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Based on observation, interviews, documentation in 5 of 20 medical records reviewed of patients who presented to the hospital for a MSE (Patients 1, 2, 7, 12 and 14), and review of hospital policies and procedures, it was determined the hospital failed to develop and enforce its EMTALA policies and procedures in the areas of MSEs, appropriate transfers, and posting of EMTALA signs.

Findings include:

1. Medical Screening Examination: Refer to findings identified under Tag A2406, CFR 489.24(r) and (c), which reflects the hospital's failure to develop and enforce its EMTALA policies and procedures related to MSEs.

2. Appropriate Transfers: Refer to findings identified under Tag A2409, CFR 489.24(e)(1-2), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to appropriate transfers.

3. Posting of signs: Refer to findings identified under Tag A2402, CFR 489.20(q), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to posting of the required EMTALA signs.

Based on observation, interview, and review of policies and procedures, it was determined that the hospital failed to enforce its policies and procedures for the posting of the required EMTALA signs, and failed to post the required sign in all places likely to be noticed by individuals entering the ED as required by this regulation.

Findings include:

1. A tour of the ED was conducted on 10/21/2014 at 1020 with the Interim ED Director and the ED Manager. The ambulance entrance and adjacent hallway used by patients entering the ED by ambulance was observed. For patients arriving by ambulance, there was no EMTALA signage posted in these areas.

2. During an interview conducted on 10/21/2014 at 1030, the ED Manager confirmed that the required EMTALA signage was not posted in the ambulance entrance or the adjacent hallway. He/she further acknowledged that patients entering the ED by ambulance would not have an opportunity to see any EMTALA signage.

3. Review of the hospital's policy and procedure titled "Emergency Medical Treatment and Active Labor Act Obligations" effective date "4/17/2014" reflected "...Signs shall be posted in the admitting areas of the emergency department and Patient Access Services of the hospital, informing all visitors and patients of their right to a MSE and stabilizing treatment."

Based on interviews, documentation reviewed in the ED record of Patient 1 who presented to the ED by ambulance with a medical condition and was taken to another hospital by public safety (PS) staff, and review of hospital policies and procedures, it was determined the hospital failed to develop and enforce its policies and procedures to ensure that all individuals who presented to the hospital for emergency services received a MSE to determine whether or not an EMC existed.

Findings include:

1. Review of the hospital's policy and procedure titled "Emergency Medical Treatment and Active Labor Act Obligations" effective date "4/17/2014" reflected "...OHSU Healthcare must...Provide an appropriate medical screening examination to a person who comes to OHSU's main campus and requests emergency services, has an emergency medical condition...or appears (to a reasonably prudent person) to be in need of medical attention...Provide the medical screening examination to determine if the person has an emergency medical condition."

The definitions section of the policy reflected "Medical screening examination: The process required to determine if an EMC exists. The MSE is an ongoing process that begins but typically does not end with triage. The scope of the examination must be tailored to the person's presenting complaint, known medical history and signs and symptoms, as well as the capability and capacity of OHSU. Depending on the presenting complaint or condition, an appropriate MSE may range from a brief history and physical examination to a complex process that may include laboratory and imaging tests, lumbar puncture and other diagnostic tests and procedures. The MSE will continue and the individual's record should reflect continued monitoring until the individual has stabilized...Qualified medical personnel: An OHSU Healthcare workforce member who is a trained physician, nurse practitioner, clinical nurse specialist, nurse midwife or resident physician or who has been designated as a QMP consistent with the professional staff bylaws."

2. The ED record for Patient 1 was reviewed. The "Trauma Information" section of the record reflected the patient presented to the ED by ambulance on 09/21/2014 at 0046 with a chief complaint of knee pain.

The "ED Notes" documented by an RN at 0050 reflected "Public safety called to triage. [Patient] unwilling to get off EMS stretcher. Becomes verbally abusive with staff."

Documentation by an RN at 0052 reflected the patient's acuity was "Urgent."

The "ED Notes" electronically filed by an RN at 0053 reflected "Pubic safety to triage. [Patient] placed in wheelchair. [Patient] then threw [his/her] cane and stated "Arrest me."

The "ED Notes" electronically filed by an RN at 0054 reflected "EMS report: bike accident last week. Left knee has wound with pus discharge. Hx of MRSA."

The "ED Vitals" section of the record at 0113 reflected vital signs were collected and the patient's pulse rate was elevated at 102. This was the only set of vital signs recorded in the medical record.

The "ED Pain" section of the record reflected the patient was experiencing left knee pain, and the patient's numeric pain score was recorded "10."

The "ED Notes" documented by an RN at 0114 reflected "[Patient] c/o left knee pain s/p crashed on bike 5 days ago. [Patient] with sore on knee with area of erythemia (sic). [Patient] state (sic) knee has a burning sensation."

