Transfer Form" required by ARRMC policies and procedures, nor was there transfer documentation elsewhere in the record. There was no documentation for Patient 22 of ARRMC physician certification of the transfer benefits versus risks, that another hospital had agreed to accept Patient 22 from ARRMC, that appropriate transportation with qualified personnel had been arranged by ARRMC, that medical records had been sent, and that all other requirements of the hospital's policy and procedure had been completed.

3. The ED record for Patient 13 reflected he/she was brought to the ED on 09/15/2018 at 0340 by the Medford police. The chief complaint was described as "Patient is incoherent and unable to answer questions at this time...Schizoaffective..." The record reflected that the patient's course through the ED included the following:
* A MSE that included a "Psychiatric Consult" was provided.
* Although ARRMC had a BHU, documentation in the "Psychiatric Consult" note dated 09/15/2018 at 1202 reflected "Psychosis...Continue to monitor patient in the PCU, unclear at this time if patient represents an immanent (sic) threat to [him/herself] or others beyond inability to care, given staff reported suicidal comments. No beds currently available on the BHU."
* Stabilizing treatment was provided in the ED PCU while an appropriate BHU bed was located and the documentation reflected that patient continued to exhibit psychiatric behaviors.
* A progress note recorded by the ED PA on 09/18/2018 at 1152 reflected "At this time, placement on the [ARRMC BHU] is not an option due to acuity and will seek placement at other acute facilities in the state...Legal Status: NMI. Patient is a high risk of decompensation and is unable to care for [him/herself]...Transfer to Cedar Hills."
* On 09/18/2018 at 1322 the PA completed and signed the "Patient Transfer Form" that contained the following entries:
- The "Risk of Transfer" was recorded as "none" and there was no documentation to reflect why the provider had determined there were no risks for this patient.
- Although psychiatric secure transportation was provided and contradictory to documentation in the progress note written at 1152 above, the PA recorded "The patient does not have an emergency medical condition."
* On 09/18/2018 at 1702 Patient 13 was transferred to Cedar Hills Hospital in Portland, Oregon.

An on-line distance calculator reflected that Cedar Hills Hospital in Portland, Oregon is 274 miles and five hours and 20 minutes drive time from ARRMC in Medford Oregon.

4. The ED record for Patient 14 reflected he/she was brought to the ED on 09/19/2018 at 1353 by ambulance. The chief complaint was described as "...pt is on a PD hold, bipolar, off [his/her] medications, is hallucinating...PD Office states that the pt is shown signs of homicide and suicide yesterday and today, and that [he/she] was agitated and confrontational to family and the public..." The record reflected the patient's course through the ED included the following:
* A MSE that included a PCU assessment and stabilizing treatment for continued self-harm and psychiatric behaviors.
* Documentation in the "Psychiatric Consult" note dated 09/20/2018 at 1419 reflected "Patient continues to be at risk of harm to self or others, demonstrates an inability to care for self, or is at high risk of decompensation if discharged prematurely and continues to require inpatient hospitalization. [He/she] will be transferred to Cedar Hills hospital for further care as there is no bed available currently on the [ARRMC BHU]."
* On 09/20/2018 at 1040 the PA completed and signed the "Patient Transfer Form" that contained the following entries:
- Although psychiatric secure transportation was provided and contradictory to documentation in the progress note written at 1419 above, the PA recorded "The patient does not have an emergency medical condition."
- The medical records section of the form to reflect what records were sent with the patient was blank and there was no other documentation to reflect that medical records were sent.
* On 09/20/2018 at 1612 Patient 14 was transferred to Cedar Hills Hospital in Portland, Oregon.

An on-line distance calculator reflected that Cedar Hills Hospital in Portland, Oregon is 274 miles and five hours and 20 minutes drive time from ARRMC in Medford Oregon.

5. During interviews with staff present at the time of the EHR reviews for Patients 13 and 14 on 10/25/2018 beginning at 1425 they confirmed the lack of required transfer documentation.


