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Based on observation, interview, review of documentation in the medical records for 7 of 20 patients who presented to the hospital for emergency services (Patients 1, 3, 4, 6, 9, 11 and 14), and review of hospital policies and procedures, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure compliance in the following areas:
* Required posting of EMTALA signs;
* Provision of MSEs;
* Appropriate transfers of patients.

Findings include:

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

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

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

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 patients' EMTALA rights in all areas likely to be noticed and where patients waited for examination and treatment.

Findings include:

1. The hospital policy and procedure titled "EMTALA Rights and Responsibilities," dated "Effective Date: 04/25/2019" was reviewed. It reflected "The hospital will post EMTALA signage in all areas where a patient is likely to present seeking emergency medical care. All caregivers and physicians will be oriented to EMTALA and receive ongoing education. Quality review of records will take place periodically."

2. During tour of the FBC on 05/28/2019 at 1344 with CNO, EDD and FBCM, it was observed that the department had one primary ambulatory entrance. Staff present during the tour confirmed that individuals who were in labor presented to the FBC department at that entrance for a MSE.
There was no EMTALA signage observed in the FBC patient and visitor waiting area, at the entrance into the FBC, or anywhere else in the department.
These findings were confirmed with the FBCM during the tour on 05/28/2019.

3. During tour of the ED on 05/28/2019 beginning at 1355 with CNO, EDD and DA there was no EMTALA signage observed in any of the triage and patient treatment rooms, where patients waited for exam and treatment.
These findings were confirmed with the EDD at the time of the tour on 05/28/2019.

Based on interview, review of medical record and other documentation for 5 of 9 patients who presented to the hospital for emergency services and without receiving a MSE (Patients 1, 3, 4, 6 and 11), and review of policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that all patients were provided a complete and appropriate MSE, or that attempts were made to advise the patients of the risks of leaving before an MSE was completed.

Findings include:

1.a. The hospital policy and procedure titled "EMTALA Rights and Responsibilities," dated "Effective Date: 04/25/2019" was reviewed. It reflected "The purpose of this policy is to describe how St. Charles Health System, Inc. (St. Charles) and its hospitals will comply with the Emergency Medical Treatment and Active Labor Act (EMTALA). In general, St. Charles and its hospitals will comply with EMTALA by ... providing, through a qualified medical professional, an appropriate, nondiscriminatory medical screening examination (MSE) within its capabilities to each patient who comes onto the hospital property seeking examination or treatment of what may be an emergency medical condition (EMC) ... providing necessary stabilizing treatment or an appropriate transfer to each patient determined to have an EMC ..."

"Definitions ... Medical Screening Examination (MSE) - A medical evaluation conducted by a qualified medical professional that is designed to identify the presence of an EMC. A MSE is different from and, in most cases, additional to a medical triage."

"Each person who comes to the emergency department seeking treatment of a medical condition will be given an appropriate MSE, without delay, within the capacity of the dedicated emergency department. The MSE will be performed by a QMP ..."

b. The hospital policy and procedure titled "Against Medical Advice (AMA)" dated "Effective Date: 05/01/2019" was reviewed. It reflected "While St. Charles Health System, Inc. ("St. Charles") respects the right of each adult of decision making capacity to discharge himself/herself (the patient) from any St. Charles hospital or facility against medical advice. St. Charles hospital caregivers will use best efforts to ensure that the potential risks and consequences of the patient's action are properly explained to the patient and documented in the medical record."

