HospitalInspections.org

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Based on observation, review of video-recordings, interviews, email communications, review of central log and medical record documentation for 17 of 30 encounters of individuals who presented to the hospital for emergency services (Patients/Encounters 1, 2, 3, 5, 9a, 9b, 16, 17, 19, 21b, 21c, 21d, 21e, 21f, 21g, 22b, and 33), review of incident and internal investigation documentation, review of P&Ps, and review of other documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured it met its EMTALA obligations in the following areas:
* To post required EMTALA signage in conspicuous places where individuals, patients, and their representative waited for examination and treatment.
* To maintain a complete and accurate central log of all individuals who presented to the hospital for emergency services.
* To provide adequate MSEs to all individuals who presented for emergency services to determine whether an EMC existed.
* To not dissuade individuals from staying at the hospital to receive MSEs, and for those who left prior to an MSE, to obtain or attempt to obtain written and informed refusal of MSE in accordance with its P&Ps.
* For those individuals for whom an EMC had not been resolved or ruled out, to affect appropriate transfers to other hospitals for further examination and stabilizing treatment not within the hospital's capabilities or capacity at the time, that included physician certification of patient specific benefits and risks of transfer, use of appropriate medical transportation with qualified personnel, and provision of medical records.

Findings include:

1. Refer to the findings cited under Tag A-2402 related to the posting of EMTALA signage.

2. Refer to the findings cited under Tag A-2405 related to the maintenance of a central log.

3. Refer to the findings cited under Tag A-2406 related to the provision of MSEs.

4. Refer to the findings cited under Tag A-2409 related to the elements of appropriate transfer.



40575

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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 and where individuals waited for examination and treatment.

Findings include:

1. Review of the P&P titled "Emergency Treatment and Active Labor Act (EMTALA)" dated effective "02/2022" reflected " ... Signage - means the signs posted by the Hospital in its dedicated ED(s), L&D/Perinatal department(s) and in a place or places likely to be noticed by all individuals entering the dedicated ED(s), ), (sic) L&D/Perinatal department(s), as well as those individuals waiting for examination and treatment. The signage must inform individual (sic) of their rights under EMTALA. Each Hospital will post signage in the dedicated ED and L&D/Perinatal Department specifying ... the rights of individuals under the law with respect to examination and treatment for emergency medical conditions ... the rights of women who are pregnant and are having contractions ... whether the hospital participates in the Medicaid program ... "

2. During a tour of the ED on 12/20/2023 beginning at 1015 with the EDM and other hospital staff, the following observations were made:
* The main ED waiting room did not have any EMTALA signs observed in that waiting area. These observations were confirmed during an interview with the EDM at the time of the observation. The EDM confirmed the goal is that all individuals waiting for exam and treatment would be triaged in one of the three triage rooms, where EMTALA signage is posted. The signage in the three triage rooms was observed.

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Based on review of video-recordings, interviews, review of the central log and medical records for 5 of 30 encounters of patients who presented to the hospital for emergency services and were reviewed for the central log (Patient/Encounters 21b, 21c, 21f, 21g, and 22b), and review of P&Ps, it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure maintenance of a central log that contained clear and accurate information about each encounter for all individuals who presented to the hospital for emergency services:
* Not all encounters of individuals who presented to the hospital were entered on the log.
* The log did not clearly or accurately reflect for each patient the information provided on the log: time of arrival, chief complaint, disposition, and time of disposition.

Findings include:

1. The P&P titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated as "Last Revised 02/2022" was reviewed. It included the following information: "Central log - is a log maintained by the hospital on each individual who comes to its dedicated ED or L&D/Perinatal Department. Each dedicated ED and L&D/Perinatal Department of the Hospital will maintain a central log recording the names of individuals who present to the department seeking treatment and indicate whether these individuals refuse treatment, were denied treatment, or were treated, admitted, stabilized, and/or transferred or were discharged."

2. The central log for Patient 21b reflected that they presented to the ED on 12/31/2023 at 0340 with a "Chief Complaint" of "[ambulance]." The "ED Disposition" on the log was "Ama" on 12/31/2023 at 0354.
* Regarding the chief complaint, the medical record reflected the patient was BIBA. It was unclear for what reason EMS brought the patient to the hospital.
* Refer to Tag A-2406 for the detailed findings of this encounter.

3. Review of the central log revealed no evidence of Patient 21c's second 12/31/2023 encounter shown in video recordings that resulted in the patient being brought back into the ED after the first encounter above. The video recordings showed the patient transported by wheelchair back into the ED at 0425 and being transported by SO from the ED toward the bus stop on the street at 0433.
* Refer to Tag A-2406 for the detailed findings of this encounter.

4. The central log for Patient 21f reflected that they presented to the ED on 01/02/2024 at 1404 with a "Chief Complaint" of "Followup Medical Problem." The "ED Disposition" on the log was "Discharge" on 01/02/2024 at 1644.
* Regarding the chief complaint, the medical record reflected the patient was BIBA. It was unclear what "Followup Medical Problem" meant and for what reason EMS brought the patient to the hospital.
* Regarding the time of disposition, video recordings reflected that the patient was removed from the ED to the exterior ambulance parking area at 1449, and that SOs transported the patient by wheelchair away from the hospital toward the bus stop on the street at 1518.
* Refer to Tag A-2406 for the detailed findings of this encounter.

5. The central log for Patient 21g reflected that they presented to the ED again on 01/02/2024 at 1644 with a "Chief Complaint" of "Possible Sepsis." The "ED Disposition" on the log was "Transfer to Another Facility" on 01/02/2024 at 2232.
* Regarding the time of arrival, video recordings reflected that the patient was BIBA and presented to the ED at 1619.
* Refer to Tag A-2406 for the detailed findings of this encounter.

6. The central log for Patient 22b reflected that they presented to the ED on 12/30/2023 at 1712 with a "Chief Complaint" of "Mental Health Evaluation; Agitation." The "ED Disposition" on the log was "Discharge" on 01/01/2024 at 1418.
* Regarding the disposition, the medical record reflected that the patient was admitted to the PMH inpatient BHU when a bed became available.
* During interview at the time of the record review on 01/31/2024 beginning at 1445 the MBH confirmed that the patient was admitted to the hospital as an inpatient.

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Based on review of video-recordings, interviews, email communications, review of central log and medical record documentation for 10 of 30 encounters of individuals who presented to the hospital for emergency services who did not receive an adequate MSE or who left the hospital prior to an MSE, including for some patients who had multiple encounters (Patient/Encounters 3, 5, 9a, 9b, 19, 21b, 21c, 21d, 21e, and 21f ), review of incident and internal investigation documentation, review of P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured that individuals who presented to the hospital for emergency services received an adequate MSE within the hospital's capabilities and capacity to determine whether an EMC existed, or were not dissuaded by hospital staff from staying at the hospital to receive an MSE:
* A houseless patient brought to the hospital by ambulance on did not receive an adequate MSE and was discharged to LEOs who had been called to remove them from the hospital for refusal to be discharged. Hospital staff failed to provide further MSE in spite of repeated verbalized concerns by LEOs about the patient's somnolent and unresponsive condition while they were still in the ED and after they had been transported to the LEO car in the parking lot. The patient was driven to a second hospital by LEOs and was found to be unconscious upon arrival. Resuscitation efforts were taken in the second hospital's ambulance bay but were not successful and the patient died.
* A houseless patient brought to the hospital by ambulance on multiple occasions during a three-day period and who exhibited behavioral/psychiatric symptoms and worsening physical condition did not receive adequate MSEs that included behavioral health evaluation and was discharged each time to a bus stop. On the sixth visit during those three days the patient's behaviors escalated, they were found to be septic, they required intubation and a ventilator, and they were transferred to another hospital for ICU management.
* For other patients who left the hospital without receiving an MSE it was unclear whether hospital staff did or said anything to dissuade them from staying. There was no indication they had been informed of the risks of leaving the hospital without an MSE, nor that attempts to obtain informed written refusal for a MSE had been made.

