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Based on observation, interview, review of medical record or other documentation for 10 of 19 patients who presented to the hospital for emergency services (Patients 1, 4, 8, 9, 11, 12, 14, 16, 19 and 20), review of central log documentation and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and enforce EMTALA policies and procedures to ensure it met its EMTALA obligations in the following areas:
* To conspicuously post signs in all areas individuals wait for examination and treatment that specify individual's rights under EMTALA.
* To maintain a central log that is complete and accurately reflects patients' dispositions from the ED.
* To not delay examination and/or treatment in order to inquire about the individual's insurance or payment status.
* To provide MSEs for all individuals who present to the hospital for emergency services.
* To obtain or attempt to obtain written and informed refusal of MSEs, treatment or an appropriate transfer in the case of an individual who refuses examination, treatment or transfer.
* To ensure availability of on-call specialty physicians to come into the hospital at the request of the ED physician, and to accept patients from other hospitals that request transfer for speciality services SCHHC has capabilities to provide.
* To provide necessary stabilizing treatment to an individual with an EMC or an individual in labor.
* To affect appropriate transfers to other hospitals for patients who require further examination and stabilizing treatment that is not within the capability and capacity of SCHHC.
* To accept transfers of patients with emergency medical conditions from other hospitals if SCHHC has the specialized capabilities not available at the transferring hospital and has the capacity to treat those patients.
* To not take adverse action against a physician or qualified medical personnel who refuses to transfer an individual with an emergency medical condition, or against an employee who reports a violation of these requirements.

Findings included:

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

2. Refer to the findings identified under Tag C2405, CFR 489.20(r)(3) that reflects the hospital's failure to maintain a complete and accurate ED central log.

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

4. There were no policies and procedures developed to ensure the hospital met its EMTALA obligations that included, but were not limited to:
* Posting of signs.
* Maintenance of the central log.
* Provision of MSEs to all individuals who present for emergency services.
* Assurance that MSEs or treatment would not be delayed to inquire about payment.
* Provision of stabilizing treatment within the hospital's capabilities.
* On-call physician responsibilities to come into the hospital, and to accept patients in transfer.
* Appropriate transfer when the hospital lacks capability and capacity to provide further examination and stabilizing treatment.
* Recipient hospital responsibilities to accept patients from other hospitals.
* Whistleblower protection.

5. During interview with the R&Q and the NM on 01/31/2019 during review of documents beginning at 1130 they confirmed that the hospital's EMTALA policies and procedures were incomplete and stated that "draft" policies and procedures were in progress.

Based on observation, interview and review of policies and procedures it was determined the hospital failed to develop and 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. A tour of the ED was conducted with the R&Q and the NM on 01/30/2019 at approximately 1715. There was one 8 1/2" by 11" sign posted on the wall of the hallway immediately outside of the ED department where two or three chairs were located. That was the only EMTALA sign observed in or near the ED. There was no EMTALA signage observed to be posted in other areas where individuals waited for emergency services examination or treatment that included:
* Inside of the registration office/room.
* On the walls near the registration office/room.
* In the waiting room area between the main hospital entrance and the ED.
* Inside the ED department that contained two curtained bays and two rooms with doors.

The findings were confirmed during interviews with the R&Q and the NM during the tour on 01/30/2019.

2. There were no policies and procedures related to EMTALA requirements to conspicuously post signs, that specified the rights of individuals under EMTALA with respect to examination and treatment for emergency medical conditions and women in labor, in areas where individuals wait for examination and treatment.

3. During interview with the R&Q and the NM on 01/31/2019 during review of documents beginning at 1130 they confirmed that the hospital's EMTALA policies and procedures were incomplete and stated that "draft" policies and procedures were in progress.

Based on interview, review of documentation in 8 of 19 medical records of patients who presented to the hospital for emergency services (Patients 8, 9, 11, 12, 14, 16, 19 and 20), review of central log documentation and review of hospital policies and procedures it was determined that the hospital failed to develop and enforce EMTALA policies and procedures to ensure a central log was maintained for completeness and accurately reflected individuals' dispositions from the ED.

Findings include:

1. Review of the central log for Patient 8 reflected that he/she presented to the ED on 10/16/2018 at 0019 and the reason the patient presented was "cut wrists." The disposition on the log was recorded as "home." However, review of the ED record for Patient 8 reflected that the patient was experiencing psychiatric issues including "self-harm" and he/she was transferred to BAH for further examination and stabilizing treatment. The log did not accurately reflect that the patient was transferred to another hospital.