The "ED Notes" addendum electronically filed by an RN at 0200 reflected "[Patient] verbally assaultive to this nurse. [Patient] repeatedly asking for pain medication. [Patient] offered Ibuprofen per [his/her] request, but states needs a handful. [Patient] told that [he/she] will need to get and evaluation and an xray to evaluate infection, but [patient] yelling at this nurse for pain medication. [Patient] with hx violence and meth abuse. Attempts to verbally de-escalate [patient] and allow [patient] to calm down. [Patient] reassured that [he/she] can get help here, but [patient] becomes increasingly abusive and threatening this nurse by pointing [his/her] cane and a water bottle with thrusting motions. PS contacted and [patient] taken from ed triage. [Patient] escorted of (sic) the campus."

The "ED Notes" documented by an RN at 0201 reflected the patient was discharged.

The "ED Disposition" section of the record was not timed and reflected "LWBS after triage."

The following "ED Pain" sections of the medical record were not completed and were followed by a "dash" punctuation mark:
*Diagnosis
*Description: Quality
*Faces Revised Score
*Pain Interventions
*Pain Observed
*Response to Interventions

The following sections of the medical record were documented as "None":
*Diagnosis
*Discharge Instructions
*Discharge Medications
*Discharge References/Attachments
*ED Treatment Team
*EKG Results
*Follow-up Information
*Imaging Results
*Lab Results

The following sections of the medical record were not completed and were blank:
*Discharge Instructions
*Medication Review

There was no documentation to reflect that a MSE was conducted to determine whether or not an EMC existed. There was no documentation of a history and physical examination conducted, no physician notes, no laboratory tests, no imaging tests, no further vital signs or monitoring recorded, or any other diagnostic tests or procedures in accordance with hospital policies and procedures. In addition, there was no documentation to reflect that the patient refused a MSE, or that a physician was informed that the patient was being taken from the hospital before a MSE was conducted.

3. An interview was conducted with a PS officer on 10/22/2014 at 1000. The officer stated he/she was a police officer, an employee of the hospital, and had been working in "public safety" at the hospital for eight years. The officer stated he/she was on duty in the ED when Patient 1 presented to the ED on 09/21/2014.

The officer stated that on 09/21/2014, paramedics brought the patient into the ED lobby on a gurney and waved to the officer indicating they needed assistance. The officer stated the patient was upset, threw his/her cane and didn't want to get off the gurney because he/she wanted to go to another hospital. The officer stated he/she assisted the patient from the gurney to a wheelchair, and then took the patient outside for about 10-15 minutes. The officer stated that while the patient was outside, he/she calmed down so the officer brought the patient back into the ED lobby. The officer stated that the patient had shorts on and he/she could see that the patient's knee was infected and had pus coming out of it.

The officer stated that the triage nurse, the RN who was interviewed on 10/22/2014 at 1400, called for the patient and asked the officer to "stand-by" while he/she interacted with the patient in the triage area. The officer stated he/she waited on the other side of the triage area privacy curtain and could hear the patient cursing and making derogatory remarks to the RN. The officer stated the RN then told the officer "Get [him/her] out of here." The officer stated he/she asked the RN "You're not going to treat [him/her]?" The officer stated the RN told him/her "Yes, get [him/her] out of here." The officer stated he/she then wheeled the patient out of the ED.

The officer stated that after taking the patient out of the ED, the patient told the officer he/she had a "legit injury," and requested a ride to another hospital. The officer stated he/she called the other hospital to make sure he/she could take the patient there. The officer stated he/she assisted the patient into his/her patrol vehicle and took the patient to the ED of the other hospital. The officer stated "I was stuck. It came down to me taking [the patient] to jail or to [another hospital]."

The officer stated he/she has never received EMTALA training and had never heard of EMTALA until after the incident involving Patient 1, when he/she looked it up online. He/she additionally stated he/she was not involved in the hospital's analysis of the incident involving Patient 1.

4. An interview was conducted with an RN on 10/22/2014 at 1400. The RN stated he/she was on duty in the ED when Patient 1 presented to the ED on 09/21/2014.

The RN stated that on 09/21/2014, he/she heard a "ruckus" in the ED lobby. The RN stated he/she went out to the ED lobby and Patient 1 was in a wheelchair. The RN stated that PS officers were with the patient because the patient was exhibiting disruptive behaviors. The RN stated he/she assisted the patient into a triage room, and the officers also went to the triage area and remained on the other side of the privacy curtain. The RN stated that the patient's knee was scraped and had erythema. The RN stated that the patient told him/her that his/her knee was "killing [him/her]" and he/she wanted pain medication. The RN stated he/she told the patient "I can get you some Ibuprofen." The RN stated the patient told him/her that he/she would need 500 Ibuprofen tablets to manage his/her pain. The RN stated the patient's behaviors began to escalate and the patient began to wave his/her cane and water bottle toward the RN. The RN stated he/she then called the officers and told them "This isn't working. [He/she] can't be in the triage area." The RN stated the officers asked him/her if the patient should be taken off the hill or placed on a hold. The RN stated he/she told the officers "We can't have [him/her] like that in our lobby with other patients."