Based on findings for Patient 19 described below in this Tag, and as stated in Tag A-0000 of this report, on 12/21/2023 the hospital was notified that an IJ situation had been determined to exist. An IJ Removal Plan was approved on 12/22/2023, and the IJ was subsequently removed on 12/28/2023 after verification that the IJ Removal Plan had been implemented.

Findings include:

1.a. The P&P titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated as "Last Revised 02/2022" was reviewed. It included the following information:
* "This policy applies to all patient populations presenting to an ED (including pediatric patients), L&D/Perinatal Department, or anywhere on hospital property with an emergency medical condition needing treatment or transfer to or from any Providence hospital."
* An MSE "is an exam completed by qualified medical personnel to determine whether an EMC or active labor exists ... The hospital shall not discriminate against any individual when providing an MSE. A complete and appropriate MSE will be performed on all individuals who come to the hospital requesting examination or treatment or attempts will be made to advise the patient of the risk of leaving before an MSE can be completed. An MSE will be completed regardless of an individual's ability to pay."
* "If an individual who is not a hospital patient comes elsewhere on hospital property (hospital property includes the entire main campus, the parking lots, sidewalks, driveways, and hospital departments/buildings owned by the hospital that are within 250 yards of the hospital) employees will ensure they arrive to the ED where a MSE is offered if: a. The individual requests examination or treatment for an EMC. b. If a prudent layperson observer would believe that the individual is suffering from an emergency condition."
* "If a patient presenting to ED(s) or L&D/Perinatal department(s) and while waiting for medical screening decides to leave without examination (AMA/LWBS) the following steps should be taken if possible:
a. Explain to the patient it is important to have the medical screening to rule out whether they have a medical condition that needs treatment; and
b. Use an interpreter if the patient has limited English proficiency, or use an alternate means of communication; and
c. Inform the patient of the risks of not having the medical screening; and
d. Ask the patient to sign the AMA form acknowledging they understand the risks of leaving without the medical screening; and
e. Document on the medical record the above information and if they refuse to sign the AMA, document that on the record as well."

1.b. The P&P titled "ED Patients leaving AMA, Eloped or LWBS," versions dated as "Last Revised: 02/2021" and "Last Revised: 11/2023," was reviewed. Both versions of the P&P included the following information that was unchanged when last revised::
* "[LWBS]: occurs when a registered patient leaves the ED before or after triage but before a [MSE] is initiated by a [LIP] or other individual qualified to perform an MSE ..."
* "LWBS: When a patient leaves and/or decides to leave prior to an MSE, the circumstance should be documented ...
- A reasonable effort should be made to locate the patient. Document specific attempt(s) to locate the patient. Notify security and/or law enforcement of patients who leave before treatment is initiated and for whom it is determined that they might be at risk for harm to self and/or others. Document the notification in the medical record. Consider telephoning the patient at home and/or alerting authorities, if appropriate.
- If possible, provide information to the patient on the potential risks and benefits of leaving prior to a MSE and attempt to have patient sign a LWBS/AMA form ..."
* "Elopement: occurs when a patient leaves the hospital prior to the completion of care, after an MSE has been initiated."
* "Elopement: When a patient leaves following an MSE and prior to the completion of care, the circumstance should be documented.
- Reasonable effort should be made to locate the patient. Document attempts to locate patient and outcome of attempts. Notify security and/or law enforcement of patients who leave before treatment is completed and who are determined to be at risk for harm to self and/or others. Document the notification in the medical record. Consider telephoning the patient at home or alerting authorities, if appropriate."
* "AMA: When a patient refuses to complete a [MSE] or consent to recommended treatment or transfer, risks and benefits should be discussed and a LWBS/AMA form signed.
- The ED Provider should explain to the patient in understandable terms the risks of refusal of treatment or transfer ... the reasons and benefits of treatment or transfer ... and/or alternative treatments, when applicable.
- The nurse or ED Provider should complete the LWBS/AMA form.
- The RN should document the patient's condition and circumstances surrounding the refusal of treatment or transfer in the medical record."

1.c. The P&P titled "ED Practice Guideline: Adult Initial Assessment and Reassessments" dated as "Last Revised 11/2023" was reviewed. It included the following direction:
"Reassess/monitor for outcomes -
- Complete a focused reassessment of the chief complaint upon assuming care of a patient.
- Reassess the patient to evaluate response to intervention. This includes assessment for the desired or adverse effect of administered medication(s).
- Complete a nursing note, with vital signs at least every 4 hours (and more frequently as appropriate).
- Repeat vital signs within 1 hour (and more frequently as appropriate) for any abnormal vital signs on the initial assessment.
- Vital signs should be re-evaluated within 15 minutes of admission to ICU/CCU or transfer to another facility.
- Repeat discharge assessment (including vital signs) as appropriate for condition. A recheck should occur of abnormal vital signs prior to discharge. Any vital sign that remains abnormal should be reported to the provider to verify appropriateness of patient discharge and documented."

1.d. The P&P titled "The Plan for Provision of Care Providence Milwaukie Hospital" dated as "Last Revised 09/2019" was reviewed. It reflected that the hospital's "Scope of Patient Care Services" included an inpatient "senior psychiatric unit (SPU)."

1.e. During interview on 01/31/2024 beginning at 0930 the EDM stated that a QMHP was scheduled in the ED from 0800 to 2300 seven days a week, and there were no provisions, including on-call, for QMHP coverage from 2300 to 0800.
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2.a. The central log for Patient 19 reflected that they presented to the ED on 12/12/2023 at 1834 with a "Chief Complaint" of "Wound; Cold Exposure." The "ED Disposition" on the log was "Discharge" on 12/12/2023 at 2144.

