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Based on observation, interview, review of medical record documentation for 6 of 18 individuals who presented to the hospital for emergency services (Patients 5, 6, 7, 13, 17 and 18), review of the ED central log and review of hospital policies and procedures 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 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 was complete, and accurately reflected all individuals who presented for emergency services, the reasons they presented and their 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 affect appropriate transfers to other hospitals for patients who require further examination and stabilizing treatment that is not within the capability and capacity of LUH .

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 C2406, CFR 489.24(a)&(c), that reflects the hospital's failure to ensure all individuals who presented for emergency services received an MSE.

4. 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.

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. Review of the P&P titled "Emergency Medical Treatment & Active Labor Act (EMTALA)" dated 05/06/2019 revealed no reference to the posting of EMTALA signage in all areas likely to be noticed and where patients wait for examination and treatment.

2. Observations made during tour of the hospital on 01/22/2020 beginning at 1630 revealed there was no EMTALA signage posted in all areas where patient waited for examination and treatment. At the time of the our there were no signs posted in the OB triage room, inside of the ED department, including in patient treatment spaces, nor inside the registration area where patients were registered for ED services.

Based on interview, review of medical record documentation for 3 of 18 individuals who presented to the hospital for emergency services (Patients 5, 7 and 13), review of the ED central log and review of hospital policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured an ED central log was maintained for completeness, and accurately reflected for all individuals who presented for emergency services, the reasons they presented, and their dispositions from the ED including whether they refused treatment or they were refused treatment:
* ED log entries for chief complaints and dispositions from the ED were incomplete or inaccurate.

Findings include:

1. a. Review of the following P&Ps revealed no references to maintenance of a central log:
* "Emergency Medical Treatment & Active Labor Act (EMTALA)" dated 05/06/2019.
* "Medical Screening Examination" dated 05/05/2019.
* "Triage, emergency department" dated 06/13/2019.

1. b. An undated and untitled three-page document that reflected only "ER Visits:" at the top of Page 1 was provided and described as patient registration instructions. It lacked reference to maintenance of a central log.

1. c. The P&P titled "Discharge against medical advice" dated 11/14/2019 was reviewed and reflected a formal process that included the following:
* "... before a patient leaves AMA, health care team members must carefully evaluate the patient's decision-making capacity and provide information to the patient regarding the ramifications of leaving the facility AMA."
* "If the patient insists on leaving the facility AMA, present the patient with an AMA form that addresses knowledge of the diagnosis, proposed management, alternative therapies, risk of no treatment, and specific follow-up instruction; ask the patient to sign the form in the presence of a witness."
* "If the patient refuses to sign the AMA form, document this information on the form along with the date, time, and circumstances of the refusal and obtain the signature of a witness. Place the form in the patient's medical record ... document the patient's refusal in the medical record."

2. The ED log reflected that Patient 5 presented to the hospital on 11/04/2019 at 1458. The disposition of the patient was recorded on the log as "Discharge to home or self care (routine discharge)." The time of the disposition was recorded as 1734 on 11/04/2019. However, the ED record for Patient 5 reflected that this case was not a "routine discharge" as the patient signed an AMA form at 1734 and left before the ED course was completed.

3. The ED log reflected that Patient 7 presented to the hospital on 11/16/2019 at 1411. The patient's chief complaint recorded on the log was "Cancelled (sic) Per Patient." The log did not reflect the chief complaint, presenting problem or symptom, or reason for the ED visit.

The disposition of the patient was recorded on the log as "Discharge to home or self care (routine discharge)." The time of the disposition was recorded as 1411 on 11/16/2019, the same time the patient presented. The ED record for Patient 7 reflected that this case was not a "routine discharge" as the "Admitting Diagnosis" for the visit was documented as "Cancelled (sic) Per Patient" and the patient left without receiving an MSE.

4. The ED log reflected that Patient 13 presented to the hospital on 12/09/2019 at 1449. The patient's chief complaint recorded on the log was "Pt Not Seen/LWOBS." The log did not reflect the chief complaint, presenting problem or symptom, or reason for the ED visit.

The disposition of the patient was recorded on the log as "Left Against Medical Advice or Discontinued Care." The time of the disposition was recorded as 1730 on 12/09/2019. However, the ED record for Patient 13 reflected that the patient did not leave AMA as there was no documentation that the risks of leaving "Against Medical Advice" had been discussed with the patient, and "Discontinued Care" was not accurate as he/she "LWOBS" and no care had been provided.