40575

Based on interview, review of documentation of a request from another hospital to transfer a patient to PPMC for specialty services (Patient 18), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure its compliance with recipient hospital responsibilities to accept patients from referring hospital EDs, without delay, for whom it had capability and capacity to treat.

Findings include:

1. a. The policy and procedure titled "EMTALA (ARRMC)" dated as last revised 05/27/2016 contained the following requirements:

* "In no event shall the provision of emergency services be based on or affected by an individual's race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing medical condition, physical or mental handicap, insurance status, sexual orientation, economic status or ability to pay for medical services, except to the extent that a circumstance such as age, sex, preexisting medical condition, or physical or mental handicap is significant to the provision of appropriate medical care to the individual...The hospital may not delay in providing the required MSE, or treatment, in order to inquire about the individual's method of payment or insurance status. The hospital may not seek, or direct an individual to seek, authorization from the individual's insurance company for screening or stabilization services to be furnished by the hospital or licensed practitioner, to an individual until after the hospital has provided the appropriate required MSE and has initiated any treatment that may be required to stabilize the EMC...If...a physician or QMP determines that the individual requires the services of an on-call physician, the on-call physician shall be contacted. The on-call physician shall not refuse to respond to a call on the basis of the individual's race, ethnicity, religion, national origin, citizenship, age, sex, preexisting medical condition, physical or mental handicap, insurance status, economic status, or ability to pay for medical services."

* "Transfers In: When ARRMC is contacted by an outside facility in regard to a transfer the call will be initially transferred to ARRMC's Transfer Admit Center (TAC), and /or the House Supervisor's cell phone...A member of the TAC department will obtain the patient's diagnosis and level of services being requested. ARRMC may decline a patient transfer provided: i. There is no bed available in the appropriate setting. ii. There is insufficient nursing or other staff to meet the care needs of the patient. iii. The service(s) needed are not available at ARRMC...If ARRMC does NOT have capacity, the TAC staff member and/or House Supervisor informs the transferring hospital of the reason why. If an EMTALA violation is suspected, the ARRMC Transfer Report Sheet (100-N-860) is completed. This form is given to the Director of Nursing Operations...If ARRMC DOES have capacity, the TAC staff member and/or House Supervisor (sic) will call the appropriate ARRMC medical staff member. The TAC staff member and/or House Supervisor will verify that the receiving physician is able to receive and care for the patient."

* "The physician may be unable to accept the patient based on one of the following: a. The patient is unstable and the transferring hospital must stabilize the patient prior to transfer b. The physician is unable to provide the services needed c. The physician's workload is at maximum capacity and renders them unable to provide the care needed. If a physician fails to respond or declines the transfer for reasons other than the approved reasons and appears to have capacity: a. The TAC staff member will communicate this to the House Supervisor who will confer with the appropriate Medical Staff Chain-of-Command Physician Leader(s) in accordance with the attached algorithm...The TAC staff member or the House Supervisor will complete the transfer tracking form and submit it to the Nursing Operations Manager, Nursing Operations Director and/or the VP of Nursing."

b. The "[ARRMC] Medical Staff Rules and Regulations" dated at last approved by the ARRMC Board on 08/06/2018 included the following articles:

* "Article XI Emergency Services" included a section "On-Call Responsibilities" that reflected only "It is the responsibility of the scheduled on-call physician to respond to calls from the Emergency Department in accordance with Hospital policies and procedures." There was no other language related to on-call physician responsibilities.

* "Article XIII Transfer To and From Other Facilities" included a section "Accepting Patient Transfers" reflected "When a request is made to accept the transfer of a patient from another facility the Transfer and Admission Center (TAC) shall be contacted to determine whether there is adequate capability and capacity to treat the patient.

c. The "[ARRMC] Emergency Department On-Call Policy" dated as last approved by the ARRMC Board on 08/07/2017 included the following:

* Call responsibilities begin at 7:00 a.m. on assigned days and continue until 7:00 a.m. the following day. The on-call physician must carry a smartphone or alphanumeric pager capable of receiving text messages during these hours. This will be the primary mechanism that is used to contact on-call physicians...The on-call physician may not inquire about a patient's insurance status or ability to pay...If an on-call physician determines that his or her circumstances have changed and that the physician cannot meet his or her call obligations that have been scheduled (either for an entire day or a portion of that call day), the physician shall immediately contact the page operator and the ED so that the back-up plan can be implemented..."

d. The policy and procedure titled "Provision of Patient care, ARRMC - Operational Plan" dates as last revised 04/11/2017 described the hospital's capabilities. It contained a list of "Services Provided" that included "Neuroscience and Orthopedics, Inpatient..." and "Surgery, In and Outpatient."