2.b The findings that follow for this encounter reflected discrepancies and contradictions in the EHR, inconsistencies between the EHR documentation and video recordings and interviews, and reflected that the hospital did not fulfill its EMTALA obligation for Patient 19. For example:
* ED staff decided that Patient 19's worsening condition was purposeful behavior to resist discharge from the ED.
* A MSE that included an evaluation of Patient 19's change/worsening condition and the alleged behavioral/psychiatric symptoms was not conducted, instead police were called to remove the patient from the hospital. There was no reassessment of the patient's physical condition, including vital signs and GCS taken only at the time of admission, and there was no behavioral health assessment.
* It was unclear whether an unwitnessed and undocumented fall in the ED shower had been evaluated as part of an MSE.
* In response to the patient's behaviors Narcan was administered in the absence of labwork and objective assessment of the patients' condition, including such as drug screening, vital signs, and GCS.
* The Narcan was administered ~ 20 minutes before MPDOs transported Patient 19 from the ED into a police vehicle. That was contradictory to Narcan literature that reflected "observation in the emergency room for two to four hours is prudent" for a patient to whom Narcan is administered. Further, the patient's condition was not assessed in accordance with the instructions for post-Narcan assessment.
* Patient 19 was transported with wrists handcuffed behind their back into the back seat of a MPD vehicle where they remained for ~ 40 minutes during which time MPDOs returned to the ED and expressed concern about the situation to medical staff, and during which time the hospital's HS went to the parking lot to "assess" the situation but never looked at the patient. When MPDOs made arrangements to take the patient to another hospital's psychiatric unit, they left PMH premises with the patient.
* PMH staff failed to respond appropriately to Patient 19's change of condition and MPDO's concerns by letting the patient be removed from the ED, and by not returning the patient to the ED for further examination and stabilizing treatment when further concerns were expressed by MPDOs.

2.c. The medical record for Patient 19's 12/12/2023 ED encounter was reviewed and included the following:
* The ED Care Timeline reflected the following chronology of events on 12/12/2023:
- 1834 "Patient arrived in ED" and "Arrival Complaint" recorded as "[Ambulance]."
- 1841 "Chief Complaints Updated" to "Cold Exposure" and "Wound."
- 1841 RN wrote that "Pt states being homeless and feeling cold. Pt has a wound to [their] chin and the back of neck. Pt states being tired and weak and hungry. Pt soiled [themselves] and requires clean up."
- 1846 RN recorded the only vital signs in the record as "Vitals Temp: 35.6 °C (96.1 °F) Pulse: 105 Resp: 16 BP: 124/78 SpO2: 93 %" and "Patient Acuity 3."
- 1848 RN recorded the only GCS in the record as "Glasgow Coma Scale Best Eye Response: 4-->(E4) spontaneous Best Verbal Response: 5-->(V5) oriented Best Motor Response: 6-->(M6) obeys commands Glasgow Coma Scale Score: 15."
- 1905 EDT recorded Patient 19 was moved to ED Room 19.
- 1910 MD F was "assigned as Attending [physician]" and "PROVIDER CONTACT INITIATED."
- 1938 MD F placed orders for "Nursing - Please feed patient. Please dress right jaw wound Medications - cephalexin (KEFLEX) capsule 500 mg."
- 1942 MD F discontinued orders for "cephalexin (KEFLEX) capsule 500 mg."
- 1942 MD F recorded "Orders Placed" for "Medications - sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 mg per tablet 1 tablet" and "Discharge Orders Placed" for "Medications - sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 mg per tablet."
- 1942 MD F recorded "ED Disposition set to Discharge."
- 1951 RN recorded "AVS Printed ED After Visit Summary."
- 2000 A "CM/SW Assessment" note only related to transportation was recorded and included "Planned Discharge Transportation will be provided by: other (comment) (WC Van) ..."
- 2002 RN recorded that one tablet of Bactrim DS by mouth was given to the patient.
- The next entry was recorded at 2127.
- 2127, one hour and 25 minutes later, MD F recorded "Orders Placed Medications - naloxone (NARCAN) 4 mg.nasal spray 4 mg."
- 2139 RN recorded "Medication Dispense to Home naloxone (NARCAN) nasal liquid (Prepack) 4 mg - Dose: 4 mg ; Route: Nasal ; Site: Nare-Left ; Scheduled Time: 2130" and "MAR Mini Flowsheet."
- 2143 RN wrote "Care Handoff Report given to: (PD called)" and "Pt voluntarily reluctant to leave even with security assistance and multiple redirection tactics deployed. Pt was perfectly pleasant and cooperative until transport arrived and we began to get [them] up to leave. PD will be called to escort pt off of premises."
- 2144 RN recorded "Patient discharged."

* The Medication Administration record reflected that on 12/12/2023 at 2139 the RN's "Action" taken in response to the physician order for naloxone (NARCAN) was "Dispense to Home."
* Flowsheet documentation reflected that on 12/12/2023 at 2143 the RN recorded "Care Handoff Report Given to - PD called."

* The following day, on 12/13/2023 at 0940 MD F electronically signed an "ED Provider Note" included the following information:
- "Clinical Impression and Plan Final diagnoses: Facial cellulitis Cold exposure, initial encounter Opioid abuse (HCC)"
- "ED Prescriptions Sig sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 mg per tablet Take 1 tablet by mouth 2 times daily for 7 days."
- "Follow-up Information Schedule an appointment as soon as possible for a visit with [Internal Medicine MD in Clackamas, Oregon]."
- "Method of Arrival: ambulance"
- "Patient presents covered in feces with complaints of cold exposure. Patient reports that [they are] homeless, reports that [they have] been cold over the past couple days."
- "Diagnostics and Procedures The following tests were ordered and independently interpreted by me: [None recorded] Labs Reviewed - No data to display No orders to display."
- "Physical Exam ...
Const: Alert, no acute distress, non-toxic appearance. Disheveled appearing however resting comfortable speaking full sentences without distress ...
Resp: Lungs clear without wheezes, rales or rhonchi. No increased work of breathing. No chest tenderness.
Cardiovasc: Normal rate and regular rhythm. Periphery well perfused.
Abd/GI: Soft, non-tender, non-distended. No pulsatile abdominal mass.
GU: No CVA tenderness.
Skin: Pink, warm, dry. The right mandibular region shows a 3 cm x 4 cm area of erythema with associated induration, no fluctuance or subcutaneous emphysema. No active purulence. Another large area of superficial ulceration over the posterior neck. No active bleeding from either region. No fluctuance or
subcutaneous emphysema appreciated.
Ext: Atraumatic, grossly normal range of motion. No edema. No palpable venous cords
Back: Normal inspection. No tenderness.
Neuro: Alert & oriented, speech mildly slurred no gross focal deficits. GCS 15.
Psych: Affect normal. Appropriate attention, cooperation."
- "[Pt 19] with a history of fentanyl abuse presents with cold exposure and wound to the right jaw. Patient reports that [they have] been cold over the past couple days. [Pt] reports that [they have] a chronically fractured jaw. [Pt] reports that [they have] a wound on the neck as well as the right jaw region that [they have] been picking at. Patient denies any recent trauma ... denies any worsening pain or redness but [they want] the wounds to be evaluated. [They deny] any difficulty breathing or swallowing ... reports that [they are] hungry and is asking for something to eat ... denies any fevers, recent trauma, or any further associated complaints ... is disheveled/unkempt appearing however resting comfortably speaking full sentences without acute distress ... mildly tachycardic and borderline hypothermic with otherwise stable vital signs and no signs of acute distress. The right mandibular region shows a 3 cm x 4 cm of erythema with associated induration, no fluctuance or subcutaneous emphysema. No active purulence. There is another large area of superficial ulceration over the posterior neck, no active bleeding from either region. No fluctuance or subcutaneous emphysema. Patient is protecting [their] airway ... exam is otherwise unremarkable. Clinical picture consistent with cold exposure. Patient has evidence of a wound on the right jaw as well as the neck that appears to have associated cellulitis. Patient has a normal mental status, is moving all extremities normally without any focal neurological deficits. [They are] protecting [their] airway ... borderline tachycardic with otherwise stable vital signs. No concerns for acute stroke syndrome, sepsis, impending airway compromise, or any other complicating features. During patient's emergency department visit [they were] showered and cleaned ... provided warm close [sic] and blankets. The patient was provided food and snack ... treated with a dose of antibiotics to cover for [their] acute infection, instructed to follow-up closely with outpatient providers. Patient was treated with Medications sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 mg per tablet 1 tablet (1 tablet Oral Given 12/12/23 2002) naloxone (NARCAN) nasal liquid (Prepack) 4 mg (4 mg Nasal Dispense to Home 12/12/23 2139)."
- The note included an entry by MD F that reflected at "2124: Patient was being discharged when [they were] noted by staff to seemingly volitionally fall out of the wheelchair. No traumatic injuries noted. Staff returned [Pt] back to the wheelchair where [they] sat for a brief period of time and then continued to lower [their] legs to the ground. Security attempted to keep [Pt] in the wheelchair and the patient continued to slide out of the wheelchair to the ground. The patient was returned to the bedside where [they continue] resting seemingly comfortably protecting [their] airway, is withdrawing and localizing to pain in all 4 extremities without distress. Patient is alert and tracking with [their] eyes protecting [their] airway however not answering my questions at this time. I see no traumatic injuries, no focal deficits or any signs of distress. I will try a little naloxone and continue to monitor."
- The note included an entry by MD F that reflected at "2150: Naloxone administered. Patient reevaluated. No clinical change. Continues to be alert, breathing comfortably and moving extremities normally. NO signs of significant clinical decompensation, patient is stable for discharge. Patient has history of fentanyl abuse and [their] mental status appears to be consistent with mild opioid intoxication (slurring speech, pinpoint pupils). [Pt] is oxygenating normally on room air without focal deficits. I do not think [Pt] warrants more doses of naloxone at this time. Police were summoned by staff due to patient's inability to be transported in wheelchair. Screening medical examination performed, no emergent medical condition identified."

