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Based on observation, interview, review of documentation in 4 of 4 medical records of patients who presented to the hospital for emergency services and left without an appropriate MSE conducted by qualified staff (Patients 4, 8, 15 and 19), review of documentation in 7 of 7 medical records of patients who were transferred from HDH to other hospitals for services not available at HDH (Patients 5, 6, 7, 9, 11, 12 and 16), review of staff training records, review of medical staff rules and regulations, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and enforce its EMTALA policies and procedures to ensure compliance in the following areas:
* Required posting of EMTALA signs.
* Medical screening examinations.
* Appropriate transfers of patients.

Findings included:

1. Regarding posting of EMTALA signs refer to the findings identified under Tag C2402, CFR 489.20(q).

2. Regarding medical screening examinations refer to the findings identified under Tag C2406, CFR 489.24(a) and (c).

3. Regarding appropriate transfers refer to the findings identified under Tag C2409, CFR 489.24(e).

Based on observation, 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 by individuals entering the ED, and where individuals waited for examination and treatment.

Findings include:

1. The p/p titled "EMTALA Signage," dated effective 02/15/2013 reflected:
* "The emergency department and any other place likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas of the hospital other than the traditional emergency department such as the admitting area and waiting rooms must conspicuously post appropriate signage notifying the individuals of their right to an MSE and stabilizing or treatment for an EMC and women in labor as specified under EMTALA as well as information indicating whether or not the hospital participates in the Medicaid program."
* "The hospital must post signage that, at a minimum, meets the following requirements...Signage must be conspicuously posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than the traditional emergency department (e.g., admitting area, waiting rooms, labor and delivery)..."
* "Signage must be readable from anywhere in the area..."
* "Wording must be clear and in simple terms in a language(s) that is(are) understandable by the population the hospital serves."

2. During a tour of the ED with the CNO on 08/16/2019 beginning at 1045 the following observations were made:
* The main ED waiting room located outside the ED had 6 chairs and a recessed registration desk.
* One large EMTALA sign was observed posted in the hallway on a wall on the other side of the recessed registration desk. The EMTALA sign was not visible from the registration desk or the 6 chairs in the ED waiting room. In addition, observation of individuals as they entered the ED from the direction of the ED waiting room and registration desk reflected the EMTALA sign was posted on the wall behind the individuals as they entered the ED, and therefore was not likely to be noticed.
* There were no other EMTALA signs posted in the ED waiting room.

3. During an interview with the CNO on 08/16/2019 at 1050 during the tour of the ED, he/she acknowledged the lack of visible EMTALA signage in finding 2.

Based on interview, review of documentation in 4 of 4 medical records of patients who presented to the hospital for emergency services and left without an appropriate MSE conducted by qualified staff (Patients 4, 8, 15 and 19), review of staff training records, review of medical staff rules and regulations, and review of policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce policies and procedures to ensure the provision of clear, complete, and appropriate MSEs for all individuals who presented to the hospital for emergency services.
* MSEs for patients were not conducted within the capabilities of the hospital and were not conducted by LIPs, but rather by RNs not qualified to perform MSEs.
* ED staff sent patients home before an evaluation for an EMC was completed.
* ED staff arranged for patients to be seen in a clinic before an evaluation for an EMC was completed.
* Patients were not advised of the risks of leaving the hospital before an evaluation for an EMC was completed.

Findings included:

1. a. The "Rules & Regulations Medical Staff of Harney District Hospital," undated reflected the following references to MSEs:
* "General Rules Regarding Emergency Services...The intent of the hospital and medical staff is to treat patients presenting to the hospital's Emergency Department and Obstetrics Department in accordance with current state/federal law regarding medical screening examinations, treatment, stabilization and transfer. All active staff physicians, their employed Physician Assistants or Nurse Practitioners who are also credentialed by the hospital, and the hospital employed Registered Nurses are certified to perform the medical screening examinations. The implementation procedures for such screening examinations and record requirements are detailed in the Nursing Department's Policy and Procedure Manual."

b. The "Nursing Department" p/p titled "Medical Screening Exam (MSE)," dated effective 09/21/2006 reflected the following references to MSEs:
* "All individuals presenting to the hospital premises requesting emergency examination or treatment shall be offered a medical screening examination based on the presenting signs and symptoms to determine if the individual has an emergency medical condition."
* "The MSE must be sufficient to determine if an emergency medical condition exists, including whether a woman is in labor. A triage exam is not inclusive enough to meet criteria for an appropriate MSE. All resources available to the hospital will be used to perform an MSE (i.e. laboratory tests, radiology tests, scans, lumbar puncture, etc.) as routinely available to the Emergency Department."
* "An Emergency Medical Condition shall be defined as a condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual (or unborn child) in serious jeopardy...Serious impairment to bodily function...Serious dysfunction of any bodily organ or part..."
* "If the patient is seeking psychiatric treatment the screening should include an assessment, suicidal or homicidal attempt or risk, orientation or assaultive behavior that would indicate a danger to self and/or others."
* "The MSE must be performed by a qualified medical person (physician or registered nurse). Registered nurses who have been oriented to the Emergency Department may perform an MSE. The nurse must first undergo training and demonstrate competency in performing an MSE. Competency will include evaluation by a preceptor and a written test."
* "If the on duty Registered Nurse is performing the MSE, a physician must be readily available in house or by telephone to consult with the nurse and assist in any way needed. If additional tests are needed to determine if an emergency medical condition is present, the nurse may obtain a telephone order or use established standing orders..."
* "Procedure...Patient presents to hospital requesting treatment...Obtain patient's name and DOB...Notify Admitting that patient is here for MSE...Admitting to input patient data into computer system for registration...Perform MSE...If the patient is determined to have an emergent medical condition, notify admitting...If the patient determined to NOT have an emergent medical condition, patient may be discharged from the ED..."
* "Compliance with EMTALA requires that the MSE and stabilization treatment of all individuals with similar medical conditions are consistent."
* "The MSE is considered an ongoing process. The ED record must document continued monitoring according to the patient's needs until he/she is stabilized or appropriately transferred."
* "Once a patient is screened and it is determined that the presenting condition is non-emergent, Harney District Harney (sic) EMTALA obligation ends when (sic) an emergency medical condition exists and the patient is appropriately transferred to another facility or admitted to the hospital for further stabilizing treatment. If it is determined that emergent medical condition does not exist, the patient may be discharged from the ED and instructed to follow up accordingly with their primary care provider."