Based on interview, review of medical record documentation for 1 of 18 individuals who presented to the hospital for emergency services (Patient 7) and review of policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured that every individual who presented to the hospital for emergency services received an MSE within the hospital's capability and capacity by qualified practitioners, and that hospital staff did nothing to dissuade patients from staying at the hospital for the provision of an MSE:
* An individual who presented to the hospital for emergency services left the hospital before receiving an MSE for reasons that were unclear or unexplained and may have been result of inquiries about insurance information.
* P&Ps allowed registration staff to triage patients, and directed them to inquire about financial information and insurance prior to an MSE.
* P&Ps did not clearly delineate the difference between triage and MSE for ED and OB patients, and they allowed the provision of MSEs by RNs. However, Medical Staff Bylaws and rules and regulations did not allow for provision of MSEs by RNs who were not licensed nurse practitioners, and there was no evidence that RNs had special qualifications and competencies to perform MSEs in place of medical providers.

Findings include:

1. a. The P&P titled "Emergency Medical Treatment & Active Labor Act (EMTALA)" dated 05/06/2019 was reviewed and included the following:
* "A licensed medical provider will see every patient who presents for emergency care to the emergency department."
* Upon the patient's arrival, the registration personnel will first obtain the chief complaint. The registration staff will immediately notify the emergency room nurse by phone or in person if the patient complains of the following: ... Chest pain, chest discomfort, chest pressure ... Shortness of breath or difficulty breathing ... Obvious bleeding, bone deformity or severe pain ... Slurred speech, limb paralysis ... Psychiatric or mental health concerns ... Sexual assault or police involvement ... inebriation ... Any patient presenting with a complaint or in a condition that raises concerns for the registration clerk."
* If the patient has any of the above complaints, the registration personnel will notify the RN and will continue to request patient information. The nurse will evaluate and make a determination with or without the ER physician consultation whether or not the patient will be taken directly to the ER or may be registered. If the patient does not fall into the above categories, registration may occur."
* "If any patient leaves the emergency department prior to the medical screening, the chart will be completed by the emergency room nurse as to the reason, date and time."

This P&P allowed hospital registration staff to make triage decisions about patients who presented for emergency services. It further allowed them to continue "registration" processes for those patients they had deemed did not need immediate attention. In addition, the P&P was unclear what "registration" processes consisted of.

1. b. The P&P titled "Medical Screening Examination" dated 05/05/2019 was reviewed and included the following:
* "The medical screening exam may be conducted by a registered nurse employed by Lower Umpqua Hospital or the physician."
* "The medical screening exam will not be delayed for the purpose of determining the patient ability to pay."
* "The screening examination shall not be delayed in order to obtain financial information from the patient. If the screening examination reveals an emergency medical condition, no unnecessary information shall be sought, including financial information. ..."
* "The RN will conduct a primary assessment (airway, breathing, circulation), chief complaint and document findings (to include history, circumstances surrounding chief complaint, medical history, current medications used, allergies and vital signs."
* "If it is determined an emergency or urgent condition exists, the patient will be brought into the Emergency Room. If is is determined that an emergency or urgent condition does not exist, the patient may then be registered and directed to wait until the ER has available room to be seen."

This P&P allowed provision of an MSE by an RN, however, the EMTALA P&P referenced in Finding 1.a. required that a medical provider would see every patient who presented. Further, it was unclear whether the RN "assessment" referred to was intended to be an RN triage process or a medical provider MSE process.

1. c. The P&P titled "Triage, emergency department" dated 06/13/2019 was reviewed and included the following:
* "The ER nurse will evaluate and determine whether or not the patient will be taken directly to the emergency room or if the patient may continue with the registration process."

It was unclear what the "registration process" consisted of and if it included inquiries about financial information and insurance.

1. d. The P&P titled "Obstetric triage of patients" dated 02/14/2019 was reviewed and included the following:
* Having specific procedures for obstetric triage ensure compliance with [EMTALA] regulations, which require health care practitioners to examine a patient to determine whether an emergency medical condition exists ... 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 with the scope of practice and state law) is required to certify all patient assessments and dispositions."