2.d. Patient 19's 12/12/2023 encounter was captured on hospital video recordings (without audio capability) from multiple interior and exterior camera views. Those were reviewed with the EDM, CMO, DPSR, and QMC. It was noted for this Patient 19 encounter that timestamps on exterior and interior cameras did not always align and may have resulted in timestamp discrepancies of a minute or two between interior and exterior views. The video recordings showed the following:
* 1826 Ambulance arrived and EMS transported Patient 19, who was awake and had head elevated on a gurney, into the ED through the ambulance entry.
* 1832 In the ED WR/lobby near the triage rooms EMS staff removed the blanket and unbuckled Patient 19 who was on the gurney. Patient 19 independently swiveled themselves to dangle legs off the gurney, stood up and walked without assist into TR3. EMS left the WR/lobby with the gurney.
* 1901 Patient 19 was pushed by an EDT in an ED corridor and around a corner towards Room 19.
* The 1901 image was the last time Patient 19 was shown on video recordings unit ~ 2120.
* 2120 Patient 19 pushed around corner from treatment room into ED corridor in a Stryker transport chair by a "Ride to Care" transport person, and was followed by a SO and RN. The patient was restrained around the waist, their head was slumped to the left, and they were positioned so that their back was partially on the chair seat as if they had slid down from a seated position. The SO and the RN attempted to pull the patient up in the chair. However, the patient's limp body slid further down so that their back was nearly entirely on the chair seat, their buttocks was off the chair seat, and their legs stretched out in front of the chair. The restraint was then positioned up on their chest under their arms. The patient made no purposeful movements and did not appear to be awake or alert.
* 2121 The HS and MD F approached the scene in the corridor, observed the patient, and conversed with staff.
* 2122 There was no attempt to reposition the patient and the transport chair was pulled backwards and moved back around the corner of the corridor towards the ED treatment room while the patient partially laid on the chair seat and legs were extended and dragged on the floor.
* 2154 Five MPDOs entered the ED through the ambulance entry and proceeded through the ED towards down corridor towards the ED treatment room where Patient 19 was located.
* 2209 MPDOs pushed the patient around the corner from the ED treatment room in a Stryker transport chair. There was a restraint in place around the patient's waist and the patient's hands were handcuffed behind their back. The patient's head and upper body were slumped to the right and their lower legs and feet were dragged on the ground under the chair as the chair was pushed forward. An MPDO attempted to position the patient's legs/feet on the chair's foot rests but the patient appeared to not have control of their lower extremities.
* 2212 Patient was shown being pushed in the transport chair from the hospital into the parking lot where multiple MPD vehicles were parked. The patient was slumped over in the chair. Although the nighttime parking lot video was grainy and dark, the officer's were seen to transfer the patient into the back seat of one of the police vehicles. Some MPDO's returned towards the hospital and four or five MPDO's remained in the parking lot near the vehicles.
* 2225 Three MPDOs reentered the ED through ambulance entry doors and proceeded down a corridor where they stopped and interacted with staff. MD H joined the interaction then walked towards the ambulance entry/exit after two of the officers. A conversation between the officers and MD H occurred just inside the ambulance entry.
* 2226 The officers and MD H walked out of the ED. MD H stopped just a step or two outside of the hospital at the doorway while the officers continued away from the hospital. MD H walked a few steps back into the ED, then turned around and walked back outside of the hospital and out towards the parking lot out of camera view.
* 2227 Forty seconds after MD H walked out of the ED, MD H reentered the ED through the ambulance entry.
* 2229 Two MPDOs entered the ED through ambulance entry doors and walked down corridor.
* 2232 Two MPDOs exited the ED through the ambulance entry doors.
* 2233 MD H walked down same corridor towards ambulance entry doors and exited to the sidewalk, then promptly turned around and returned into the ED and back down a corridor.
* 2236 HS exited ED through ambulance entry doors and walked into the parking lot near the vehicle that Patient 19 was placed in. The HS appeared to talk to MPDO's but did not approach the vehicle the patient was in.
* 2241 HS walked towards the police vehicle the patient was in but did not get closer than a few feet away, then walked from the parking lot back into the ED.
* 2250 The MPD vehicle the patient was in drove out of the hospital's parking lot towards the street.