2. a. The "ARRMC Medical Staff Roster" dated 10/25/2018 reflected that Physician E's specialty was Surgery and Orthopedics, he/she has been on staff at ARRMC since 09/23/2002 and his/her current status "Active."

b. An "Emergency Department Physician Specialty Services Agreement" between ARRMC and "Southern Oregon Orthopedics, Inc." was signed by Physician E on 12/03/2011 and included the following stipulations:
* "On-Call Duties. While Physician is scheduled to be on call, Physician shall be reachable promptly at previously designated local telephone number(s)."
* "Nondiscrimination. Group shall not differentiate or discriminate in performing services under this Agreement on the basis of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age or payer, or on any other basis prohibited by law."
* "Compliance With Laws. Group shall comply with all applicable laws, ordinances, codes and regulations of federal, state and local governments, including without limitation the Emergency Medical Treatment and Active Labor Act, as amended, and the regulations thereunder, and any laws that require Group to disclose any economic interest or relationship with Hospital."

c. The "Southern Oregon Orthopedics" specialty physician on-call list for October 2018 reflected Physician E was scheduled for Orthopedics call on 10/09/2018 and Physician L was scheduled for "back up call" on that same date, 10/09/2018.

3. A "Transfer Admit Center Intake Form" reflected that a call was received from "Sutter Coast ED" on 10/09/2018 at 1336. The author of the entries on the form was not evident as it was not signed and the space for "TAC RN Name" was blank. The form contained the following information:
* In the "Patient's Name" space Patient 18's name was recorded.
* In the "Diagnoses" space "[Right] hand deep tissue infection" was recorded.
* In the "Admitting Physician" space Physician E's name was recorded with a line drawn through that name, and next to that Physician L's name was recorded with a line drawn through that name.
* In the "Time MD was paged" space the time "1339" was recorded with a line drawn through that time, and next to that was recorded "1437" with the first name of an unknown individual written below that time.
* In the "Time MD Returned Call" space the time "1500" was recorded.
* In the "Transfers Only" space was a phone number.
* In the "Transferring Physician" space the name of a PA was recorded.
* In the "Physician's Representative" space was the first name of an unknown individual.

There were no other entries recorded on the form and the following spaces were blank:
* "TAC RN Name"
* "Person Spoke with"
* "Callback #"
* "Age"
* "Gender"
* "Phone #"
* "3 Way Conversation Complete: No Yes N/A"
* "Callback #"
* "Time Patient was accepted/denied/delayed"
* "Fax the following to [fax number]: Face Sheet Admit Orders"
* "Mode of Transportation: Air Ambulance Private Vehicle"
* "Diagnostics on PACS: No Yes N/A"
* "TPA?"
* "Dr Orders"
* "Admission Status"
* "Unit Preference"
* "Special Room Request"
* "Special Equipment"
* "Comments/Delay Reasons"
* "Admission Status..."