c. The "Nursing Department" p/p titled "Patient Triage in the Emergency Department," dated effective 07/01/2017 reflected the following:
* "Purpose: To define standards by which patients will be triaged when presenting to the Emergency Department (ED) for medical care according to EMTALA guidelines."
* "Triage determines the order in which patients will be seen, not the presence or absence of an emergency medical condition."
* "An RN will triage all patients arriving to the ED to identify life-threatening conditions and prioritize patients according to acuity."
* "Triage is performed by RNs who have successfully completed ED orientation. If an RN is still in training, he/she must have a preceptor overseeing their triage process."
* "Full patient assessments shall not be done during triage; only information required to assign a triage level...primary nurse is responsible for completing the remaining assessment...The full evaluation shall include...History of presenting problem or symptom...Vital signs, allergies, current medications, current tetanus status, height/weight...Physical assessment...Use of tobacco/alcohol/illicit drugs...Medical/Surgical history...Immunization status...Last menstrual period...Nursing observations...Glasgow coma scale..."
* "All patient information is documented in the patient's medical record."
* "All life and/or limb threatening emergencies shall be seen by the physician on duty immediately."
* "...ED RN shall then make a decision as to the order in which the patient shall be seen...based upon the information gathered in the initial evaluation as noted above, with more critical patients being seen first."

d. The p/p titled "AMA Against Medical Advice," dated effective 08/30/2000 reflected:
* "This policy shall establish proper actions to be taken when a patient wishes to act against medical advice within the context of patient treatment at Harney District Hospital (HDH)."
* "The nurse and/or physician shall discuss with the patient and/or family the potential complications that may occur if the patient does not follow medical advice. Circumstances of patient not following medical advice include, but are not limited to...Leaving AMA...Refusing transfer to higher level facility...Refusal to consent to examination or treatment for emergent medical condition..."
* "Staff shall document patient's refusal in the medical chart using exact statements when possible. If the patient wishes to leave AMA after explanation of potential consequences and/or complications the staff shall request that the patient sign the AMA form. A copy shall be given to the patient and the original shall be retained in the medical record."
* "Appropriate discharge instructions shall still be given to the patient as able. Documentation of method used and patient's level of understanding shall be placed in the medical record. Staff shall document the patient's condition prior to leaving the facility."
* "In the event that a patient refuses recommended medical treatment while in the hospital, the physician shall be notified by the nurse. The AMA form shall be initiated and the original shall be placed in the patient chart. A copy shall be given to the patient. All consequences/complications of the patient's decision shall be explained to the patient."
* "If a patient refuses to sign the AMA form in any of the above circumstances, this shall be noted on the form and in the nurse's notes."

2. a. During an interview with the CNO on 08/15/2019 at 1700 the CNO stated that RNs who worked in the ED conducted MSEs. The CNO provided the following information in response to a request for the process the hospital used to qualify RNs to conduct MSEs:
* The CNO stated that RNs who performed MSEs were required to first undergo training and demonstrate competency in performing MSEs. The CNO stated the required training and competencies were as follows:
- "Read and understand" a MSE training document and complete an MSE post test.
- A completed ED orientation, preceptor evaluation, and preceptor "sign off."

b. The following documents were provided by the CNO in response to a request for the training and competency documents the hospital used to qualify RNs to conduct MSEs:
* A training document titled "MSE (Medical Screening Exams)" and a "MSE Post-Test," both dated "12/2006."
* A multi-page ED orientation and preceptor evaluation document titled "Harney District Hospital Emergency Room Skills Checklist" that included numerous sections. Examples of the sections included: "STEMI and Non-STEMI Protocol...Acute CVA and stroke protocol...guiac for occult blood...Appendicitis...Gunshot/Stab wound...Multiple fractures...Shock...Traumatic amputation...child abuse/neglect...Respiratory Distress...Fetal monitoring...Violent patient...Hold room protocol...Eye tray...MSE and documentation...SANE patient...Triage calls...Transfer process & EMTALA..." The checklist had columns with spaces next to each of the sections for recording the "Preceptor," "Orienteer," "Date," and "Methodology."

3. a. The ED record of Patient 19 reflected the patient presented to the ED on 07/16/2019 at 0859 with an "Arrival Complaint" of "Motor Vehicle Accident."
* On 07/16/2019 at 0911 RN 4 documented "Pain Assessment: No/denies pain...Vital Signs...Heart Rate: 91...Resp: 18...BP: 184/122!...Temp...97.8 [degrees] F...SpO2: 94%"
* On 07/16/2019 at 0914 RN 4 documented "Vital Signs...BP: 179/104..."
* On 07/16/2019 at 0923 the record reflected "Event...First Provider Evaluation" and "User...[physician name]." The "Details" section was blank. There was no other physician or LIP documentation in the record.
* On 07/16/2019 at 0925 RN 4 documented "Departure Condition: Good" and "Mobility at Departure: Ambulatory." The spaces for "Departure Acuity," "Patient Teaching," and "Departure Mode" were blank.
* The ED Disposition" reflected:
- "LWBS after Triage"
- "Condition [blank space]"
- "Comment Discussed with [physician]. To be seen in clinic by [him/her]."
* "ED Treatment Team" section reflected "None."
* "ED Notes Report" section reflected "Current Visit Notes."
* "Results," "ECG Results," and "ED Diagnosis" sections reflected "None."
* "Home Medications" section reflected "No medications on file."
* "Medications Administration...," and "ED Prescriptions" sections reflected "None."
* "Tetanus Up To Date..." section reflected "None."
* "Sexually Active," and "Activities of Daily Living" sections reflected "Not Asked."
* "Social Documentation" section reflected "No social documentation on file."
* "Family Medical History" section reflected "None."
- "Consents" section reflected "No documents found"
* "Discharge Orders," "Discharge Instructions," "Discharge References/Attachments," and "Follow-up Information," reflected "None."

The record was unclear, incomplete, and lacked documentation that reflected an MSE was conducted within the capabilities of the hospital by qualified staff and in accordance with hospital policies and procedures. For example:
- RN 4 was not qualified to conduct MSEs as identified in findings c. and d. below.
- There was no documentation by a physician or other LIP.
- There were no physician or other LIP orders.
- There was no documentation of a MSE including no physical exam, lab testing, X-ray or other diagnostic tests or procedures.
- Although the record reflected the patient's blood pressure was 184/122! and 179/104, there was no reevaluation of the patient's blood pressure prior to departure.
- There was no documentation that RN 4, a physician or other LIP determined whether the patient had an EMC.
- Although RN 4 documented "Discussed with [physician] To be seen in clinic by [him/her]" and "LWBS after Triage," there was no documentation that reflected the patient refused an MSE and was informed of the potential risks and/or consequences/complications of leaving without an MSE. There was no information about the circumstances that resulted in the patient leaving the ED to be seen in a clinic without an MSE .

b. During an interview and review of the ED record with the CNO on 08/15/2019 at 1900, the CNO confirmed the record reflected:
* RN 4 was the only RN that documented in the record.
* No documentation of physician or other LIP notes.
* No documentation of a MSE including no physical exam, labs, imaging or other diagnostic tests or procedures.
* No determination of whether the patient had an EMC.
* No documentation that the patient refused a MSE.

c. Review of staff training records for RN 4 reflected the hospital's policies related to MSEs were not carried out as RN 4 had not completed the training and competencies required to conduct MSEs. RN 4's training records reflected:
* The required "Harney District Hospital Emergency Room Skills Checklist" in finding 2. b. dated "Start Date: 10/23/18" was incomplete. The spaces for "Preceptor," "Orienteer," "Date," and/or "Methodology" were blank for approximately 37 sections including but not limited to: "Assess reflex/motor deficits...Closed head injury...Acute CVA and stroke protocol...Overdose...Appendicitis...Renal Trauma...Hypothermia...Major trauma...Minor trauma...Multiple fractures...Shock...Traumatic amputation...MSE and documentation...SANE patient...OB triage..."

d. During an interview with the CNO on 08/16/2019 at 0955, RN 4's staff training records were reviewed. The CNO provided the following information that reflected RN 4 was not qualified to conduct MSEs:
* The CNO stated he/she had no documentation that RN 4 completed the required "MSE (Medical Screening Exams)" training and "MSE Post-Test."
* The CNO confirmed RN 4's "Harney District Hospital Emergency Room Skills Checklist" was incomplete.
* The CNO acknowledged RN 4 did not have the required MSE training and competencies, and therefore RN 4 was not qualified to conduct MSEs in accordance with hospital policies.