2.e. The current City of Milwaukie Police website page titled "Body Worn Camera Footage Released to Pending Open Records Requests" contained the following link to Body Worn Camera footage of 1 hour and 49 minutes worn by one MPDO from time of MPDO arrival at PMH through the time of arrival at the second hospital the patient was transported to: https://www.youtube.com/watch?v=nGN5hignNeM. The footage had audio, some of which was redacted. It was also redacted to cover the faces of PMH staff and other patients. It included the following excerpts and some of the times may be approximate:
* 2157 MPDOs arrived to ED Room 19 where the patient was observed with HOB slightly raised, head slumped to the left, eyes closed, face gaunt, emaciated, bones prominent on right leg mid-thigh to mid-calf area that was not covered by pant leg and sock, minimal body movement, erratic and jerky leg movements, left leg slipped down between mattress and raised siderail, minimally responsive to PMH staff and MPDOs, making moaning and guttural sounds only.
* 2158 Hospital staff heard to say the patient "was a little more tired than [they were] previously." MPDOs attempted to converse with patient who did not respond and remained limp and lethargic with periodic jerky extremity movements.
* 2208 MPDOs transferred patient to transport chair. No PMH staff were present to assist with the transfer. The patient required two person full assist from MPDOs as their body remained limp and lethargic. The patient was handcuffed with their hands behind their back.
* 2210 MPDOs pushed patient from treatment room down hallway to exit. Patient remained non-responsive, body slumped to the right, and legs/feet were periodically repositioned by MPDOs as they slid off the footrests. Hospital staff did not assist with the transport through the ED or positioning of the patient during that transport.
* 2213 MPDO pushed transport chair through parking lot to the police car. The patient's left foot was off the footrest and dragged on the ground. An MPDO stated to another "Do you at all feel comfortable with anything that is going on right now?" The reply was "No." Then one said, "Who is somebody we could call to probably help with guidance?" They decided to call the on-duty Sergeant.
* 2215 Patient was slumped over in chair in parking lot. MPDOs are heard to state that the patient "won't stand, talk ..." and the patient was "not in any condition to be released."
* 2218 MPDO stated "No way [the patient] is even coherent enough to receive citation now."
* 2223 Patient transferred with full assist into back seat of police car. They are slumped over and seat belted.
* 2228 MPDO reentered hospital and asked for the "discharge papers." Approached a staff person and said, "Do you think [the patient's] just full of it, [faking it]?" The staff person responded that the patient "was not like that at all then literally right as the [earlier planned transport to a shelter] showed up and we said your ride is here ... the patient was against everything."
* 2234 MPDO returned to the police car. An MPDO stated "What's the reason for taking [the patient to Unity]? [The patient] doesn't say [they're] gonna kill [themselves] or hurt anybody right? In fact [they haven't said anything, [they're] just drooling on [themselves] involuntarily ..."
* 2236 The patient was seen through rear passenger door of the police vehicle to be slumped over with head on chest.
* 2238 MPDO heard in radio contact with someone and stated "we're doing a POH on this subject."
* 2247 An MPDO called the patient's name and another officer responded that the patient was "not responsive."
* 2250 The MPDO car with the patient inside drove away off hospital premises.
* 2305 MPDO drove into the LEMC UCBH ambulance bay.
* 2306 MPDOs waited for staff to present to the ambulance bay. One looked into the back seat window and stated to the other "do you see [the patient's] chest rising? "
* 2308 MPDOs opened car door and one stated they didn't know if the patient had a pulse. The MPDOs transferred the patient from the car to the ambulance bay floor, removed the handcuffs and started CPR.

2.f. During interview with staff that included the EDM, CMO, DPSR, and QMC on 12/19/2023 at 1515 they stated that the hospital had started its investigation and was still in process, they had identified some preliminary areas to address related to complex patient safety and decision making issues, but had not implemented any changes at the time of this survey.

2.g. During surveyor interview with MD F on 12/20/2023 at 1600 they confirmed they were Patient 19's physician on 12/12/2023 and provided the following information:
* MD F saw Patient 19 for the first time when the patient was in ED treatment room 19. The MD had been told by staff that the patient had a "minor fall" with no report of injuries since they'd been in the ED.
* The patient was "awake, alert, chronically unhealthy, and had not signs of distress or acute issues."
* They "provided an MSE" that consisted of a discussion of the patient's wounds and history, and the MD "examined the patient." MD F determined the wounds could be infected so ordered antibiotics and assessed no indications for further workup or interventions. MD F determined that patient was "ok to discharge."
* They did consider labs and other diagnostic testing but "didn't see" any signs of sepsis, distress, or other clinical necessity for lab orders.
* The reported fall "didn't have any relevance to the patient's ED clinical course."
* Regarding the decision to discharge MD F stated that there were "no emergency needs that would require reassessment." They stated that the "social worker" indicated they were able to get the patient to a shelter. They stated that "no one brought any concerns to indicate that that wasn't a good plan."
* Regarding the 85 minute gap in the medical record between 2002 and 2127 the MD stated the "I had moved on to other patients ... I was aware that the patient was waiting to discharge ... patient waiting for transport to shelter ... no one reported any issues."
* "Next thing" the RN reported that when they were trying to discharge the patient the patient had a "change of condition" and that the patient was purposefully dragging their legs and feet to prevent the wheelchair from being pushed forward.
* MD F proceeded to the hallway where the patient was located to assess the behavior being described and witnessed staff physically picked up the patient's legs and placed them on the foot rest. The patient was "alert, eyes open, made eye contact with me ... when the wheelchair was pushed forward the patient seemingly intentionally placed feet off of the footrest to the ground ... patient made eye contact but no verbal interactions ... a behavioral change was noted and I directed them to take patient back to the treatment room ... back in room 19 I reassessed patient ... they were awake, alert, tracking, moving extremities ... they were in no distress but were not answering questions ... I had no idea what was the change in patient's behaviors ... could have been possible reaction to previous Fentanyl use ... ther

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Based on interviews, review of central log and medical record documentation for 5 of 6 individuals who presented to the hospital for emergency services and were transferred to other hospitals for further examination or stabilizing treatment not within its capacity at the time (Patients/Encounters 1, 2, 16, 17, and 33) and review of P&Ps, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that it effected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved:
* Patients were transferred to other hospitals without a physician certification that included identification of patient specific and individualized benefits and risks of transfer.
* Patients were transferred to other hospitals in POVs by family members, contrary to section (2)(iv) of this CFR that requires "The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer." Medical transportation with qualified personnel and equipment was not used for transfer to ensure proper monitoring and response to changes in patient condition. It was not clear whether hospital staff or the patients initiated discussions about transport by POV, and what additional risks secondary to transport by POV without qualified personnel and emergency equipment had been identified and discussed.
* It was unclear whether all required and necessary medical records available at the time of transfer had been sent to the receiving hospital at the time the patient was transferred, or were provided to the receiving hospital as soon as they were available.

Findings include:

1.a. The P&P titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated as "Last Revised 02/2022" was reviewed. It included the following information:
* An MSE "is an exam completed by qualified medical personnel to determine whether an EMC or active labor exists."
* "A LIP or qualified medical personnel will perform a MSE to determine whether an EMC exists and treat the patient or stabilize the patient's condition within the capability and capacity of the ED or L&D/Perinatal Department."
* "Prior to transfer, an explanation of the need to transfer and the alternative to transfer will be made to the patient. Individualized risks and benefits will be summarized verbally and documented on the EMTALA Patient Transfer Form in the electronic medical record (EMR)."
* "Stabilized patients may be transferred to another hospital if the patient so desires. Patients may be transferred (1) at their own request, (2) at the request of a legally responsible person on the patient's behalf or (3) if physician or qualified medical personnel certifies in writing that the benefits of transferring the patient to another facility outweigh the risk. 1. Arrangements for proper conveyance will then be made; a LIP or qualified medical personnel will determine the safest method of transport. 2. If a LIP or qualified medical personnel feels it is necessary for the patient's safety, they or their qualified designee will accompany the patient during transfer."
* "The referring and receiving LIP share the responsibility for patient transfer and they should consult regarding the arrangements and details of patient transfer, including the method of transportation. The LIP or qualified medical personnel arranging transportation is responsible for determining what additional care is required before transfer. The LIP or qualified medical personnel will also determine what transportation equipment is needed, including the use of necessary and medically appropriate life support measures during the transfer."
* "Accompanying records sent with patient: 1. A copy of the ED or L&D/Perinatal Department treatment record (if applicable) 2. Flow sheet(s) 3. Laboratory results 4. X-rays 5. Progress notes 6. ECGs and/or other clinical monitoring recording 7. Transfer form(s) 8. Any other pertinent information."
* "Documentation of patient transfer will be completed electronically for each transfer. The EMTALA transfer form needs to be printed from Epic after completion, signed by the patient, and sent to HIM to be included in the EMR. A copy of the form should be sent with the patient to the accepting facility."