1. e. An undated and untitled three-page document that reflected only "ER Visits:" at the top of Page 1 was reviewed and included the following:
* "Do not ask for insurance until nurse has triaged patient. (It is the law). If patient volunteers insurance information that is ok. You for ask for patient's ID. Make sure to ask for insurance information as soon as patient has been triaged if possible."
* "If Patient does not have insurance, offer patient or representative an Uncompensated Services Form. Put this information under Admission Notes. Also verify with AIS to check if patient has OMAP if no cards are available and the patient is from Oregon."

This document described as the directions for ED registration processes, required that staff ask for patient insurance information before an MSE was conducted. It further directed staff to engage patients in discussion about finances, insurance and Medicaid before an MSE.

1. f. The P&P titled "Credentials, competency Requirements for Nursing Staff" dated 05/06/2019 was reviewed and included the following:
* Required credential to work in ... Emergency Room ... ER RN (BLS, ACLS, TNCC) ... Trauma Nurse Core Course (TNCC) certification will be the ongoing requirement (and Advanced Cardiac Life Support Support) to work in the Emergency Room ... Annual competency requirements for staff are as follows ... All Nurses ... EMTALA ... ICU/ER Nurses ... EMTALA ..."

This P&P contained no information to reflect that RNs had specialized training and competencies, and formal approval or privileging by the hospital's medical staff and governing body to conduct MSEs in place of medical providers.

1. g. The "Medical Staff Bylaws" dated as "Approved by the governing body" on 01/20/2015 were reviewed and included the following:
* "Emergency Privileges" would be granted to "practitioner member of the medical staff" and to "Nurse practitioners" who "shall function in consolation with the on-call Emergency Room physician."
* "Classification of Allied Health Professionals. This category will consist of professional personnel other than medical staff members, including but not limited to the following persons: ... Physician Assistant ... Certified Nurse Midwife, R.N. ... Optometrist ... Clinical Psychologist."

There were no references to the provision of MSEs for ED and OB patients by RNs who were not nurse practitioners.

1. h. The "Medical Staff Rules and Regulations of Lower Umpqua Hospital" dated as last "Revised August 2008" were reviewed. They contained no references to provision of EMTALA requirements, including, but not limited to: designation of who may conduct MSEs to determine whether individuals presenting to the hospital for emergency services have an EMC.

1. i. The P&P titled "Discharge against medical advice" dated 11/14/2019 was reviewed and included the following:
* "... before a patient leaves AMA, health care team members must carefully evaluate the patient's decision-making capacity and provide information to the patient regarding the ramifications of leaving the facility AMA."
* "If the patient insists on leaving the facility AMA, present the patient with an AMA form that addresses knowledge of the diagnosis, proposed management, alternative therapies, risk of no treatment, and specific follow-up instruction; ask the patient to sign the form in the presence of a witness."
* "If the patient refuses to sign the AMA form, document this information on the form along with the date, time, and circumstances of the refusal and obtain the signature of a witness. Place the form in the patient's medical record ... document the patient's refusal in the medical record."

2. The ED medical record for Patient 7 reflected that he/she presented to the hospital on 11/16/2019 at 1411. The only document in the record was an "Admission/Discharge Record" that reflected the patient's "Admitting Diagnosis" was "Cancelled (sic) Per Patient." As required by the P&P described under Finding 1.a. above, there was no documentation in the record by an RN to describe the reason the patient did not receive an MSE. The record did not reflect the patient's course during the ED encounter that resulted in no MSE, including, but not limited to: why the patient came to the ED, who he/she interacted with, what was said, and whether attempts were made to follow the AMA P&P described above under Finding 1.a.

3. During interview with the CNO and DNS on 01/23/2020 beginning at 1330 they stated that for those patients who arrived and were brought directly back into the ED, they were triaged by an RN, received an MSE by a physician, and information about insurance and finances were not obtained from them until after an MSE when discharge arrangements were being made.

During the interview with CNO and DNS and MoA on 01/23/2020 at 1535 it was not clear when during the ED course information about insurance and finances were obtained for "other patients" or those not brought directly back into the ED, but who were directed to wait in the lobby or waiting area. The MoA stated that for those patients who were not "triaged to the ED right now, registration" would continue.

In addition, the MoA stated that the "ER visits" document described above under Finding 1.e. only applied to registration of patients who presented to the hospital when registration staff were on duty, generally between the hours of 0600 in the morning to 2100 or 2200 at night. The MoA stated that there were "no policies and procedures for after hours patient registration by nursing staff."