4. a. The ED record of Patient 4 reflected the patient presented to the ED on 02/17/2019 at 1727 with an "Arrival Complaint" of "blood in stool" and acuity "Urgent."
* On 02/17/2019 at 1734 RN 1 documented "Chief Complaints Updated" was "...Black or Bloody Stool."
* On 02/17/2019 at 1735 the triage notes documented by RN 1 reflected "Patient had a BM today with several visible blood clots. The stool was bright red in color. [He/she] called the phone triage line and was instructed to come to the ED."
* On 02/17/2019 at 1736 RN 1 documented the patient's vital signs were temperature 98.5, pulse 99, blood pressure 134/73, and respirations 14.
* On 02/17/2019 at 1749 RN 1 documented:
- "Pain Assessment: 0-10 Pain Score: 2"
- "Pain Type: Chronic pain"
- "Pain Location: Abdomen"
- "Pain Descriptors: Cramping (baseline)"
- "Restart Pain Assessment Timer: Yes"
The "General Assessment" by RN 1 on 02/17/2019 at 1749 consisted of:
- "General Appearance: No acute distress...Respiratory: Lungs clear to auscultation...Skin Condition/Temp: Warm; Dry...Level of Assistance: Independent...Cardiac Regularity: Regular...GI/GU: Normal inspection (Reports bloody stool with several blood clots this evening.)."
* "ED Treatment Team" section reflected Provider [RN 1]." No other individuals were listed.
* "ED Notes Report" section reflected "Current Visit Notes."
* "Results," "ECG Results" and "ED Diagnosis" sections reflected "None."
* "Home Medications" section reflected "No medications on file."
* "Medications Administration..." and "ED Prescriptions" sections reflected "None."
* "Consents" and "Tetanus Up To Date..." sections reflected "None."
* "Alcohol use Status," "Drug Use Status," "Sexual Active," and "Activities of Daily Living" sections reflected "Not Asked."
* "Discharge Orders," "Discharge Instructions," "Discharge References/Attachments," and "Follow-up Information" reflected "None."
- "Comment Case reviewed with [physician]. Patient sent home with instructions to follow up at the clinic early this week. If [he/she] continues to have bloody BM's, becomes lightheaded, dizzy, has increased abdominal pain, or a rigid abdomen come back to the ED right away or call EMS."
* On 02/17/2019 at 1754 RN 1 documented "Patient discharged...ED Disposition...LWBS after Triage..." This was the last entry by RN 1.

The record was unclear and inconsistent, and lacked documentation that reflected an MSE was conducted by qualified staff and within the capabilities of the hospital in accordance with hospital policies and procedures. For example:
- RN 1 was not qualified to conduct MSEs as identified in finding c. below.
- There were no physician or other LIP orders.
- There was no documentation by a physician or other LIP.
- There was no documentation of a guiac test for occult blood, lab testing, X-ray or other diagnostic tests or procedures.
- The record unclearly reflected "GI/GU: Normal inspection (Reports bloody stool with several blood clots this evening.)." It was unclear what was meant by "normal inspection" with respect to the reported "bloody stool with several blood clots this evening." There was no documentation of a physical examination of the patient's "GI/GU" or abdomen.
- The record reflected "black or bloody stool" and "...several visible blood clots...stool was bright red in color." It was unclear if the patient's stool was black, bright red, had visible blood clots or some or all of those. There was no documentation that reflected duration, frequency or amount of stools.
- The record reflected "Restart Pain Assessment Timer: Yes." There was no further information that reflected what this meant with respect to the patient's abdominal pain and report of bloody stool. There was no reassessment of the patient's abdominal pain.
- The record reflected "Home Medications...No medications on file." There was no evaluation of the patient's current medications as required by hospital policy, including potential blood thinning medications with respect to the patient's reported bloody stool.
- The record reflected no information related to "Alcohol use Status" and "Drug Use Status" required by hospital policy.
- There was no Glasgow coma scale required by hospital policy.
- The record reflected "Case reviewed with [physician]...sent home with instructions to follow up at the clinic..." However, there was no documentation that RN 1, a physician or other LIP determined whether the patient had an EMC.
- Although RN 1 documented "LWBS after Triage," there was no documentation that reflected the patient refused an MSE and was informed of the potential risks and/or consequences/complications of leaving without a MSE. There was no documentation that the patient was informed of the hospital's EMTALA obligation to conduct an MSE.

b. During an interview and review of the ED record with the CNO on 08/15/2019 at 1750, the CNO confirmed the record reflected:
* RN 1 was the only RN that documented in the record.
* No documentation of labs, imaging or other diagnostic tests or procedures.
* No documentation of physician or other LIP notes.
* No determination of whether the patient had an EMC.

c. During an interview with the CNO on 08/16/2019 at 0945, the CNO provided the following information related to the lack of RN 1's qualifications to conduct MSEs:
* The CNO stated he/she had no documentation that RN 1 completed the required "MSE (Medical Screening Exams)" training and "MSE Post-Test."
* The CNO stated he/she had no documentation that RN 1 completed the required "Harney District Hospital Emergency Room Skills Checklist."
* The CNO acknowledged RN 1 did not have the required MSE training and competencies, and therefore RN 1 was not qualified to conduct MSEs in accordance with hospital policies.

5. a. The ED record of Patient 8 reflected the patient presented to the ED on 04/26/2019 at 2101 with a chief complaint of anxiety.
* On 04/26/2019 at 2107 RN 2 documented the "General Complaint" consisted of:
- "Onset: Today"
- "Chronicity: Chronic"
- "Activity at Onset of Symptoms: None"
- "Pain Related to Recent Injury: No"
* On 04/26/2019 at 2114 the triage notes documented by RN 2 reflected "Patient presented to ER stating 'I'm having anxiety attack'. Patient in no distress. Patient is restless. Patient states [he/she] usually takes lamictal but ran out of the medication and forgot to get [his/her] prescription filled today after seeing the doctor."
* On 04/26/2019 at 2116 RN 2 documented a pain assessment and vital signs.
* On 04/26/2019 at 2118 RN 2 documented "Care Provider Communication: [Physician name] made aware via telephone."
* On 04/26/2019 at 2125 RN 2 documented "Departure Condition: Good...Patient Teaching: Verbalized understanding...Mobility at Departure: Ambulatory...Departure Mode: By Self" and "ED Disposition...LWBS after Triage."
* The "ED Disposition" section reflected "Patient MSE'd to see PCP at clinic...patient agreed to go home and take over the counter sleeping aid that [he/she's] used in the past. Patient is to see provider at symmetry care for an evaluation and for medication compliance. Patient also states that [he/she] will have [his/her] prescription for lamictal filled in the morning to take..."