2. Review of the central log for Patient 9 reflected that he/she presented to the ED on 10/18/2018 at 1101 and the reason the patient presented was "poss PTSD." The space on the log for the disposition from the ED was blank.

3. Review of the central log for Patient 11 reflected that he/she presented to the ED on 10/30/2018 at 1505. The space on the log for the reason the patient presented was blank.

4. Review of the central log for Patient 12 reflected that he/she presented to the ED on 11/01/2018 at 0657 and the reason the patient presented was "personal (sic) issue" and the disposition on the log was recorded as "home." Review of the ED record for Patient 12 reflected that the patient presented for acute pain and swelling of the genitals. The record further reflected that the ED MD consulted the BAH urologist on call and sent the patient to the BAH urologist for further examination and stabilizing treatment. The log did not accurately reflect the reason the patient presented and did not reflect that the patient was sent to another hospital's on-call physician. Refer to Tag C2409 that reflects the detailed findings of an inappropriate transfer for Patient 12.

5. Review of the central log for Patient 14 reflected that he/she presented to the ED on 12/05/2018 at 1919 and the reason the patient presented was "chest pain." The space on the log for the disposition from the ED was blank.

6. Review of the central log for Patient 16 reflected that he/she presented to the ED on 12/13/2018 at 1215 and the reason the patient presented was "atrial flutter." The disposition on the log was recorded as "observation." It was not clear whether the patient's disposition from the ED was admitted as an inpatient, transferred to another hospital or discharged to home.

7. Review of the central log for Patient 19 reflected that he/she presented to the ED on 12/26/2018 at 1444 and the reason the patient presented was "[shortness of breath]." The disposition on the log was recorded as "observation." It was not clear whether the patient's disposition from the ED was admitted as an inpatient, transferred to another hospital or discharged to home.

8. Review of the central log for Patient 20 reflected that he/she presented to the ED on 01/05/2019 at 0800 and the reason the patient presented was "pregnancy concern." The disposition on the log was recorded as "home." However, review of the ED record for Patient 20 reflected that the patient was experiencing "fetal distress" and he/she was directed by the ED MD to go to another hospital for obstetrical services via private vehicle. The log did not accurately reflect that the patient was sent to another hospital for further examination and stabilizing treatment. Refer to Tag C2409 that reflects the detailed findings of an inappropriate transfer for Patient 20.

9. There were no policies and procedures related to EMTALA requirements to maintain a complete and accurate central log for the purpose of tracking all individuals who came to the hospital for emergency services.

10. During interview with the R&Q and the NM on 01/31/2019 during review of documents beginning at 1130 they confirmed that the hospital's EMTALA policies and procedures were incomplete and stated that "draft" policies and procedures were in progress.

Based on interview, review of documentation in 4 of 7 medical records of patients who were transferred from SCHHC to another hospital for specialty services not available at SCHHC (Patients 1, 4, 12 and 20) and review of hospital policies and procedures, it was determined that the hospital failed to develop and enforce EMTALA policies and procedures to ensure that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved. The following required appropriate transfer elements were not carried out:
* It was unclear whether stabilizing treatment within the hospital's capability had been provided.
* The receiving hospital had not been contacted and agreed to accept the patient for further examination and stabilizing treatment within the receiving hospital's capability and capacity.
* There was no physician certification, or the physician certification lacked patient specific and individualized medical benefits vs patient specific risks of transfer.
* Transfers were not affected using appropriate transportation with qualified personnel and necessary and medically appropriate life support measures during transfer.
* Medical records were not sent to the receiving hospital.

Findings include:

1. The hospital's organizational chart dated 01/11/2019 and the hospital's website reflected that the hospital provided medical, surgical, respiratory, laboratory, radiology, pharmacy, emergency and swing-bed services. Services provided did not include obstetrical services.

2. There were no policies and procedures that complied with EMTALA requirements to ensure that all patients for whom an MSE determined required further examination and stabilizing treatment not within the capability or capacity of SCHHC would receive an appropriate transfer to another hospital that had the capability and capacity. Policies and procedures provided were unclear, incomplete and inaccurate. Those policies and procedures were not customized for SCHHC and did not clearly and accurately reflect provisions to ensure the hospital's compliance with its obligations under EMTALA. The only references to appropriate transfers were in the following three documents:

a. An undated "Lippincott Procedure" titled "Obstetric triage of patients" was dated as revised 02/16/2018 and contained the following reference to EMTALA: "Having specific procedures for obstetric triage ensures compliance with Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, which require health care practitioners to examine a patient to determine whether an emergency medical condition exists, to provide necessary stabilizing treatment when an emergency medical condition is identified, and to stabilize the patient or, if a practitioner certifies that the benefits of transfer outweigh the risks, arrange for proper transfer to another facility. In addition, hospitals are prohibited from delaying patient assessment and treatment because of a patient's insurance coverage or ability to pay. Under EMTALA, a physician, certified nurse-midwife, or other qualified medical professional (acting within the scope of practice and state law) is required to certify all patient assessments and dispositions."