"Instructions: If a patient expresses a desire to refuse or withdraw from a treatment or diagnostic study AMA or if a patient expresses a desire to leave a St. Charles hospital or facility AMA, the following procedure will be instituted:
a. The patient's nurse will request that the patient discusses the AMA decision with the treating physician and will immediately notify the treating physician and nursing supervisor of the patient's desire to refuse or withdraw treatment/study or leave the St. Charles hospital or facility AMA.
b. The treating physician will discuss with the patient the reason for the AMA decision and will advise the patient of the potential consequences of the AMA decision. Reasonable effors should be made to address any issues presented as reasons for the AMA decision ...
c. The physician should document his/her discussion with the patient in the medical record including, if possible, the following:
1. The patient's diagnosis;
2. The reason for the patient's AMA decision;
3. The benefits of following and risks of not following medical advice; and
4. Discharge instructions, including notation of any follow up visits or referrals and any prescriptions that were provided, should the patient decide to leave. Following discussion with the patient, Physician shall offer the patient an opportunity to return to the hospital for treatment if the patient changes mind.
d. The patient's nurse should have the patient sign the AMA form Against Medical Advice (A.M.A.) and Refusal. If the patient refuses to sign, the nurse should read the AMA form to the patient, using interpretive services or other forms of assistive communication when needed, and document on the AMA form the patient's refusal to sign.
e. Nursing will document in the nurses' notes all pertinent information concerning the patient's action, including the patient's stated reasons for refusal, withdrawal or leaving, quoted verbatim.
f. The nurse should place the signed AMA form in the patient's chart and if possible, complete the discharge per established process.
g. For each patient who has critical values or who presents with a significant patient safety concern, the nurse will enter a report into SAS under Emergency/Trauma/Transfer and select either AMA - Not Seen By Physician or AMA - Seen By Physician and attempt a call back. Call back will be documented in the medical record.
If a patient leaves without the knowledge of St. Charles staff:
h. Upon noticing the patient's absence, security, if available, and/or house supervisors will be contacted to attempt to locate the patient.
i. Nursing will thoroughly document in the nurses' notes all pertinent information and action concerning the patient's absence. Include any patient's statements prior to patient's absence, quoted verbatim.
j. For each patient who has critical values or who presents with a significant patient safety concern, the nurse will enter a report into SAS under Emergency/Trauma/Transfer and select either AMA - Not Seen By Physician or AMA - Seen By Physician and attempt a call back. Call back will be documented in the medical record."


2.a. The ED Central Log revealed that Patient 3 was registered and entered into the log with dates/times of: 04/16/2019 at 1955, 04/16/2019 at 2358 and 04/17/2019 at 0135.

b. The medical record of Patient 3 reflected that he/she presented to the ED on 04/16/2019 at 1955 with a chief complaint of "Chest pain." The record reflected:
* An ED Provider Note dated 04/16/2019 at 1955 reflected the patient was brought in by "Bend Fire" complaining of chest pain. On arrival into the ED, the patient stated that he/she was no longer having chest pain and instead complained of upper and mid back pain. The patient requested "trigger point injections" which were done at 2052.
* At 2104 ED RN notes reflected "Discharge instructions/follow-up care reviewed; Verbalized understanding ..." The record reflected the patient was discharged at 2105.

* On 04/16/2019 at 2358 the medical record of Patient 3 reflected he/she returned to the ED with an "Arrival Complaint" of "Seizures, Mental Eval."

* On 04/17/2019 at 0015 the medical record reflected the disposition was "LWBS before Triage." There was no documentation that reflected vital signs were collected, triage was complete or a MSE was done. There was no other information or documentation for this encounter.
There was no documentation that reflected hospital policies and procedures related to the patient leaving without being seen were carried out. For example: The hospital policy reflected "If a patient decides to leave the hospital without being seen (LWBS) before receiving the MSE, then the patient should be asked to complete the Against Medical Advice (A.M.A) and Refusal form before leaving. If possible, the patient should be advised to return to the emergency department immediately if his or her symptoms persist or get worse."
Although the interview in 1c. reflected the patient was suicidal and he/she ran out of the hospital while engaging with ED staff there was no documentation that reflected the patient was asked to complete the AMA and Refusal form per policy.