During the interview, the RN acknowledged he/she told the officers to take the patient out of the ED. The RN stated he/she learned later that after taking the patient from the ED, the officers took the patient to another hospital. The RN acknowledged that the patient did not receive a MSE, and stated "The doctor didn't see the patient."

5. On 10/21/2014 at 0910 the Manager of Regulatory Affairs was interviewed. He/she reported that on approximately 09/22/2014, hospital administration learned of a potential EMTALA violation involving Patient 1. During the interview he/she indicated that the hospital conducted an analysis and a summary of events related to the incident thereafter.

6. On 10/22/2014 at 1040 the Deputy Chief of the DPS was interviewed. The deputy reported he/she participated in the hospital's analysis of the 09/21/2014 incident involving Patient 1. The deputy indicated that through the analysis, it was learned that the "hand-off" language used between "medical staff" and PS officers was unclear, inconsistent and needed to be standardized in order for PS officers to know whether or not a patient was discharged when "handed-off" to PS staff.

Based on documentation reviewed in 4 of 8 ED records of patients (Patients 2, 7, 12 and 14), who presented to the hospital's ED with an EMC and who were transferred to other facilities, and review of hospital policies and procedures, it was determined that the hospital failed to effect appropriate transfers of those individuals as required by the hospital's policies and procedures. The hospital failed to ensure the required physician certification that the benefits of the transfer outweighed the increased risks of transfer. Patient specific risks of transfer were not identified for those patients.

Findings include:

1. Review of the hospital's policy titled "Emergency Medical Treatment and Active Labor Act Obligations," effective "4/17/2014" reflected
"...If individual has an EMC that is not stabilized and the patient (or the patient's representative) has not requested a transfer, OHSU may not transfer the individual unless an OHSU physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred...The certification must contain a summary of the risks and benefits upon which it is based. The certification must state the reason(s) for transfer. The narrative rationale need not be a lengthy discussion of the individual's medical condition reiterating facts already contained in the medical record, but it should give a complete picture of the benefits to be expected from appropriate care at the acute care setting necessary to effect the transfer. The risks and benefits certification should be specific to the condition of the patient upon transfer."

2. The ED record for Patient 12 was reviewed. The record reflected the patient presented to the ED on 05/10/2014 at 0828. The RN notes recorded at 0834 reflected the patient's acuity was "Emergent."

The record reflected the patient received a MSE. Physician notes dated 05/10/2014 at 0912 reflected "...[male/female] h/o Crohn's disease - seen...in Seattle yesterday due to bleeding and pus noted from the rectum X 3 weeks...Awoke this AM with significant abdominal pain and emesis consistent with previous bowel obstructions per [mother/father] and patient. Awoke with distended abdomen. Pain described as 10/10, primary complaint at this time...ED Course and Medical Decision Making...Called GI/Surgery and it was determined between services that due to the patient's age and previous experience with...GI at [another hospital] that this facility would best suit [his/her] needs at this time. [Father/mother] consented for transfer and we contacted their ED for transfer for further care, evaluation and likely admission."

The "ED Notes" documented by the RN at 1158 reflected "EMS arrived to transport [patient]...[Patient] resting comfortably, but pain worsened upon transfer to EMS stretcher...IV patent and infusing."

The "ED Notes" documented by the RN at 1200 reflected the patient was discharged.

A form titled "Emergency Services Hospital Transfer" was reviewed. The bottom portion of the form reflected "Faculty Physician Certification of Transfer (to be completed by Faculty Physician at time of transfer)." The form was signed and dated by a physician on 05/10/2014, but was not timed. The "Risks of Transfer" were recorded "Transportation risks".

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

3. The ED record for Patient 14 was reviewed. The record reflected the patient presented to the ED by ambulance on 08/05/2014 at 1503 with a chief complaint of chest pain and suicidal ideation.

The record reflected the patient received a MSE. Physician notes dated 08/05/2014 at 1744 reflected "...Cardiovascular: Positive for chest pain. Psychiatric/Behavioral: Positive for suicidal ideas...ED Course and Medical Decision Making: In summary...[male/female] with past medical history significant for DM, HTN, depression, substance abuse, who presents with complaint of SI and depression in context of recent cocaine and crystal meth binge. ROS positive for vaguely described chest pain and flank pain...[Patient] seen by SW who agrees with assessment...will attempt to admit to [another hospital] psych for stabilization."