This procedure contained the following reference to transfers that reflected "If the patient is to be transferred to another facility: Ensure that the patient has been informed of the risks involved and has signed a consent form for transfer. Confirm that permissions has been obtained from both facilities, that the practitioner has certified in writing that the benefits of transfer outweigh the risks, that the patient's necessary medical records will accompany her, and that any necessary equipment and qualified personnel will be present during transport. Make sure that the reconciled list of the patient's medications has been communicated to the next practitioner who will be caring for the patient...Make sure that handoff communication is provided to the person who will assume responsibility for the patient's care and that it is documented in the patient's medical record." There were were no other references to EMTALA appropriate transfer requirements in the 10-page document.

b. An undated "Lippincott Procedure" titled "Patient Transfer" contained the following reference to EMTALA: "To provide guidelines for the safe transfer of patients to another facility in accordance with Federal and State laws and regulations including but not limited to Emergency Medical Treatment and Labor Act (EMTALA), as well as industry best practices...Patients may be transferred from [SCHHC] for a variety of reasons including patient's condition requiring treatment not available at SCHHC or patient request...Provider makes decision to transfer patient to another facility and determines appropriateness of transfer, in accordance with all federal and state regulations...Provider contacts receiving provide for patient acceptance and gives report to receiving provider. Provider completes appropriate transfer form...Hospital staff arranges for patient transportation via provider designated level of transportation...Nursing staff copies patient's visit information including, as applicable: [all medical record documentation]..." There were were no other references to EMTALA appropriate transfer requirements in the document.

c. The SCHHC "Medical Staff Rules & Regulations" dated as approved on 01/12/2016 contained the following reference to EMTALA transfers:
* "[SCHHC], in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA), along with all members of the Medical Staff, will comply with the policies regarding patient transfers and shall comply with all applicable laws regarding patient transfers."

There was no other information related to EMTALA transfers.

3. a. The ED medical record of Patient 20 reflected that he/she presented to the hospital for emergency services on 01/05/2019 at 0805 and included the following documentation related to Patient 20's ED encounter:
* At 0825 an RN documented on an "ED Nursing Triage" note that the patient was "37.3 weeks pregnant, not feeling baby kick x 2 days," the patient's BP was 149/94, and "Dopplered baby HR, started at 80bpm finished at 144bmp (sic)."
* At 0847 an MD documented on an "ED Provider Note" that "ER Disposition...Diagnosis: Decreased fetal movement...Discharged...You should go directly to Bay Area Hospital for further evaluation."
* At 0850 an RN documented on an "ED Nursing Documentation" note that "Pt concerned with baby not kicking much x2 days, doppler heartrate 80bpm with contraction, 144bpm otherwise. Instructed to go to BAH right away after discharge."
* At 0855 Patient 20 signed an "ED Discharge Instructions" document that reflected "Discharge Instructions...Diagnosis: Decreased Fetal movement...Disposition: Discharged; Condition: Stable; Diagnosis Specific Education: Diagnosis related handout given; Medication Risks, Benefits, Alternatives; You should go directly to Bay Area Hospital for further evaluation."
* At 0904 an MD documented on an "ED Provider Note" that "Patient is 37 weeks pregnant and presents stating that [he/she] has felt decreased fetal movements for the past couple of days and wants to make sure the baby has a heartbeat. Up until this point, there have been no complications with the pregnancy. [He/she] has not had any pain. No vaginal bleeding or leakage of fluids...Limited bedside ultrasound performed to assess fetal viability. Fetus had decreased activity. FHR initially was around 120-140. However, while the probe was still on the abdomen, the HR dropped to around the 80's. The patient stated [he/she] felt like [he/she] may be having a contraction. This is a sign of fetal distress, and I instructed the patient to go directly to Bay Area Hospital for OB eval, likely NST. The patient was here with [his/her] sibling], who will take [Patient 20] directly to Bay Area...Disposition: Discharged, Condition: Stable."
* There was no transfer form required by the transfer policy identified under finding 2. b. above.