* On 04/17/2019 st 0135 the medical record reflected the patient returned to the ED by "Law Enforcement" for a chief complaint of "Suicidal." An ED Provider Note from 04/17/2019 at 0135 reflected "States he/she wants his/her life to end because he/she has so much pain. Patient states he/she thought about hanging himself/herself. Prior suicide attempts in the past. History of polysubstance abuse, chronic pain, antisocial personality disorder."
* On 04/17/2019 at 0135 a ED Provider Note reflected the physician felt the patient's suicidal ideation was stemming from his/her chronic pain issues and would benefit from a medical admission for benzodiazepine withdrawal. The patient was admitted to the medical inpatient unit for further work up and treatment.

c. During interview and review of report documentation related to Patient 3 with the EDD on 05/28/2019 at 1414, he/she reported that the patient was examined and treated for chest pain on 04/16/2019 at 1955. The patient was discharged at 2105 to the ED waiting room where he/she was waiting for transportation.
* At 2356 the patient left the building.
* At 2358 the patient returned to the registration desk requesting to be checked back in for "mental health eval and seizures." The patient was registered. Securtiy officers were also present at this time.
* Security went into the ED to notify the CN that the patient was at the registration desk. The CN told security to call the police to trespass the patient, that he/she had no reason to be seen again.
* The CN came out into the waiting room to talk to the patient. The patient expressed that he/she was suicidal and needed to be seen. At this time it was mentioned that the police had been called and the patient jumped out of the wheelchair he/she was sitting in and ran outside into the parking lot.
* Bend PD arrived in the parking lot and began talking to Patient 3. The PD brought the patient back into the hospital at 0134 on 04/17/2019 for SI.

d. During interview with the EDD on 05/28/2019 at 1414, he/she stated that the ED CN knew Patient 3 arrived the second time at 2358 on 04/16/2019 with a chief complaint of being suicidal and seizures and that the patient did not receive a MSE and was told to leave by the Charge RN and the EDD said "yes."

Although the interview in 1c. reflected the patient was suicidal and he/she ran out of the hospital while engaging with ED staff there was no documentation that reflected the patient was asked to complete the AMA and Refusal form per policy.

3.a. The medical record of Patient 4 reflected that he/she presented to the ED on 04/12/2019 at 1933 with a chief complaint of "SOB." The record reflected:
* On 04/12/2019 at 1954 the ED Disposition note reflected the patient "LWBS before Triage" with comment, "PT left the ED and left in a car per Security staff prior to being triaged." There was no other documentation or information for this encounter. There was no documentation that reflected a MSE including no vital signs and no physician or other QMP documentation.
* There was no other documentation in the medical record to reflect that ED staff made attempts to make the patient aware of the possible risks of leaving the hospital before being seen by a QMP or that the patient was asked to sign an AMA form per hospital policy.

b. During interview with CRM on 05/28/2019 at the time of the medical record review, he/she confirmed that there was no other documentation for this encounter in the patient's medical record.

4.a. The medical record of Patient 6 reflected that he/she presented to the ED on 03/21/2019 at 1714 with a chief complaint of "dizziness." The record reflected:
* On 03/21/2019 at 2136 the ED Disposition note reflected the patient "Left Against Medical Advice."
* ED Provider note at 1714 by the ED PA reflected, "May be anxiety, but I also think a head CT is indicated due to the combination of headaches and vertigo. [ED PA] placed this order, but am told only minutes later patient told RN that [ED PA] wasn't going to help him/her and had eloped."
* The PA ED Provider Note at 1714 also reflected "Discharge instructions were discussed in detail and all questions addressed. The patient understood and agreed. In addition, written discharge instructions were provided, linked in this medical record." However the medical record lacked a link or any other documentation that reflected discharge instructions were created.
* Although the medical record reflected a MSE was initiated and a CT was indicated, there was no documentation the MSE was completed to determine whether or not the patient had an EMC. There was no other documentation in the medical record to reflect that ED staff made attempts to make the patient aware of the possible risks of leaving the hospital against medical advice or that the patient was asked to sign an AMA form per hospital policy.

b. During interview with CRM on 05/28/2019 at the time of the medical record review, he/she confirmed that there was no other documentation for this encounter in the patient's medical record.