1.b. There was no reference or acknowledgement in the EMTALA P&P that an "appropriate transfer" for patients with EMCs that had not been ruled out, removed, or resolved included, as required by section (2)(iv) of this CFR: "The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer." Further, the P&P provided no assurance that staff would not offer POV transport as an option, and there were no provisions or steps for managing cases where patients refused medical transportation and insisted on using a POV without qualified personnel and equipment. The P&P did not recognize the additional risks of transport by POV that exist in the situation where a lay-person, caregiver, family member drives an individual with an EMC that has not been ruled out, removed, or resolved through the city during rush hour or in the middle of the night.

1.c. The P&P titled "Transfer of Maternal Perinatal Patient" dated as "Last Revised "10/2021" was reviewed. It included the following information:
* "... the transfer shall be effected through qualified personnel and transfer equipment."
* "A woman experiencing contractions is in true labor unless a qualified medical person (as defined in a hospital's medical staffing bylaws) certifies that after a reasonable time of observation the woman is in false labor."
* "The transferring LIP will determine what additional care is required before transfer, mode of transfer and what equipment and capabilities should be available en route."

1.d. The "Transfer of Maternal Perinatal Patient" P&P reflected that "The transfer is effected through qualified personnel and transportation equipment" as required by section (2)(iv) of this CFR. Similar to the EMTALA P&P, this P&P also included no provisions for transfer by POV, and no steps for managing cases where patients refused medical transportation and insisted on using a POV without qualified personnel and equipment.
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40575


2.a. The central log for Patient 1 reflected that they presented to the ED on 07/08/2023 at 0105. The chief complaint was recorded as "Laboring (Possible water broke at 2330)." The disposition on the log was "Transfer to Another Facility."

2.b. The medical record for Patient 1's 07/08/2023 ED encounter was reviewed and reflected the following information:
* At 0117 an RN Note reflected "Pt arrives from camping stating [their] water broke at 2330 and immediately started to have contractions 3-4 minutes apart. Pt 35.5 weeks pregnant receiving prenatal care at Newberg."
* At 0118 an ED Provider Note reflected "16 y.o. [sex of pt] Patient is planning on delivering in Newberg ... Patient states that [they] got up to go to the bathroom and felt a gush of fluid ... did not feel like urination ... feels like [patient] has been having contractions that are approximately 4 minutes apart ... Multiple diagnoses were considered including, but not limited to early labor, preterm rupture of membranes, urination, Braxton Hicks contractions, among others."
* "[DO K] discussed the case with [MD] at PPMC who is amenable to receiving the patient in transfer for further labor monitoring and assessment of amniotic fluid presents, however as patient is local to our area and is planning on delivering in Newberg ... [PPMC MD] states that it would not be unreasonable to also let the patient him [sic] back to Newberg for assessment."
* "[DO K] then discussed the case with Newberg on-call OB/GYN [MD name] who states that [MD name] is familiar with the patient, however patient has not formally established care with [MD] group in Newberg. Furthermore [MD] states the patient is actually 35 weeks and 2 days. Based on this if the patient did deliver in Newberg [MD] gives the neonate a 50-50 chance of requiring transfer to a higher level NICU center and indicates that the patient would likely be better served transferring to PPMC for labor evaluation."
* "The results of [MD] conversations are described to the patient and [patient] is amenable to POV transfer to PPMC."
* At 0215 The ED Timeline reflected "ED Disposition set to Transfer to Another Facility."

2.c. The electronic two-page "Patient Transfer" form in Patient 1's record contained EMTALA physician transfer certification and other required documentation and included the following:
* Beginning on Page 1 the form reflected:
- In the space for "Reason for Transfer:" was written "Service unavailable"
- In the space for "Summary of transfer benefits:" was written "Condition"
- In the space for "Patient specific transfer benefits:" was written "Access to labor monitoring and OBGYN"
- Pre-printed language on the form: "Summary of transfer risks: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport."
- In the space for "Patient specific transfer risks:" was written "Delivery en route"
- Patient 1's signature recorded at the bottom of page 1 was dated and timed as 07/08/2023 at 0219.
* The form continued on Page 2 and reflected:
- Pre-printed language on the form: "The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures. After discussion with the receiving physician, the patient and/or family, the agreed mode of transportation is ___." Written in that space was "Private auto."
- Pre-printed language on the form: "I discussed the risks and benefits with the patient/patient representative and they verbalized understanding and are in agreement with the decision to transfer. By completing this form, I authorize transfer of this patient."
- DO K's electronic signature recorded under those entries on Page 2 was dated and timed as 07/08/2023 at 0215.
- Section IV of the form reflected "Records sent with Patient: Other (enter in comments) EMTALA."

2.d. There was no documentation on the transfer form or elsewhere in the medical record to reflect what individualized and specific risks of transfer for Patient 1 and their unborn child the DO K had "discussed."

2.e. The mode of transport decision and risk discussion for this EMTALA transfer was not clear. The transfer form reflected the "The patient will be transferred by qualified personnel and transportation equipment as required ..." However, it then reflected "Private auto" as the mode to be used which does not reflect transfer by "qualified personnel and transportation equipment." It was not clear in the medical record whether Patient 1 had been initially informed that EMS transport was to be used for this transfer as required, and whether DO K or Patient 1 initiated the idea of transport by POV. There was no documentation on the transfer form or elsewhere in the medical record to reflect that DO K had informed Patient 1 of the additional risks of transfer to themselves and their unborn child secondary to transport by POV without qualified personnel and emergency equipment through the city to the other hospital during the middle of the night. In addition, the type and extent of medical records sent was not specified to ensure all required records were sent.
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3.a. The central log for Patient 2 reflected that they presented to the ED on 07/14/2023 at 1442. The chief complaint was recorded as "Abdominal Pain." The disposition on the log was "Transfer to Another Facility."