The "ED Notes" documented by the social worker on 08/06/2014 at 1009 reflected "[Patient] continues to endorse SI and continues to request inpt admission."

The record reflected the patient was discharged on 08/06/2014 at 1539.

A form titled "Emergency Services Hospital Transfer" was reviewed. The "Transportation:" section of the form reflected "Secure Transport." The bottom portion of the form reflected "Faculty Physician Certification of Transfer (to be completed by Faculty Physician at time of transfer)." The form was signed and dated by a physician on 8/06/2014, but was not timed. The "Risks of Transfer" were recorded "Transportation risks."

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

4. The ED record for Patient 7 was reviewed. The record reflected the patient presented to the ED by ambulance on 08/11/2014 at 1411 with a chief complaint of stroke symptoms.

The "ED Notes" documented by the RN on 08/11/2014 at 1415 reflected the patient's acuity was "Emergent."

The "ED Notes" documented by the RN on 08/11/2014 at 2142 reflected "...[Patient] reports sudden onset dizziness, left sided chest pain and loss of strength in left extremities while driving to work. Upon arrival [patient] was hypertension and endorsing no sensation or ability to move in the left extremities...[Patient] has HX of conversion DO and was seen one other time at OHSU 11/2013 after being found down by [husband/wife]...At this time [patient] can lift left arm, grip is weak, [patient] reports no sensation in the left leg below the knee and is not responding to painful stimuli...[Patient] to transfer to [another hospital] for continued neuro monitoring."

The record reflected the patient received a MSE. The physician notes electronically filed on 08/12/2014 at 0116 reflected "...Assessment...Chest pain Possible conversion disorder...Recommendation...I examined the patient shortly after SBAR receipt and noted the following: [Patient] complaining of persistent L arm and LLE numbness and weakness. Otherwise neurological exam is unremarkable. [Patient] also endorsing mild headache, so given NS bolus and toradol. I discussed with neurology re: thoughts about likely etiology. Feel this is most likely conversion disorder...I also talked to psychiatry who feel uncomfortable with admission to 1NW given no definitive diagnosis and concern for possible organic cause. I then talked to [another hospital] requesting transfer to internal medicine, [patient] may need psychiatry consultation then...[Patient] transferred to [another hospital]...Final Assessment...L-sided weakness and numbness."

The record reflected the patient discharged on 08/11/2014 at 2159.

A form titled "Emergency Services Hospital Transfer" was reviewed. The bottom portion of the form reflected "Faculty Physician Certification of Transfer (to be completed by Faculty Physician at time of transfer)." The form was signed and dated by a physician on 08/11/2014, but was not timed. The "Risks of Transfer" were recorded "Medical condition could worsen during transport, possibly resulting in disability or death Transportation risks Injury, crash."

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

5. The ED record for Patient 2 was reviewed. The record reflected the patient presented to the ED by police on 04/28/2014 at 1855.

The "ED Notes" documented by the RN on 04/28/2014 at 1856 reflected the patient's acuity was "Emergent."

The record reflected the patient received a MSE. Physician notes dated 04/28/2014 at 1916 reflected "...Medical Decision Making...[male/female] with hx of bipolar disorder, schizophrenia and PTSD brought in by police for "unusual behavior." Police were called by bystanders who noted that the patient was throwing bottles around with no real purpose. [He/she] was stopped by a meter officer and made confrontational verbal and physical threatening moves. Police note that the patient was "angry" and was angry at everyone. Patient transported by PPD on police office's (sic) hold...My primary concern is the patient's apparent "impulsive behavior," lack of judgement and insight and apparent volatile personality where [he/she] is calm at times but extremely angry and impulsive. Patient recent admission to OHSU psych...[He/she] is not currently receiving any medication and has no apparent follow up plan or mental health provider...[Patient] requires hospitalization beyond acute emergency department care. Factors favoring inpatient status include: suicidal or homicidal ideation with feasible plan...Impression...Bipolar disorder and schizophrenia With extreme impulsive behavior in patient with with (sic) potential harm to others."

The "ED Notes" documented by the RN on 04/29/2014 at 1130 reflected the patient was transferred to another hospital.

A form titled "Emergency Services Hospital Transfer" was reviewed. The bottom portion of the form reflected "Faculty Physician Certification of Transfer (to be completed by Faculty Physician at time of transfer)." The form was signed and dated by a physician on 04/29/2014, but was not timed. The "Risks of Transfer" were recorded "Medical condition could worsen during transport, possibly resulting in disability or death Transportation risks As above."

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.