5.a. The medical record of Patient 11 reflected that he/she is a 2-year old that presented to the ED on 02/23/2019 at 1108 with a chief complaint of "Allergic Reaction." The record reflected:
* On 02/23/2019 at 1128 a ED Dispostition note reflected the patient "LWBS after Triage" with comment, "No vitals taken in triage, pt appears well at this time, [family] decided to leave at this time but agrees to return if symptoms do."
* There was no other documentation or information that reflected a MSE including no vital signs and no physician or other QMP documentation. There was no other documentation for this encounter. There was no other documentation in the medical record to reflect that ED staff made attempts to make the [family] aware of the possible risks of leaving the hospital before being seen by a QMP or that the patient was asked to sign an AMA form per hospital policy.

b. During interview with CRM at the time of the medical record review, he/she confirmed that there was no other documentation for this encounter in the patient's medical record.

6.a. The medical record of Patient 1 reflected that he/she presented to the ED on 05/24/2019 at 1713 with a chief complaint of "Rash." The record reflected:
* On 05/24/2019 at 1757 a ED Disposition note reflected the patient "LWBS after Triage" with comment, "Pt states that all [his/her] symptoms have resolved. They are staying at a hotel just down the street and will return if symptoms return." There was no other documentation or information for this encounter. No documentation that reflected a MSE including no vital signs and no physician or other QMP documentation.
* There was no other documentation in the medical record to reflect that ED staff made attempts to make the patient aware of the possible risks of leaving the hospital before being seen by a QMP or that the patient was asked to sign an AMA form per hospital policy.

b. During interview with CRM on 05/28/2019 at the time of the medical record review, he/she confirmed that there was no MSE and no other documentation for this encounter in the patient's medical record, including no MSE.

Based on interview, review of medical records and other documentation for 1 of 4 patients who were transferred from SCMC to other hospitals for specialty services not available at SCMC (Patient 9), and review of policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved:
* Physician certification of medical benefits versus risks were not documented.
* Appropriate mode of transfer was not effected and documented.
* There was no documentation that medical records were sent to the receiving facility.

Findings include:

1.a. The hospital policy and procedure titled "EMTALA Rights and Responsibilities," dated "Effective Date: 04/25/2019" was reviewed. It reflected "The purpose of this policy is to describe how St. Charles Health System, Inc. (St. Charles) and its hospitals will comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) ... St. Charles and its hospitals will comply with EMTALA ... providing, through a qualified medical professional, an appropriate, nondiscriminatory medical screening examination (MSE) within its capabilities to each patient who comes onto the hospital property seeking examination or treatment of what may be an emergency medical condition (EMC) ... providing necessary stabilizing treatment or an appropriate transfer to each patient determined to have an EMC ..."

"Transfer Responsibilities. To ensure that each transfer is completed in accordance with the EMTALA requirements, each St. Charles facility shall ... Send or otherwise make accessible to the receiving facility all essential medical records related to the EMC for which the patient is being transferred, including the face sheet and patient encounter summary ... Ensure that the transfer is accomplished by qualified personnel and transportation equipment, with life support capabilites being available, as needed."

b. The hospital policy and procedure titled "Acceptance of Transfers in and Sending Transfers to Outside Facilities" dated "Effective Date: 02/02/2017" was reviewed. It reflected "Patients may be transferred to other facilities upon request or when patient care needs exceed services available at St. Charles facilities. All transfers must be made with concern for safety of the patient and appropriate documentation that facilitiates continuing care at the receiving facility."

"Transfer: Moving a patient to another medical facility (another hospital) for further treatment/diagnosis at the same or higher level of care; usually done under conditions of continuous medical supervision."