There was no documentation in the ED medical record, including on the transfer form required by hospital transfer procedures, to reflect that an appropriate transfer had been affected:
* It was not clear whether stabilizing treatment within the hospital's capabilities had been provided.
* BAH had not accepted the patient in transfer.
* The ED MD had not certified that the reasons and benefits for the transfer outweighed the patient-specific risks of transfer.
* Medical records were not sent.
* Patient 20 who had signs of "fetal distress" was not transferred using appropriate transportation, equipment and qualified personnel and instead was told to drive to BAH in a private vehicle.
* It was not evident whether the patient had refused appropriate transportation or whether the use of a private vehicle was offered or encouraged by ED staff.
* Patient 20 had not been informed of the additional risks of transport via private vehicle with an EMC that had not been ruled out, removed or resolved.

b. An on-line distance calculator reflected that the distance between SCHHC and BAH is approximately 27 miles and drive time of 43 minutes on rural, coastal two-lane highway.

c. Further, review of the central log for Patient 20 reflected that he/she presented to the ED for a "pregnancy concern" and the disposition from the ED was recorded as "home." However, review of the ED record for Patient 20 reflected that the patient was experiencing "fetal distress" and he/she was directed by the ED MD to go to another hospital via private vehicle immediately. The log did not accurately reflect that the patient was sent or transferred to another hospital. Refer to Tag C2405 that reflects the central log for Patient 20 was not accurate.

d. Documentation on SCHHC "Follow up Communication Center" notes included the following in relation to Patient 20's ED encounter:
* On 01/18/2019 at 1133 an entry reflected "Spoke with nurse on duty...[he/she] stated [he/she] was under the impression that [ED MD] had consulted someone at BAH before [the nurse] discharged the patient...[he/she] assumed [ED MD] had spoken to someone at BAH before we discharged the pt."
* On 01/21/2019 at 1204 an entry reflected "...we were able to identify that we made an EMTALA violation. [BAH staff] reported that [Patient 20] went in for an immediate C Section. Baby's apagars (sic) we (sic) 3 and 5. The baby stayed for a brief time and was transferred to [SHRB]."
* On 01/21/2019 at 1547 an entry reflected "[ED RN] states [he/she] 'assumed [ED MD] had consulted someone'...also said, 'I asked [ED MD] if the patient was going to go by ground ambulance? the provider told [ED RN] no the pt is going by private vehicle.'

e. During interview with hospital leadership staff that included the CEO, CNO and R&Q on 01/30/2019 at 1640 it was confirmed that Patient 20 who presented to the ED on 01/05/2019 with complications of pregnancy had not been appropriately transferred, including having been directed by the ED physician to drive him/herself to BAH for obstetric services. They further stated that as soon as they became aware of the violation they initiated an investigation and began to implement corrective actions that included policy development, and medical staff and ED staff training.

4. a. The ED medical record of Patient 1 reflected that he/she presented to the hospital for emergency services on 08/04/2018 at 1755 and included the following documentation related to Patient 1's encounter:
* At 1806 an RN documented on an "ED Nursing Triage" note that "patient states this is [his/her] 4th pregnancy...1 previous miscarriage at 6 weeks of gest,...complaint of vag bleeding and cramping since 1400 [yesterday], reports being 5 weeks pregnant."
* At 1830 an MD documented on an "ED Provider Note" that "Patient with vaginal bleeding and pelvic pain in [his/her] 1st trimester differential diagnosis should include, (sic) abortion, ectopic pregnancy, molar pregnancy. H&H within normal limits, serum quantitative HCG pending, vital signs within normal limits, no ultrasound available at this time in this facility. case discussed with the emergency physician from Bay Area Hospital [BAH ED MD] who accepted the patient for transfer. I had an extensive discussion with the patient about need for follow up and indications to return. They agree to this plan and can return if needed."
* At 1834 an RN documented on an "ED Nursing Documentation" note that and IV access was obtained and labs were drawn from that access.
* At 1918 the MD documented on the "Patient Transfer Form" that "I authorize/order the transfer of [Patient 1] to BAH...I further certify that this patient's emergency medical condition is stabilized and he/she is able to be transferred by non-ambulance transfer...Support/treatment during transfer [none]...Condition: Stable [not checked]...Unstable [not checked]...Physician Certification...Benefit(s) of transfer: ultrasound...Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific): Accident...Risks of transport: All transfers have the inherent risks of traffic delays, accident during transport..."
* At 1945 the "Patient Left the Building" as documented by an RN on the "Patient Transfer Form." The RN also documented that the patient had an "IV access 20[gauge]" in place; that numerous records were sent with the patient that included "Xrays/CT Scans."
* At 1955 an RN documented on an "ED Nursing Documentation" note that "Disposition: Transferred...Transferred Via: Ambulatory, Private auto; Accompanied by: Patient, Spouse/SO; Reason for Transfer: Patient requires services which are not available at the transferring hospital at time of the patient's transfer...Mode of Transportation: Private Care; Support/Treatment During Transfer: None...Accompanying Documentation sent via: Patient/Responsible Party...Transport team from ___ at bedside to provide transport to receiving hospital for further care. Verbal report given. Transfer Form and accompanying documentation sent with this team for receiving hospital...Pt transferred and self transported to BAH to report to the ED...Pt has IV in place. MD states to leave IV intact. Receiving nurse advised. Pt transported by spouse via private auto."