3.b. The medical record for Patient 2's 07/14/2023 ED encounter was reviewed and reflected the following information:
* At 1450 an ED Triage Note reflected "Pt started having abd pain last night with some n/v. Pt was seen at UC today and encouraged to come to the ER for appy rule out. Pt ate breakfast at 1030 today and informed to stay NPO."
* At 1623 "Patient roomed in ED, to room ED21."
* At 1648 an ED Provider note reflected "There is area of possible hemorrhagic ovarian cyst versus active bleeding from a small pelvic vessel in the left adnexal region. I spoke with [PPMC OB] who advised obtaining a pelvic ultrasound and repeating [patients] blood work after 4 hours. Pelvic ultrasound revealed 9.7 complex left adnexal mass with blood flow internally. The left ovary cannot be distinguished from the mass along this region. Moderate amount of free fluid in the pelvis. Repeat hemoglobin hematocrit was 10.6 and 31.0. I contacted [PPMC OB] again and discussed findings with [PPMC OB]. [PPMC OB] felt patient would benefit from transfer and admission for further evaluation. I discussed findings with the patient and [the patient] was agreeable to transfer at this time. [Patient 2] remained normotensive and no findings of tachycardia or hemodynamic instability. We discussed EMS transport versus private auto where [patient's] partner would take [patient] and [patient] opted to go by private vehicle. I felt that the patient's clinical picture was most consistent with left ovarian mass and nontraumatic hemoperitoneum. Advised patient not to eat or drink anything and go immediately to Portland Providence Medical Center for inpatient admission and further evaluation."
* At 1706 Morphine 4mg IV and Zofran 4mg IV were documented as given.
* At 1926 US Pelvis started.
* At 2027 Morphine 4mg IV documented as given.
* At 2150 an ED Note titled "ED Discharge Dot Phrase" reflected "Transportation mode: POV with [family member]," "Was this transportation mode determined to be the safest way to transport patient? yes" and "Pt is alert and oriented and in NAD. Pain was addressed with medication prior to discharge and pt will report directly to PPMC ED from here. Pt and [family member] instructed not to make any stops, pt not to eat or drink anything en route. Pt reminded of necessity to maintain PIV without tampering or using this on the way to PPMC."
* At 2228 the ED Timeline reflected "Patient discharged."

3.c. The electronic two-page "Patient Transfer" form in Patient 2's record contained EMTALA physician transfer certification and other required documentation and included the following:
* Beginning on Page 1 the form reflected:
- In the space for "Reason for Transfer:" was written "Service unavailable"
- In the space for "Summary of transfer benefits:" was written "Higher level of service available"
- In the space for "Patient specific transfer benefits:" was written "Urgent evaluation and treatment of ovarian mass and hemoperitoneum"
- Pre-printed language on the form: "Summary of transfer risks: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport."
- In the space for "Patient specific transfer risks:" was written "Worsening pain or bleeding or hypertension"
- Patient 2's signature recorded at the bottom of page 1 was dated and timed as 07/14/2023 at 2220.
* The form continued on Page 2 and reflected:
- Pre-printed language on the form: "The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures. After discussion with the receiving physician, the patient and/or family, the agreed mode of transportation is ___." Written in that space was "Private auto."
- Pre-printed language on the form: "I discussed the risks and benefits with the patient/patient representative and they verbalized understanding and are in agreement with the decision to transfer. By completing this form, I authorize transfer of this patient."
- MD B's electronic signature recorded under those entries on Page 2 was dated and timed as 07/15/2023 at 2209.

3.d. The mode of transport decision and risk discussion for this EMTALA transfer was not clear. The transfer form reflected "The patient will be transferred by qualified personnel and transportation equipment ..." However, it then reflected "Private auto" as the mode to be used which does not reflect transfer by "qualified personnel and transportation equipment." It was not clear in the medical record whether Patient 2 had been initially informed that EMS transport was to be used for this transfer as required, and whether MD B or Patient 2 initiated the idea of transport by POV. There was no documentation on the transfer form or elsewhere in the medical record to reflect that MD B had informed Patient 2 of the additional risks of transfer to themselves secondary to transport by POV without qualified personnel and emergency equipment through the city to the other hospital.

3.e. During interview with EDM and QMC on 12/20/2023 at the time of the ED record review, they confirmed the lack of clear transfer risk and POV transport information in the records of Patients 1 and 2.
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4.a. The central log for Patient 16 reflected that they presented to the ED on 11/17/2023 at 1734 with a "Chief Complaint" of "Homeless; Mental Health Evaluation." The "ED Disposition" on the log was "Transfer to Another Facility" on 11/18/2023 at 1058.

4.b. The medical record for Patient 16's 11/17/2023 ED encounter was reviewed, reflected that an MSE was conducted by an MD, and included the following information:
* At 1734 the patient's "Arrival Complaint" was recorded as "Pt unable to remain calm."
* At 1740 an RN recorded that "Brought in by [family member]. Pt been homeless and unable to stay calm ... Hx schizophrenia. Not taking any meds."
* At 1942 a QMHP electronically signed an evaluation that reflected "... current psychosis causing grave disability ... the patient's symptoms are considered too severe for a lower level of care as exhibited by psychotic behavior and paranoid behavior ... acutely psychotic requiring an IP setting to stabilize ... will remain in the ED boarding model pending final psychiatric disposition ..."
* At 2103 MD F electronically signed an "Emergency Department Provider Note" that included the following: "Clinical picture consistent with psychosis secondary to untreated schizoaffective disorder. Patient is homeless. [The patient] denies SI/HI but is not showing signs of being able to adequately care for self in the community. The patient was evaluated by social work who recommend [sic] inpatient evaluation."
* On 11/18/2023 at 0005 an RN recorded that "... pt pulling hair out, when asked why pt is pulling hair pt does not respond ..."
* At 0749 an RN recorded "Elopement Risk: Yes
* At 1058 DO G completed and electronically signed the EMTALA "Patient Transfer" form described in the finding below.
* At 1527 an RN recorded "Elopement Risk: Yes"
* At 1747 an RN recorded "Patient discharged."
* At 1951 MD B electronically signed a note that "Patient was placed on a transport hold. Secure transport arrived and [the patient] was discharged into their care for transfer for inpatient psychiatric admission."

4.c. The electronic two-page "Patient Transfer" form in Patient 16's record contained EMTALA physician transfer certification and other required documentation and included the following:
* In the space for "Reason for Transfer:" was written "Service unavailable Patient requires inpatient psychiatric care"
* Pre-printed language on the form: "Summary of transfer risks: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
* In the following space for "Patient specific transfer risks:" was written "Worsening behavior."
* Pre-printed language on the form: "The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures. After discussion with the receiving physician, the patient and/or family, the agreed mode of transportation is ___." Written in that space was "Secure transport."
* Pre-printed language on the form: "I discussed the risks and benefits with the patient/patient representative and they verbalized understanding and are in agreement with the decision to transfer. By completing this form, I authorize transfer of this patient."
* DO G's electronic signature recorded under those entries on Page 2 was dated and timed as 11/18/2023 at 1058.
* Section IV of the form reflected "Records sent with Patient: Medical Records;" [sic]

4.d. There was no documentation on the transfer form or elsewhere in the medical record to reflect what individualized and specific risks of transfer for Patient 16 DO G had "discussed." It was not clear whether the "discussion" had occurred with the severely psychotic patient or with their representative. The physician certification of transfer risks reflected that DO G had written "Worsening behavior." However, that risk is akin to the "worsening ... condition" inherent to all transfers. It was not clear what "worsening behavior" meant in the case of Patient 16. In addition, the type and extent of medical records sent was not specified to ensure all required records were sent.

4.e. During interviews with the MES and the QMC at the time of the ED record reviews on 12/21/2023 beginning at 1445 no additional information regarding transfer risks was provided.

4.f. Internet/GPS distance calculators reflected that HMC in Hillsboro, Oregon was ~ 26 miles, and ~ 45 minutes drive-time in "light traffic", from PMH in Milwaukie, Oregon.
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5.a. The central log for Patient 17 reflected they presented to the ED on 12/01/2023 at 1759. The chief complaint was recorded as "Suicidal, Homicidal." The disposition on the log was "Transfer to Another Facility."