The record was unclear and inconsistent, and lacked documentation that reflected an MSE was conducted within the capabilities of the hospital by qualified staff and in accordance with hospital policies and procedures. For example:
* RN 2 was not qualified to conduct MSEs as identified in findings c. and d. below.
* There was no documentation by a physician or other LIP.
* There were no physician or other LIP orders.
* There was no documentation of lab testing, X-ray or other diagnostic tests or procedures.
* The record reflected "Pain Related to Recent Injury: No." There was no further information about a "Recent Injury."
* The record reflected "Patient...stating 'I'm having anxiety attack...no distress...restless." It was unclear how the patient who reported having a panic attack and was restless, was "in no distress."
* The record reflected "Patient...takes lamictal but ran out of the medication." There was no further information about the medication the patient "ran out of." For example, there was no documentation that reflected the indication, dosage or how long the patient had been out of medication.
* The record unclearly reflected "Patient MSE'd to see PCP at clinic..." There was no further information that reflected what that meant with respect to the hospital's EMTALA obligation to conduct an MSE.
* Although the record reflected "patient agreed to go home" and "LWBS after Triage," there was no documentation that reflected the patient refused an MSE or that the patient was informed of the risks and/or potential complications/consequences of leaving without an MSE. There was no documentation the patient was informed of the hospitals's EMTALA obligation to conduct an MSE.
* There was no documentation that RN 2, a physician, or other LIP determined whether the patient had an EMC.

b. During an interview and review of the ED record with the CNO on 08/15/2019 at 1935, the CNO confirmed the record reflected:
* RN 2 was the only RN that documented in the record.
* No documentation of labs, imaging or other diagnostic tests or procedures.
* No documentation of physician or other LIP notes.
* No determination of whether the patient had an EMC.

c. Review of staff training records for RN 2 reflected the hospital's policies related to MSEs were not carried out as RN 2 had not completed the training and competencies required to conduct MSEs. RN 2's training records reflected:
* The required "Harney District Hospital Emergency Room Skills Checklist" dated "Start Date: [blank]" was incomplete and numerous sections were not signed off by the preceptor. For example:
- The spaces for "Preceptor," "Orienteer," "Date," and "Methodology" were all blank for the following sections: "Antepartum/postpartum complications...OB Triage procedure and documentation...Review gyne tray...Preparing gurney for gyne exam...Fetal monitoring."
- The spaces for "Orienteer" were blank for 57 additional sections including but not limited to "Assess reflex/motor deficits...Assessing visual and communication deficits...Glasgow Coma Scale...Acute CVA and stroke protocol...Overdose...Violent patient & Alert tab...MSE and documentation...SANE patient...Identify signs/symptoms of physical or sexual abuse...Transfer process & EMTALA...Burn Center Policy..." Although those sections were initialed by a preceptor and dated, they were all dated 06/01/2019 which was after Patient 8's ED visit on 04/26/2019.
- The last page of the checklist had spaces for recording "Completed Date:," "Supervisor Signature," and "Orientee Signature." Those spaces were all blank.

d. An interview and review of RN 2's staff training records was conducted with the CNO on 08/16/2019 at 0940. The CNO provided the following information related to the lack of RN 2's qualifications to conduct MSEs:
* The CNO stated he/she had no documentation that RN 2 completed the required "MSE (Medical Screening Exams)" training and "MSE Post-Test."
* The CNO confirmed RN 2's "Harney District Hospital Emergency Room Skills Checklist" was incomplete and was not signed off by the preceptor.
* The CNO acknowledged RN 2 did not have the required MSE training and competencies, and therefore RN 2 was not qualified to conduct MSEs in accordance with hospital policies.

6. a. The ED record of Patient 15 reflected the patient presented to the ED on 06/25/2019 at 1329 with a chief complaint of shortness of breath.
* On 06/25/2019 at 1348 the physician documented "Assign Attending [physician name], MD assigned as Attending...Assign Physician." There was no other physician or LIP documentation in the record.
* On 06/25/2019 at 1356 RN 3 documented "Respiratory Complaint Onset: 3-7 days ago Chronicity: New...Signs and Symptoms: SOB; Non-productive cough..."
* On 06/25/2019 at 1357 RN 3 documented "Pt (sic) been having swelling in hands and SOB for approximately a week per pt report. Pt was checked in clinic and was hypoxic. Sent to ER for evaluation."
* On 06/25/2019 at 1358 RN 3 documented:
- "Vital Signs...Heart Rate: 59...SpO2: 92%"
- "Pain Assessment 0-10 Pain Score: 9"
- "Pain Type: Chronic pain"
- "Pain Location: Leg"
- "Pain Orientation: Left"
* On 06/25/2019 at 1401 RN 3 documented "Focused Assessment...Airway (WDL)...Breathing (WDL)...Circulation (WDL)...Disability (WDL)." There was no assessment of the patient's breath sounds. There was no physical assessment of the patient's hand swelling or painful left leg.
* On 06/25/2019 at 1415 RN 3 documented "SpO2: 93%..." This was the last documentation of the patient's SpO2%.
* The next documentation by RN 3 was on 06/25/2019 at 1500. It reflected "Pt became irritable and stated [he/she] was 'fine' and was 'tired of waiting'. Pt left the ER and was found out in the waiting room. RN encouraged [him/her] to come back to [his/her] room, but pt refused. Pt stayed long enough to sign an AMA Form. Pt's oxygen remained above 89% while in the ER. Pt denied SOB while [he/she] was in ER."

* An AMA form titled "Patient Decisions Against Medical Advice" signed by the patient and dated 06/25/2019 did not include the risks of refusing a MSE as required by hospital policy. The sections on the form for recording "Risk of Refusal to Consent to Examination/Treatment" and "Risks to health from leaving Harney District Hospital against medical advice" were blank. There was no documentation on the AMA form or elsewhere in the record that reflected the patient was informed of the risks or potential consequences/complications of leaving the hospital without an MSE.
* There were no physician or other LIP orders.
* There was no physical exam, lab testing, X-ray or other diagnostic tests or procedures.