The record contained the following inconsistencies and omissions:
* There was no documentation to reflect the details of the MD's "extensive discussion with the patient."
* There was no documentation to reflect that "Xrays/CT Scans" identified on the transfer form had been obtained during the ED visit.
* The disposition documentation by the RN was not clear where it reflected that the patient was transported both by a "transport team" and by "spouse via private auto."

The documentation reflected that an appropriate transfer had not been affected:
* It was not clear whether stabilizing treatment within the hospital's capabilities had been provided.
* The ED MD's certification that the reasons and benefits for the transfer outweighed the risks of transfer did not identify the patient-specific, "clinically specific" risks of the transfer and identified only "Accident" as a risk when that was already identified as a generic risk for all transport.
* Patient 1 was not transferred using appropriate transportation with qualified personnel and instead was told to drive to BAH in a private vehicle with an IV access in place.
* It was not evident whether the patient had refused appropriate transportation or whether the use of a private vehicle was offered or encouraged by ED staff.
* Patient 1 had not been informed of the additional risks of transport via private vehicle with an EMC that had not been ruled out, removed or resolved.

b. An on-line distance calculator reflected that the distance between SCHHC and BAH is approximately 27 miles and drive time of 43 minutes on rural, coastal two-lane highway

5. a. The ED medical record of Patient 12 reflected that he/she presented to the hospital for emergency services on 11/01/2018 at 0657 and included the following documentation related to Patient 12's ED encounter:
* At 0704 an RN documented on an "ED Nursing Triage" note that the "Pt states concerned [he/she] 'broke [his/her] penis' Pt states had morning erection and adjusted self then heard loud 'pop' and felt sharp pain in penis. States penis is swollen No dysuria. no difficulty urinating."
* At 0900 Patient 12 signed an "ED Discharge Instructions" document that reflected "Discharge Instructions...Diagnosis: Penile fracture." There was no other patient specific information and no directions to go "immediately" to the BAH urologist.
* At 0904 an MD documented on an "ED Provider Note" exam and assessment findings that included "Genitourinary: 4 centimeters x 1 centimeters hematoma dorsal aspect of penis no blood at the meatus...After taking history and performed physical exam differential includes penile fracture versus superficial penile injury versus urethral injury patient hemodynamically stable no active bleeding able to urinate on physical exam diagnosis most consistent with penile fracture [BAH urologist] consulted and requested that patient Dr. (sic) immediately to [his/her] office for evaluation patient able to drive to Coos Bay for evaluation no indication for medical transport patient is hemodynamically stable and appropriate for outpatient management I had an extensive discussion with the patient about need for follow up and indications to return. They agree to this plan and can return if needed...Diagnosis: Penile fracture."
* At 0907 an RN documented on an "ED Nursing Documentation" note that the patient was "discharged to: Home...11/01/2018 0906."

The record lacked the following:
* There was no documentation to reflect the details of the consultation from the BAH on-call urologist including why the BAH on-call urologist accepted the patient and directed that the patient be sent "immediately," yet instructed that the patient be sent to the BAH on-call urologist office instead of the BAH ED.
* There was no documentation to reflect the details of the ED MD's "extensive discussion with the patient."
* There was no documentation to reflect that any diagnostic testing within the capabilities of the hospital had been conducted.
* There was no documentation to reflect that any stabilizing treatment had been provided.