"Transfer Out. Who may be transferred to another medical facility? Patient and/or, when appropriate, the patient's health care representitive may request transfer to another facility. Obtain written request for transfer using transfer form Patient Transfer Form and complete the following actions: St. Charles will arrange emergency transport as deemed appropriate by the provider. In the event the patient or guardian opts for personal transportation, patient will be signed out AMA or discharged with the expectation that the patient will present themselves immediately at the receiving facility. Provider or RN will have patient sign the Ambulance Refusal form and scan it into the medical record. If patient or guardian refuses to sign AMA and Refusal form, RN and Provider will document within the medical record 'patient refused transfers'."
* The policy reflected that if the patient opted for personal transportation, the RN would have the patient sign an ambulance refusal form. However, the policy also reflected that the patient would be signed out AMA or discharged with expectation he/she would present to the receiving facility immediately: It was unclear why the patient would be signed out AMA under those circumstances. In addition, the policy did not include how the receiving facility would be informed of the patient's transfer or "discharge" by private vehicle.

"Patient whose care needs are best met at another facility provided: The physician's assessment identified treatment, education, developmental, or social factors and other support needs so that transfer may be made to the appropriate facility. The patient's condition is stabilized so that there is no reasonable medical probability that any ill effects will occur during, or as a result from transfer; or their physician determines and documents that the benefits of transfer outweigh the risks and the patient or health care representative consents to transfer. The physician recognizes the patient's right to refuse transfer after explanation of the risks associated with remaining at the hospital and the risks associated with the transfer process."

"How to accomplish a transfer to further care. Before transportation is arranged to another Acute Care Facility: The Attending or Emergency Physician discusses with the patient/health care representitive the reason for and the risks (if any) of transfer. Such discussion is documented in the progress notes or dictated into the discharge summary. If a patient requests to be transferred, the same explanation of the risks (if any) should occur. Obtain a written physician's order. Obtain written consent or refusal from the patient or patient's health care representative on the Transfer form ... The referring physician is responsible for informing the nursing staff of the following information: The name of the accepting physician, the receiving facility and the reason for transfer ... Patient transportation will include equipment and trained personnel appropriate to his/her life support need(s) and should be documented as such. The referring physician will prescribe the care the patient needs during transport, refer to Transport Criteria decision matrix to determine appropriate transport resource. A copy of the patient's medical record will accompany the patient and should include: copy of face sheet, transfer form, current physician's orders, current medication administration record, progress notes, history and physical, operative report, laboratory reports, diagnostic imaging reports and/or films and advanced directive(s) if any. Any additional relevant documentation from other disciplines waiting for all the medical records should not unduly delay the transfer ... The physician and nurse complete the Patient Transfer Form."

2.a. The ED record for 2-year old Patient 9 reflected he/she presented to the ED on 03/08/2019 at 0819 with a chief complaint of "choking." The medical record reflected:
* At 0906 the ED physician noted the the patient choked on an apple last night, patient "has new onset of coughing and wheezing." A chest xray was ordered and resulted at 1011. It reflected "mild air trapping is suspected in the right hemithorax ... obstructing right endobronchial foreign body."
* At 0912 an RN charted "pt has audible stridor, pulse 178, SpO2 93%."
* At 1020 the ED physician note discussed the case with a physician from the OHSU emergency department who accepted the patient as a transfer. "Discussed images and plan with [family]. They agree with the plan for transfer."
* At 1143 an RN noted "pt to go directly to OHSU ER, parents agreeable to keep pt npo, report to OHSU ER RN."
* The "Patient Transfer Form" reflected the box for "The individual's EMC has not yet been stabilized ..." was checked.
* There was no documentation in the medical record to reflect the ED physician attempted to arrange an appropriate transfer with qualified personnel and transportation equipment for this 2-year old patient, who had audible stridor and an oxygen saturation of 93%, or that the family/responsible person refused such arrangements. There was no documentation of a refusal that reflected the family/responsible person was informed of the risks of going by private vehicle had been discussed with the family/responsible person. The record also lacked documentation that a copy of the medical record was sent with the patient.

b. During interview with the QMC on 05/28/2019 at the time of the medical record review, he/she confirmed there was no documentation in the record that reflected the physician arranged an appropriate transfer that included qualified medical personnel and transportation equipment.

c. OHSU is approximately 176 miles and takes 3 hours and 35 minutes driving time from SCMC.