The record reflected the patient left AMA without an MSE. However, the record reflected hospital policies and procedures related to the patient leaving AMA without an MSE were not carried out. For example, the record reflected:
* No documentation the nurse, physician or other LIP informed or attempted to inform the patient of the risks and/or potential consequences/complications of leaving AMA without an MSE. Those sections on the AMA form were not filled out.
* No documentation that the nurse informed the physician or other LIP that the patient left AMA without an MSE.
* No documentation of the patient's condition prior to leaving as required by hospital policy. Although the record reflected "Pt's oxygen remained above 89% while in the ER...," the last documentation of the patient's oxygen level was at 1415, 45 minutes before the patient left at 1500.
* No documentation of discharge instructions provided or attempts to provide discharge instructions as required by hospital policy.

b. During an interview and review of the ED record with the CNO on 08/15/2019 at 1900, the CNO confirmed the record reflected:
* RN 3 was the only RN that documented in the record.
* The patient left AMA without an MSE.
* No documentation that RN 3 or any other nurse notified the physician of the patient leaving AMA without an MSE.
* No documentation that the patient was informed of the risks and/or potential consequences/complications of leaving AMA without an MSE.
* No documentation that discharge instructions were provided to the patient. No documentation the patient refused discharge instructions.

c. Review of staff training records for RN 3 reflected the hospital's policies related to MSEs were not carried out as RN 3 had not completed the training and competencies required to conduct MSEs. RN 3's training records reflected:
* The required "Harney District Hospital Emergency Room Skills Checklist" dated "Start Date: [blank]" was incomplete. The spaces for "Preceptor," "Orienteer," "Date," and/or "Methodology" were blank for approximately 30 sections including but not limited to: "Aspiration...Tuberculosis and negative pressure isolation...Closed head injury...Acute CVA and stroke protocol...Overdose...Seizure disorders...Appendicitis...Gunshot/Stab wound...Hypothermia...Major trauma...Traumatic amputation...Pediatric cardiac arrest...Near drowning...Violent patient...SANE patient...Identify signs/symptoms of physical or sexual abuse..."

d. An interview and review of RN 3's staff training records was conducted with the CNO on 08/16/2019 at 0950. The CNO provided the following information related to the lack of RN 3's qualifications to conduct MSEs:
* The CNO stated he/she had no documentation that RN 3 completed the required "MSE (Medical Screening Exams)" training and "MSE Post-Test."
* The CNO confirmed RN 3's "Harney District Hospital Emergency Room Skills Checklist" was incomplete.
* The CNO acknowledged RN 3 did not have the required MSE training and competencies, and therefore RN 3 was not qualified to conduct MSEs in accordance with hospital policy.

Based on interview, review of documentation in 7 of 7 medical records of patients who were transferred from HDH to other hospitals for services not available at HDH (Patients 5, 6, 7, 9, 11, 12 and 16), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and enforce its EMTALA policies and procedures to ensure it effected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved:
* The receiving facility had not accepted patients for transfer as required by this CFR.
* The physician certification with risks and benefits of transfer were not identified or were not patient specific for patients as required by this CFR.
* The transfer was not effected through qualified personnel and transportation equipment for patients as required by this CFR.
* Medical records were not sent to the receiving facility for patients as required by this CFR.
* A verbal agreement was not obtained from a physician at the receiving facility to accept the patients as required by hospital policy.
* Transfer Forms were not completed and signed by the physician as required by hospital policy.
* A nurse had not contacted the receiving facility and confirmed bed availability for patients as required by hospital policy.
* A nurse had not given report to a nurse at the receiving facility for patients as required by hospital policy.

Findings included:

1. a. The p/p titled "EMTALA," dated effective 04/05/2013, was reviewed. It reflected:
* "This policy covers all patients who come to the Emergency Department at Harney District Hospital seeking care."
* "If a patient is to be transferred for a medical necessity Harney District Hospital will follow the following guidelines..."
- "The individual (or legally responsible person acting on the individual's behalf) requests transfer after being informed of the risks of the transfer. The request must be in writing and indicated the reasons for the request as well as indicate that he or she is aware of risk and benefits of the transfer..."
- "A physician has signed a certification that based upon the information available at the time of transfer; the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman and the unborn child, from being transferred. The certification must contain a summary o (sic) the risks and benefits upon which it is based..."
- "...Harney District Hospital will send to the receiving hospital all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of studies, treatment provided, results of any tests and informed written consent or certification. In the event copying records could jeopardize the patient, the records may be sent on STAT basis to the receiving facility as soon as completed..."
- "Harney District Hospital will provide treatment to minimize the risks of transfer..."
- "Harney District Hospital will obtain consent of the receiving hospital to accept the transfer..."
- "The physician will order appropriate qualified personnel and transportation equipment, including the use of medically appropriate life support measures..."
- "Harney District Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge..."

b. The p/p titled "Transfer: Non-Trauma," dated effective 11/20/2017 reflected:
* "Purpose: To ensure that patients receive...proper informed transfer to an appropriate hospital which can provide a higher level of care.
* "Harney District Hospital shall comply with all EMTALA guidelines in the transferring of patients between facilities..."
* "Procedure..."
- "Patient is assessed...and stabilized to the greatest degree possible..."
- "Physician will make initial contact with transfer center or receiving facility..."
- "Verbal agreement to accept patient by specialist or on-call physician at appropriate medical center obtained..."
- "Sending Physician determines most appropriate method of transport..."
- "Physician to obtain patient's consent and signature for transfer (if patient is able) or by a family member..."
- "Nurse to contact receiving facility and speak with house supervisor or bed control to confirm bed availability..."
- "Physician and Registered Nurse complete appropriate transfer form...including obtaining physician signature..."
- "Nurse to give report to receiving nurse at facility and to transport team..."
- "Copies of all available patient data are sent with patient..."

c. A "Medical Staff Rules & Regulations" document titled "Patient Transfers" dated effective "11/2007," reflected:
* "Harney District Hospital," in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA), along with all members of the medical staff, will comply with all applicable laws regarding patient transfers."
* "The medical record will reflect the reason for diagnostic testing, including laboratory and other invasive and noninvasive diagnostic testing and imaging procedures, relevant to the determination of the patient's healthcare needs."
* "There shall be a transfer note written in the progress notes by the transferring medical staff member. It shall be a concise recapitulation of the hospital course...developed to assist the receiving physician..."
* "No patient will be transferred without such transfer being approved by the responsible practitioner after consultation and coordination with the receiving physician."
* "The transferring physician is responsible for the means of transport and the care of the patient until the patient arrives at the receiving facility."

2. a. The ED record of Patient 16 was reviewed with the CNO on 08/15/2019 at 1850. The record reflected the patient presented to the ED by police on 07/03/2019 at 0643 with a chief complaint of "Mental Health Problem."

* RN triage notes on 07/03/2019 at 0648 reflected "Patient presented to ER...after having a psychiatric break at a hotel. Patient is agitated, loud and erratic."
* RN notes on 07/03/2019 at 0715 reflected "Medication given...Haldol...injection 5 mg...Right deltoid..."
* RN notes on 07/03/2019 at 0901 reflected "Pt was in ER and was discharged with police transportation to Idaho. During [his/her] stay in the ER pt voiced homicidal ideation...Pt was verbal (sic) aggressive in the ER...Pt. refused to have vitals and labs drawn."
* RN notes on 07/03/2019 at 0906 reflected "Departure Mode...with police transportation..."