5.b. The medical record for Patient 17's 12/01/2023 ED encounter was reviewed and reflected the following information:
* At 1809 a ED Triage Note reflected "Pt arrives with [parent], states not feeling will mentally, asks [parent] to step out of room to share info states uncomfortable with [parent] in room, pt states tried to kill myself on Thanksgiving, took [family member's] tequila, ibuprofen, wine and THC CBD gummy, no eval, reports SI denies plan but "doesn't mean I don't want to do it," reports HI against [2 family members] worse than punch them because of what they've done, no psych meds or therapist, lives with [siblings], [parent] and step [parent], not older [sibling] or bio [parent], switch custody in June, reports feels safe at home."
* At 1817 "Patient roomed in ED, to room ED12."
* At 1820 an RN documented an ED Quick Note that reflected "Additional Note: informing pt of POC and changing to scrubs/belongings for safety, pt states [they have] a razor blade in [their] phone case, pt removed and given to RN, placed in sharps container."
* At 2006 an "ED Behavioral Health Emergent Assessment Evaluation" was completed by a LCSW. The BH evaluation reflected "Formulation of plan: Due to risk of harm to self, I believe the patient meets criteria for Psychiatric Hospitalization at this time. The patient meets criteria for inpatient admission."
* At 0922 on 12/02/2023 a ED Behavioral Health Reevaluation reflected "pt remains unable to safety plan for discharge. Based on current acuity of depression with recent impulsive suicide attempt and self-harm, pt continues to meet criteria for inpatient treatment. Addendum 1630: per ProvAIR, pt had been accepted for transfer to inpatient treatment at CAPU ... SW requested secure transport ..."
* At 1627 on 12/02/2023 "ED Disposition set to Transfer to Another Facility."

5.c. The electronic two-page "Patient Transfer" form in Patient 17's record contained EMTALA physician transfer certification and other required documentation and included the following:
* Beginning on Page 1 the form reflected:
- In the space for "Reason for Transfer:" was written "Service unavailable" under this line was "Comments: Adolescent psychiatry"
- In the space for "Summary of transfer benefits:" was written "Higher level of service available at receiving facility."
- In the space for "Patient specific transfer benefits:" was written "Adolescent psychiatry"
- Pre-printed language on the form: "Summary of transfer risks: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death."
- In the space for "Patient specific transfer risks:" was written "Worsening of condition"
- Patient 17's Guardians signature recorded at the bottom of page 1 was dated and timed as 12/03/2023 at 1245.
* The form continued on Page 2 and reflected:
- Pre-printed language on the form: "I discussed the risks and benefits with the patient/patient representative and they verbalized understanding and are in agreement with the decision to transfer. By completing this form, I authorize transfer of this patient."
- MD D's electronic signature recorded under those entries on Page 2 was dated and timed as 12/02/2023 at 1628.
- Section IV of the form reflected "Records sent with Patient: yes."

5.d. There was no documentation on the transfer form or elsewhere in the medical record to reflect what individualized and specific risks of transfer for Patient 17 MD D had "discussed." The physician certification of transfer risks reflected that MD D had written "Worsening of condition." However, that is risk inherent to all transfers, and it was not clear what "Worsening of condition" meant in the case of this suicidal patient. In addition, the type and extent of medical records sent was not specified to ensure all required records were sent.

5.e. During interview with EDM and QMC on 12/20/2023 at the time of the ED record review, they confirmed the lack of clear transfer risk information for Patient 17.
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6.a. The central log for Patient 33 reflected they presented to the ED on 05/11/2023 at 1405. The chief complaint was recorded as "Neck Pain." The disposition on the log was "Transfer to Another Facility."

6.b. The medical record for Patient 33's 05/11/2023 ED encounter was reviewed and reflected the following information:
* At 1420 an RN documented "Triage Started."
* At 1422 an ED Triage Note reflected "Pt c/o sudden 4/10 neck pain starting earlier today. Recent hx of stroke and brain anyreusm [sic] stapled sx about 1x month ago, and a shunt placement about 2 weeks ago. Denies weakness/numbness."
* At 1511 Lab work and CT Angio Head Neck orders were placed.
* At 1659 "Patient roomed in ED, To room EDO7."
* At 1713 an ED Provider Note reflected "... recent intracranial aneurysm that had a subarachnoid hemorrhage and required clipping. The patient also underwent VP shunting. The patient was just discharged from the inpatient neurosurgical stay 1 week ago ... The patient was sent for CT scan of the head which reveals a new small sub-1 cm subdural hematoma on the right. Neurosurgery from [PSVMC] was consulted and they requested the patient be transferred back to St. Vincent's for further monitoring and repeat imaging."
* At 1735 "Peripheral IV Line ... placed."
* At 1656 a Unit Coordinator documented "CM/SW Assessment, Planned Discharge, Transportation Will Be Provided By: taxi, Planned Transportation Date: 05/11/23, Planned Transportation Time: 2145, Ride - Contact Name: Ride to Care (taxi) ComTrans ETA @ 2015-2145."
* At 2003 Vital signs were documented as BP: 133/102, Pulse: 76, Resp: 17.
* At 2119 "Patient discharged" and "Departure Condition, Mobility at Departure: Wheelchair, Departure Mode: With transport tech."

6.c. The electronic two-page "Patient Transfer" form in Patient 33's record contained EMTALA physician transfer certification and other required documentation and included the following:
* Beginning on Page 1 the form reflected:
- In the space for "Reason for Transfer:" was written "Service unavailable."
- In the space for "Summary of transfer benefits:" was written "Higher level of service available at receiving facility"
- In the space for "Patient specific transfer benefits:" was written "Neurosurgical services"
- Pre-printed language on the form: "Summary of transfer risks: All transfer have the risk of traffic accidents, bad weather and /or road conditions as well as limitations of personnel and equipment during transport. There is potential for worsening of medical condition during transport resulting in possible disability and/or death."
- In the space for "patient specific transfer risks:" was written "Due to time away from the acute care setting necessary to effect the transfer, the patient is at risk of clinical deterioration of the following condition(s): Subdural hematoma (HCC) (primary encounter diagnosis) Patient/condition specific risks of transfer include: Worsening subdural"
- The "Patient/Guardian Signature" line was blank.
* The form continued on Page 2 and reflected:
- The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures. After discussion with the receiving physician, the patient and/or family, the agreed mode of transportation is ALS."
- Pre-printed language on the form: "I discussed the risks and benefits with the patient/patient representative and they verbalized understanding and are in agreement with the decision to transfer. By completing this form, I authorize transfer of this patient."
- MD E's electronic signature recorded under those entries on Page 2 was dated and timed as 05/11/2023 1940.
- Section IV of the form reflected "Records sent with Patient: yes."

6.d. The patient arrived to PSVMC in a taxi instead of the ALS transport the MD E requested. It is not clear how or why a taxi was set up for transport instead of an ambulance with proper medical personnel and equipment. The transfer form listed patient specific risks as "Subdural hematoma" which is the primary encounter diagnosis.

6.e. During interview with EDM and QMC on 02/15/2024 at 0905, they confirmed the transportation for this patient was not appropriate in this case. In addition, the type and extent of medical records sent was not specified to ensure all required records were sent.