4. Undated notes documented by a TAC RN regarding Patient 18 reflected the following sequence of communications and events:
* "1336-Call received from [SCH ED staff] requesting if we had a hand specialist on call. I shared that I would call Ortho to see and asked [him/her] to push any films to PACS. [He/she] had already done so...provider was [SCH ED PA]."
* "1339-Once I saw the films were available I paged Orthopedics and noted on the schedule that [Physician E] was on call."
* "1437...I spoke with [first name] whom I believe is one of the Ortho office staff and asked to speak with [Physician L] who was back up call since I had not heard from [Physician E] in an hour."
* "1500-I got a call back from [Physician E] and explained the need for transfer. While I set up the conference call [he/she] pulled up the films. [SCH ED PA] and [Physician E] discussed the patient and I remember expressions about how very swollen the hand was and that it was something [Physician E] was very impressed with. I honestly do not remember how it came up that the patient was on California Medi-Cal but do remember that [Physician E] said that their practice did not accept that insurance and voiced that the patient would be responsible for the bill. [He/she] recommended that Sutter look for a California facility that has a hand specialist and who accepts the patient's insurance so that [he/she] would not incur the expenses [he/she] would if [he/she] came to Medford. I did not hear back from Sutter about this patient."

In addition to the prohibited inquiries and communications about the patient's insurance, the TAC RN note reflected that Physician E did not respond to the call from the TAC promptly, for approximately one hour and twenty minutes. During interview with the VPMA on 10/26/2018 at 0930 he/she stated that the on-call medical staff must respond to calls from ARRMC within 30 minutes.

5. During interview with Physician E on 10/25/2018 beginning at 1215 he/she provided the following information:
* Physician E had been employed with ARRMC since 2002 and had been taking call as scheduled since that time.
* Physician E was scheduled as on-call for Orthopedics on 10/09/2018 at 0700, to 0700 the next day, 10/10/2018.
* Physician E received a call from the TAC RN in the early afternoon and participated in a three way call with a SCH ED PA about Patient 18's condition.
* Physician E reported that the PA said that SCH had a patient with a hand abscess that had been treated for the past three days with antibiotics, and the PA reported that the SCH Orthopedic physician stated the patient needed an I&D by a hand surgeon.
* Physician E stated that he/she assumed the PA was requesting a transfer to ARRMC since the call came through the TAC.
* Physician E stated that it was his/her understanding that ARRMC had capacity to provide care for Patient 18.
* Physician E stated that he/she told the PA that because SCH was in California that they may want to look into options for finding beds in California "for the patient's benefit" and that "if [Patient 18's] health insurance was subsidized by California...that may benefit the patient economically."
* Physician E stated that the PA said he/she would "look into it" and that was the end of the conversation and he/she had no further contact with SCH or the ARRMC TAC RN.
* Physician E reported that two hours later he/she received a call from PMMC, another hospital in the same city at which Physician E was also on-call on 10/09/2018. The call was a transfer inquiry from SCH about Patient 18.
* Physician E stated that he/she accepted Patient 18 to be transferred for Orthopedic specialty services to PMMC.
* Physician E stated that he/she "didn't say no" to SCH's request to transfer Patient 18 to ARRMC. However;
* Physician E stated the he/she "did not" accept the patient for transfer to ARRMC.

6. Review of the "24-Hour House Supervisor Report for the month of October 2018," the log that contained the record of transfer inquiries from other hospitals, revealed no entries for Patient 18 on 10/09/2018. During interview with the DON on 10/26/2018 at approximately 1004 he/she confirmed the lack of documentation about Patient 18 on the supervisor report log.

7. Review of the ED Central Log revealed no entries to reflect that Patient 18 had been transported and presented to ARRMC for care and services on 10/09/2018.

8. Review of the EPIC EHR system revealed no records to reflect that a transfer inquiry from SCH had been made for Patient 18 on 10/09/2018, or that Patient 18 had received care and services at ARRMC on 10/09/2018 or on any other date. During interview with the DON on 10/26/2018 at approximately 1004 he/she confirmed the lack of any records related to Patient 18 in the ARRMC EPIC EHR system.

9. Although ARRMC had capability and capacity to provide further exam and stabilizing treatment for Patient 18, on-call specialty Physician E failed to accept the patient for transfer to ARRMC. Further, Physician E's failure to respond to the initial call from the ARRMC TAC in a prompt and timely manner, and his/her subsequent failure to accept the patient for transfer to ARRMC causing the sending hospital to attempt to affect the needed transfer elsewhere, created a delay in the provision of care and services for Patient 18.









































40575