* The record reflected the patient was transferred from HDH to SJRMC on 07/03/2019 at 0907.

* Physician notes electronically signed by the physician and dated 07/03/2019 at 0912 reflected:
- "[Patient]...with hx of 'bipolar disorder' who presents this morning via Burns PD with...[family member] with delusional and homicidal thinking. Pt's [family member] states that [patient] was recently admitted in Redding, CA for 12 days and discharged several days ago. [He/she] states [he/she] wants to 'kill' [family member]. According to [family member] pt's bipolar is poorly controlled and [he/she] has been hospitalized frequently for manic episodes. Currently pt denies any suicidal ideations but states [he/she] wants to 'kill' [family member]...[Family member] states that over the last 1-2 days pt has started to decompensate. Pt is stating that [he/she] is a 'shaman' and a 'shotting-star' (sic) and continues to sing 'twinkle twinkle little star' very loudly followed by crying hysterically."
* "...Pt to be transported via Burns PD to St. Joe's. Facility knows patient well and will be awaiting [his/her] arrival. Per Symmetry Care...we do not need a doc-to-doc phone call...Agitation improved with Haldo (sic)...Remains actively psychotic with persistent homicidal ideations towards [family member]. [He/she] was discharged to police custody..."
* "...Symmetry representative here now, attempting to coordinate dispo. Burns PD remains in pt's room..."
* "Clinical Impression Psychosis...Homicidal ideations Bipolar disorder, currently manic, severe, with psychotic features..."
* "Disposition Discharge to Burns PD for transport to St. Joe's."

* QMHP "Symmetry Care" notes electronically signed by the QMHP on 07/03/2019 at 2138 reflected:
* "Description of Crisis Situation...[family member]...arrived at the ED and provided some background...states [patient] and [he/she] were packing their belongings in Idaho and were getting ready to move to Reedsport, Oregon...further states that [patient] started getting escalated about a week ago when they started packing...states [he/she] has Bipolar and has refused to take [his/her] medication recently accounting for [his/her] unstable mood...most recent hospitalization was about two weeks ago from the Idaho State Hospital North in Orofino, ID...This crisis worker contacted [Symmetry Care Director] and informed [him/her] of the situation...[Symmetry Care Director] said to call the State Hospital North in Orofino and see if they would be able to admit [patient]...[family member] stated that [patient] has been admitted to State Hospital North on two previous occasions in the past years."
* "...called [State Hospital North]...spoke to the head nurse...The head nurse was informed of the situation and [patient's] current mental status. The head nurse stated that they do not admit patient's directly that [patient] would need to go to the St. Joseph Hospital in Lewiston, ID...to their ED where they would evaluate [patient] and determine if [he/she] needed to be referred to the Idaho State Hospital North...[Symmetry Care Director] contacted [police officer] and did arrange transportation and asked when [patient] could be released...physician on duty stated that [he/she] could be release (sic) immediately for transport to St. Joseph..."
* [Patient] is being transported by Law Enforcement to St. Joseph hospital in Lewiston, ID..."
* "...at 3:56 pm, received phone call from [police officer] who had arrived at St. Joseph ED in Lewiston. [Police officer] relayed that the ED physician was upset because we did not contact them to make arrangements for [patient] to be sent there. The physician...got on the phone with this crisis worker and stated we did not follow protocol and could face a hefty fine..."

* The record reflected the patient was transferred from HDH to SJRMC on 07/03/2019 at 0907.

The record lacked documentation that reflected an appropriate transfer was carried out as follows:
* The record reflected "Pt to be transported...to St. Joe's. Facility knows patient well and will be awaiting [his/her] arrival." However, there was no documentation that reflected who at SJRMC would "be awaiting [his/her] arrival." There was no documentation that SJRMC had accepted the patient for transfer as required by this CFR, and had available bed space and resources necessary to care for the patient's inpatient psychiatric needs.
* There was no documentation of a physician certification of transfer with the risks and benefits as required by this CFR.
* There was no documentation that medical records were sent to SJRMC as required by this CFR.
* There was no documentation that HDH requested and received a verbal agreement from a physician at SJRMC to accept the patient as required by hospital policy.
* There was no documentation that the nurse contacted SJRMC and confirmed bed availability as required by hospital policy.
* There was no documentation that a Transfer Form was completed and signed by the physician as required by hospital policy.
* There was no documentation that the nurse gave report to a nurse at SJRMC and to the transport team as required by hospital policy.

b. Review of an undated document titled "Psychiatric Patient Transfer" provided by the CNO related to Patient 16's ED visit on 07/03/2019 was reviewed and reflected:
* "On 7/3/19 plans were made to transfer the patient to the ER in St. Joseph's hospital in Lewiston, Idaho..."
* "The patient was transferred to St. Joseph's after a 6.5 hour drive by law enforcement..."
* "[SJRMC]'s CNO called...[he/she] explained no one at their facility knew of the transfer. There was no contact with their facility, no paperwork when the patient presented, and no accepting physician..."

c. Online driving directions reflected SJRMC located in Lewiston, ID is 335 miles and 6 hours and 24 minutes driving time from HDH.

d. During an interview and review of the ED record with the CNO on 08/15/2019 at 1850, he/she provided the following information:
* The patient was transferred from HDH to SJRMC for inpatient psychiatric services that were not available at HDH, and therefore HDH lacked capability. The CNO stated the plan was for the patient to go to SJRMC in Lewiston, Idaho for inpatient psychiatric treatment and then "go to the state hospital from there."
* There was no documentation that reflected SJRMC was notified of the transfer and had accepted the patient for transfer.
* There was no physician certification of transfer with the risks and benefits.
* There was no documentation that medical records were sent to SJRMC.

3. a. The ED record of Patient 11 was reviewed and reflected the patient presented to the ED on 05/24/2019 at 1447 with a chief complaint of "Alleged Sexual Assault."

* RN triage notes on 05/24/2019 at 1508 reflected "'Pt states since awakening this am [he/she] has felt like [he/she] was 'run over by a truck' achy all over, 'feels weird', believes [he/she] was drugged, 'feels like my uterus is going to fall out' c/o vaginal pain."
* RN notes on 05/24/2019 at 1511 reflected "...Pain Score: 8...Pain Type: Acute Pain..."
* RN notes on 05/24/2019 at 1656 reflected "Patient to be transferred via POV to SCMC Bend ER d/t no SANE nurse available at this facility..."
* RN notes on 05/24/2019 at 1714 reflected "...Departure Mode: With friend."