Based on interview, review of documentation in 3 of 5 ED medical records of patients who were transferred from LUH to another hospital for specialty services not available at LUH (Patients 6, 17 and 18) 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:
* 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.

Findings include:

1. a. The P&P titled "Transfer to Another Hospital" dated 05/05/2019 was reviewed and included the following:
* "Policy: To safely and efficiently transfer to another facility."
* "Evaluate the patient's and families' understanding of the transfer and provide information accordingly."
* "Make arrangements for ambulance if necessary ... Patients are transported out using Lower Umpqua Hospital ambulance ... Patients needing transfer by ambulance who come by private vehicle are transported based on residence and level of care."
* "After the Dr. has made arrangements with receiving Doctor, call the facility ..."
* "Complete COBRA transfer form and keep the original on patient's chart."
* "Copy pertinent information from the chart ... and send with patient."

The P&P did not clearly and completely describe and make provisions for the aspects of an appropriate transfer required by EMTALA regulations.

1. b. The "Medical Staff Rules and Regulations of Lower Umpqua Hospital" dated as last "Revised August 2008" were reviewed. They contained no references to provision of EMTALA requirements, including, but not limited to: appropriate transfer requirements.

2. The ED medical record for Patient 6 reflected that he/she presented to the hospital for emergency services on 11/15/2019 with a chief complaint of "chest pain." The patient received an MSE and stabilizing treatment for a diagnosis of "Probable non-ST elevation myocardial infarction." Patient 6 was subsequently transferred by ACLS to SHRB for cardiology services not available at LUH.

The "Consent to Transfer" form included a section for "Individualized Summary of Risks, Alternatives, Benefits of Transfer" that had not been completed and was blank. Nor was there documentation of that information elsewhere in the medical record.

According to Internet distance information, SHRB in Springfield. Oregon is approximately 93 miles and two hours drive-time from LUH in coastal Reedsport, Oregon.

3. The ED medical record for Patient 17 reflected that he/she presented to the hospital for emergency services on 01/12/2020 at 2040 with a chief complaint of "Out of PTSD/OCD Med over 1 week." An ED Nursing Note dated 01/12/2020 at 2101 reflected "Pt presents ambulatory to ED, states that [he/she] is feeling violent, states [he/she] feels [he/she] could harm [him/herself] or others. Has children at home and is concerned that [he/she] doesn't want to hurt [him/her]."

The patient received an MSE and diagnoses included "Mental Health Crisis" and "Mood disorder not otherwise specified." The ED physician documentation included that Patient 17 "is denying hallucinations, no suicidality, no homicidality. [He/she] is just feeling extremely explosive, unstable, wound up, and like [he/she] is losing control ... Ultimately [he/she] was calm and cooperative, without psychomotor agitation, without any hallucinations, and [he/she] was transferred by private vehicle to [BAH]" for "behavioral health evaluation" services not available at LUH.

The "Consent to Transfer" form included a section for "Individualized Summary of Risks, Alternatives, Benefits of Transfer." Information recorded in that section reflected "Safe place, mental health eval, outpatient planning [including prescription] problem solving." There was no documentation related to the risk of transfer and alternatives on the form or elsewhere in the medical record. In addition, there was no documentation that the risk of transfer by a patient experiencing the mental health crisis described, in a private vehicle, on rural coastal highway at nightime, was addressed.

According to Internet distance information, coastal BAH in Coos Bay, Oregon is approximately 25 miles and 40 minutes drive-time from LUH in coastal Reedsport, Oregon.

4. The ED medical record for Patient 18 reflected that he/she presented to the hospital for emergency services on 01/15/2020 with a chief complaint of "MVC Trauma." The patient received an MSE and stabilizing treatment for injuries sustained in the accident that included "complex" facial, eyelid and scalp lacerations. Patient 18 was subsequently transferred by ACLS ambulance to OHSU for "further laceration management and plastic surgery" not available at LUH.

The "Consent to Transfer" form included a section for "Individualized Summary of Risks, Alternatives, Benefits of Transfer." Information recorded in that section reflected "Transfer to higher level of care for treatment of complex lacerations." There was no documentation related to the risk of transfer and alternatives on the form or elsewhere in the medical record.

According to Internet distance information, OHSU in Portland, Oregon is approximately 200 miles and four hours drive-time from LUH in coastal Reedsport, Oregon.