Although the BAH on-call urologist accepted Patient 12 for further examination and stabilizing treatment, there was no documentation in the ED medical record, including on the transfer form required by hospital transfer procedures, to reflect that an appropriate transfer had been affected:
* Stabilizing treatment had not been provided within the hospital's capabilities.
* The ED MD had not certified that the reasons and benefits for the transfer outweighed the patient-specific risks of transfer.
* Medical records were not sent.
* Patient 12 was not transferred using appropriate transportation with qualified personnel and instead was told to drive to BAH in a private vehicle.
* It was not evident whether the patient had refused appropriate transportation or whether the use of a private vehicle was offered or encouraged by ED staff.
* Patient 12 had not been informed of the additional risks of transport via private vehicle with an EMC that had not been ruled out, removed or resolved.

b. An on-line distance calculator reflected that the distance between SCHHC and BAH is approximately 27 miles and drive time of 43 minutes on rural, coastal two-lane highway.

c. In addition, review of the central log for Patient 12 reflected that he/she presented to the ED for "personal (sic) issue" and the disposition from the ED was recorded as "home." However, review of the ED record for Patient 12 reflected that the ED MD consulted the BAH urologist on call and sent the patient to the BAH urologist for further examination and stabilizing treatment. The log did not accurately reflect the reason the patient presented and did not reflect that the patient was sent "immediately" to another hospital's on-call physician. Refer to Tag C2405 that reflects the central log for Patient 12 was not accurate.

d. According to an article on the NCBI NHI website dated September 2014: "Penile fracture is an uncommon urological trauma,,,It is defined as a rupture of the tunica albuginea due to trauma or abrupt lateral bending of the penis in an erect state...Classic features include the patient reporting an audible 'popping' sound, rapid detumescence, pain, penile swelling and deviation of the penis often to the side opposite the injury secondary to mass effect of the hematoma at the injury site. Following injury, if Buck's fascia remains intact, the hematoma develops and results in the characteristic 'eggplant deformity.' The defect at the fracture site is often palpable and has been described as the 'rolling sign.' This represents a firm, mobile, tender mass, where the penile skin can be rolled over the blood clot. An ultrasound has a limited role in penile fractures, but useful in penile penetrating injuries. Magnetic resonance imaging has been highly accurate to demonstrate corpus cavernosum lesions. Urinalysis was done in all cases of penile fracture patients to exclude urethral injury that was then confirmed by ascending urethrography/urethroscopy. This is in accordance with the international recommendation on urethral injury with a fracture penis. The incidence of urethral injury is between 20% to 38%. Treatment is immediate surgical repair because the complication rate of conservative management is 25% to 53%....early surgical management in penile fracture cases provides better results than delayed and conservatively managed cases."

6. The ED medical record of Patient 4 reflected that he/she presented to the hospital for emergency services on 09/06/2018 at 1125 and included the following documentation related to Patient 4's encounter:
* At 1138 an RN documented on an "ED Nursing Triage" note that "Pt states was assaulted last noc...Pt c/o HA, neck pain, low back pain; Feels stiff all over; Pt states [he/she] think [he/she] was unconscious for a second secondary to being choked. Pt noted to have black eye left side; Back tender to palpation upper and lower; Neck tender to palpation; no obvious deformities noted..Pt states [he/she] has many psychological problems."
* At 2018 the RN documented on an "ED Nursing Documentation" note that Patient 4 had "Suicidal ideation, Flight of ideas."
* At 0037 on 09/07/2018 an RN documented that the patient had "Suicidal ideation, before falling asleep patient mentioned that [he/she] has attempted suicide in the past by cutting and trying to hang [him/herself]."
* At 0839 on 09/07/2018 the ED MD documented on an "ED Provider Note" that "Patient with prolonged stay in the ED due to lack of psych beds. [He/she] continues suicidal and homicidal...1040 Patient evaluated by mental health, they consider patient is at risk for suicide and [he/she] should be Admitted to a psychiatric unit. care discussed with [psychiatrist] from Good Samaritan Hospital in Corvallis, [psychiatrist] accepted the patient for transfer."
* At 1800 on 09/07/2018 the MD documented on the "Patient Transfer Form" that "Benefit(s) of transfer: psych evaluation/treatment...Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific): Accident...Risks of transport: All transfers have the inherent risks of traffic delays, accident during transport..."

The documentation reflected that an appropriate transfer had not been affected as the ED MD's certification that the reasons and benefits for the transfer outweighed the risks of transfer did not identify the patient-specific, "clinically specific" risks of the transfer.

7. During interview with the R&Q and the NM on 01/31/2019 during review of documents beginning at 1130 they confirmed that the hospital's EMTALA policies and procedures were incomplete and stated that "draft" policies and procedures were in progress.