* Physician notes electronically signed by the physician and dated 05/27/2019 at 1833 reflected:
- "[Patient]...presents today c/o sexual assault that occurred the night before last (5/22/19)...C/o B/L shoulder pain, abd pain and wrist pain...feels like [his/her] 'shoulders were held behind [his/her] back and [he/she] was placed in handcuffs...'"
- "Physical Exam...Genitourinary: Genitourinary Comments: Deferred"
- "Review of Systems...Gastrointestinal: Positive for abdominal pain and nausea...Genitourinary: Positive for pelvic pain..."
- "MDM...Diagnosis management comments...presents after an alleged assault. Pt will need to be seen at a facility with SANE program, such as Bend. Will get KUB prior to discharging, otherwise will defer labs and ppx medications to SANE facility. Pt is to go now via POV...with [friend]..."
- "Clinical Impression Sexual assault of adult, initial encounter"
- "Disposition Transfer to Another Facility"

The record lacked documentation that reflected an appropriate transfer was carried out as follows:
* There was no documentation that reflected SCMC had accepted the patient for transfer as required by this CFR and had available bed space and resources necessary to care for the patient.
* There was no documentation of a physician certification of transfer with the risks and benefits as required by this CFR.
* There was no documentation that medical records were sent to SCMC as required by this CFR.
* There was no documentation that HDH requested and received a verbal agreement from a physician at SCMC to accept the patient as required by hospital policy.
* There was no documentation that the nurse contacted SCMC and confirmed bed availability as required by hospital policy.
* There was no documentation that a Transfer Form was completed and signed by the physician as required by hospital policy.
* There was no documentation that the nurse gave report to a nurse at SCMC as required by hospital policy.
* The record reflected the patient was transferred from HDH to SCMC by private vehicle with a friend. There was no documentation that the physician arranged an appropriate transfer that was effected through qualified personnel and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer, or that the patient refused an appropriate transfer and was informed of the hospital's EMTALA obligation and the risks and benefits of transfer.

b. Online driving directions reflected SCMC located in Bend, Oregon is 129 miles and 2 hours and 9 minutes driving time from HDH.

c. During an interview and review of the ED record with the CNO on 08/15/2019 at 1810, he/she provided the following information:
* The patient was transferred from HDH to SCMC for further examination and treatment by a SANE because HDH did not have SANE services, and therefore HDH lacked capability.
* There was no documentation that reflected SCMC had accepted the patient for transfer.
* There was no physician certification of transfer with the risks and benefits. The CNO stated "No, I didn't see that in there."

4. a. The ED record of Patient 6 was reviewed and reflected the patient presented to the ED by law enforcement on 02/28/2019 at 1804 with an "Arrival Complaint" of "Mental Health Crisis."

* RN triage notes on 02/28/2019 at 1826 reflected "'Pt states [he/she] got lost while trying to ride a bus to go see [family member]. [He/she]...is needing a mental health evaluation."

* QMHP "Symmetry Care" notes dated 02/28/2019 and "Time of Arrival" 1850 reflected:
- "[Patient] was arrested after breaking into a residence today around 5 pm. [He/she] was asked if [he/she] had any weapons and [he/she] said yes. [He/she] did have a gun on [him/her]...states [he/she] brought (sic) public transportation to Burns with the firearm with the intent to kill self..."
- "Recommendations: Needs to be evaluated by psychiatrist. At this time [patient] presents being a danger to self with planned suicide, danger to others with history of domestic battery...Sage View intake is working on getting [patient] put on a 5 day psychiatric hold at Sage View for an evaluation...HDH does not have the means for a 5 day psychiatric hold."

* Physician notes electronically signed by the physician and dated 02/28/2019 at 2220 reflected:
- "[Patient]...presents to the ED for evaluation of mental health...brought in to the ED by law enforcement...apparently wandered into someone's home with a firearm, police were called and [he/she] was taken into custody. Patient tells me (in rather disorganized fashion) that [he/she] has been feeling somewhat depressed and had a gun with the intent of 'blowing my brains out in the street'. [He/she] wandered into the home due to 'confusion'..."
* "Final Clinical Impression...Suicidal ideation...Bipolar affective disorder, current episodic hypomanic..."
* "Disposition: Transfer to Another Facility"
* "Plan...[He/she] will be transported by Peace Officer to Sage View for inpatient admission."

* RN notes on 02/28/2019 at 2322 reflected "...Transported to...St Charles Bend ER...Transported with...Law Enforcement..."

The record lacked documentation that reflected an appropriate transfer was carried out as follows:
* There was no documentation of a physician certification of transfer with the risks and benefits as required by this CFR.
* There was no documentation that a Transfer Form was completed and signed by the physician as required by hospital policy.

b. Review of state agency licensing records reflected that Sage View Psychiatric Center is located in Bend, Oregon and is a licensed satellite location and a department of SCMC through which SCMC provides inpatient psychiatric services.

c. Online driving directions reflected SCMC located in Bend, Oregon is 129 miles and 2 hours and 9 minutes driving time from HDH.

d. During an interview and review of the ED record with the CNO on 08/15/2019 at 1730, he/she provided the following information:
* There was no physician certification of transfer with the risks and benefits.
* There was no Transfer Form.

5. a. The ED record of Patient 9 was reviewed and reflected the patient presented to the ED by ambulance on 03/04/2019 at 1117 with an "Arrival Complaint" of "Trauma/Burn."

* Physician notes dated 03/04/2019 reflected:
- "[Patient]...apparently had a self-inflicted gasoline burn to the face and neck chest abdomen both arms and hands...These are deep thickness burns covering approximately 50% total body surface area...charring or (sic) mouth and evidence of airway injury and compromise and was intubated immediately on arrival...Transfer arrangements were made for...burn unit. Transport is in the air currently. 2 large-bore IVs were placed...[He/she] was intubated...nasogastric tube placed, Foley catheter placed. Appropriate trauma labs and drug screen obtained...given warm fluids, covered with dry sheets and a Bair hugger warming device placed."

* The record reflected the patient was transferred by "Life Flight Fixed Wing" from HDH to LEMC on 03/04/2019 at 1330 for specialized burn unit services.

The "Certification of Transfer" form dated 03/04/2019 was reviewed and reflected it was unclear and incomplete. It reflected:
* "...Legacy Emanuel receiving facility has agreed to accept the patient..."
* The physician certification section was not signed or dated by the physician. The spaces for "Signature of Transferring Physician" and "Date" were both blank. The only signature on the form was in the "Patient/delegate accepting transfer/second physician" section and that signature was illegible.
* The "Risks" of transfer section reflected the following preprinted generic choices with checked boxes next to each choice:
- "Possible worsening of condition during transport"
- "Potential for accident during transport"
- "Risks related to specific DX & situation"
- "Lack of resources." This was followed by a blank line.
There was no documentation on the transfer form or elsewhere in the record that reflected patient specific individual risks of transfer for this patient with deep thickness burns and airway injury who was intubated and required air transport.

b. An online flight calculator reflected LEMC located in Portland, Oregon is approximately 55 minutes flight time from HDH.

c. During an interview and review of the ED record with the CNO on 08/15/2019 at 1945, he/she provided the following information:
* The patient was transferred from HDH to LEMC for further exam and treatment of the patient's burn injuries because HDH did not have specialized trauma and burn services, and therefore HDH lacked capability.
* The CNO confirmed the physician certification of transfer was not signed by the physician.
* The CNO confirmed the record lacked documentation of patient specific individual risks of transfer.

6. a. The ED record of Patient 7 was reviewed and reflected the patient presented to the ED by ambulance on 03/02/2019 at 1636 with an "Arrival Complaint" of "stroke like symptoms."

* RN triage notes on 03/02/2019 at 1704 reflected "...[family member] called EMS because [he/she] observed [patient] having difficulty forming [his/her] thoughts into words and also mobility."

* Physician notes electronically signed by the physician and dated 03/02/2019 at 2107 reflected:
- "...[Patient] says [he/she] has been having trouble with fevers for the last 2 weeks or so...says they have been low grade...has been fatigued...was seen in the office on February 19 with complaint of shaking chills...complained [he/she] was profoundly fatigued and sleepy...slight cough and some increased shortness of breath...seen again in the clinic on February 25 for follow-up...continued to have dyspnea...ECHO was scheduled for this coming Wednesday..."
- "Physical Exam...Mental Status...does not know what year it is but does know it's March...cannot tell me who the president is..."
- "...we have been on divert here at Harney District Hospital for the past 24 hours. On the upside, patient will likely require a transesophageal echo which is not available here, nor are MRI's on the weekend. For these reasons we have requested transfer to St. Charles in Bend...[physician] and the house supervisor graciously agreed to accept patient in transfer. Blood cultures x2 were obtained here. Patient given 2 g of Rocephin and the ambulance crew will start 1 g of vancomycin IV en route..."

* The "Transfer Order" form signed by the physician and dated 03/02/2019 reflected "Diagnosis...Endocarditis.

* The record reflected the patient was transferred from HDH to SCMC by ground ambulance on 03/02/2019 at 2000.

The "Certification of Transfer" form signed by the physician and dated 03/02/2019 reflected:
* "Reason For Transfer...Benefits...Diagnostic test/procedures are not available at HDH...No Hospital beds available [at] Harney District Hospital"
* The "Risks" of transfer section reflected the following preprinted generic choices were selected with checked boxes next to each choice:
- "Possible worsening of condition during transport"
- "Potential for accident during transport"
- "Risks related to specific DX & situation"
- "Lack of resources." This was followed by a blank line.
There was no documentation on the transfer form or elsewhere in the record that reflected patient specific individual risks of transfer for this patient who was experiencing fevers and endocarditis.

b. Online driving directions reflected SCMC located in Bend, Oregon is 129 miles and 2 hours and 9 minutes driving time from HDH.

c. During an interview and review of the ED record with the CNO on 08/15/2019 at 1710, the CNO confirmed the record lacked documentation of patient specific individual risks of transfer.

7. a. The ED record of Patient 5 was reviewed and reflected the patient presented to the ED by ambulance on 02/26/2019 at 1035 with an "Arrival Complaint" of "R Knee Pain."

* RN triage notes on 02/26/2019 at 1042 reflected "Patient presents...after a slip and fall at home. Obvious deformity to right upper leg."

* Physician notes electronically signed by the physician and dated 02/26/2019 at 1255 reflected:
- Labwork and X-rays were completed.
- "Final Clinical Impression(s)...fracture of femur, right..."
- "Plan: Discussed case with [physician] of St. Luke's on call ortho. Pt transfer via ground...Pt NPO, LR during transport with pain medication and foley catheter placement..."
- "Disposition: Transfer to Another Facility St. Luke's Nampa: Full Code."

* The record reflected the patient was transferred by ACLS "Ground" transportation from HDH to "St Luke's Nampa" on 02/26/2019 at 1245.

The "Certification of Transfer" form signed by the physician and dated 02/26/2019 was reviewed and reflected:
* "...St Luke's Nampa receiving facility has agreed to accept the patient..."
* The "Risks" of transfer section reflected the following preprinted generic choices with checked boxes next to each choice:
- "Possible worsening of condition during transport"
- "Potential for accident during transport"
- "Risks related to specific DX & situation"
- "Lack of resources." This was followed by a blank line.
There was no documentation on the transfer form or elsewhere in the record that reflected patient specific individual risks of transfer for this patient with a femur fracture.

b. Online driving directions reflected SLNMC located in Nampa, Idaho is 168 miles and 2 hours and 47 minutes driving time from HDH.

c. During an interview and review of the ED record with the CNO on 08/15/2019 at 1940, he/she provided the following information:
* "St Luke's Nampa" is St. Luke's Nampa Medical Center in Nampa, Idaho.
* The patient was transferred from HDH to SLNMC for further exam and treatment of the patient's femur fracture because HDH did not have orthopedic surgeon services, and therefore HDH lacked capability.
* The CNO confirmed the record lacked documentation of patient specific individual risks of transfer.

8. a. The ED record of 13-year old pediatric Patient 12 was reviewed and reflected the patient presented to the ED by ambulance on 06/07/2019 at 1249 with an "Arrival Complaint" of "Fall from horse."

* RN notes on 06/07/2019 at 1306 reflected "Patient arrived in ER by EMS...fell off of a horse and [his/her] leg was caught in the saddle. [Patient] was dragged about 50 yards...EMS notes abrasions to back and side. Decreased respirations on right side."

* Physician notes electronically signed by the physician and dated 06/07/2019 at 1504 reflected:
- Labwork, X-rays and CT were completed.
- "Review of Systems...HENT: Positive for nosebleeds...Respiratory: Positive for shortness of breath. Cardiovascular: Positive for chest pain. Gastrointestinal: Positive for abdominal pain..."
- "Physical Exam...Head is with abrasion and with contusion...Pulmonary/Chest...decreased breath sounds in the right upper field, the right middle field and the right lower field. Chest wall is dull to percussion...exhibits tenderness and crepitus."
- "ED Course...1341 Call to [St. Alphonsus] access center, patient has been autoaccepted as direct trauma transfer prior to this. Updated on known injuries, s/p chest tube placement and questionable fluid finding in the pelvis adjacent to the bladder...[EMT]...to pick up flight crew with ETA 1430...."

* The record reflected the patient was transferred to SARMC by ACLS "Airlink" transportation on 06/07/2019 at 1510 for trauma services.

The "Certification of Transfer" form signed by the physician and dated 06/07/2019 was reviewed and reflected:
* "...St Als Boise receiving facility has agreed to accept the patient..."
* The "Risks" of transfer section reflected the following preprinted generic choices with checked boxes next to each choice:
- "Possible worsening of condition during transport"
- "Potential for accident during transport"
- "Risks related to specific DX & situation"
- "Lack of resources." This was followed by a blank line.
There was no documentation on the transfer form or elsewhere in the record that reflected patient specific individual risks of transfer for this 13-year old trauma patient.

b. Online flight calculator reflected SARMC located in Boise, Idaho is approximately 44 minutes flight time from HDH.

c. During an interview and review of the ED record with the CNO on 08/15/2019 at 1820, he/she provided the following information:
* The patient was transferred from HDH to SARMC for further exam and treatment of the patient's trauma related injuries because HDH did not have a trauma surgeon, and therefore HDH lacked capability.
* The CNO confirmed the record lacked documentation of patient specific individual risks of transfer.