HospitalInspections.org

Based on observation, interview, review of documentation in 31 of 31 medical records of patients who presented to the hospital for emergency services without a scheduled appointment during CY 2018 (Patients 10 - 16 and 18 - 41), review of transfer request documentation for 9 of 9 patients for whom other hospital EDs requested transfer to CHH for specialty psychiatric services who were not accepted for transfer (Patients 1 - 9), review of central log documentation, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure compliance in the following areas:
* EMTALA policies and procedures, and medical staff bylaws and rules and regulations, were incomplete and unclear and did not ensure EMTALA compliance.
* Appropriate MSEs by LIPs to determine whether an EMC existed were not conducted for patients who presented to the hospital.
* Appropriate transfers were not affected for patients transferred to other hospitals from CHH for further exam and stabilizing treatment of an EMC.
* Central log information was recorded on three different logs and was fragmented, incomplete, and unclear.
* EMTALA signage contained incomplete and unclear information and was not posted so that it could be easily viewed in all areas patient and their representatives waited for exam and treatment.
* Recipient hospital obligations were not met as patients were not accepted for transfer by CHH in the order in which they were received at the time of the requests, but rather were evaluated for acceptance based on insurance and ability to pay.

Findings include:

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

2. Regarding the central log refer to the findings identified under Tag A2405, CFR 489.20(r)(3).

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

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

5. Regarding recipient hospital responsibilities refer to the findings identified under Tag A2411, CFR 489.24(f).



29708

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 clearly and accurately 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 or their representatives waited for examination and treatment.

Findings include:

1. On 04/16/2019 at 0900 an 8 1/2" x 11" EMTALA sign was observed posted on the wall behind the hospital's front lobby counter. In order to read the sign one had to stand and lean over the end of the counter that was attached to the wall. The sign was not readable from the chairs in the lobby waiting area. There were no other EMTALA signs posted in the lobby waiting area or areas where individuals or their representatives waited for exam or treatment.

The posted sign consisted of the following language:
"IF YOU HAVE A MEDICAL EMERGENCY OR ARE IN LABOR, YOU HAVE THE RIGHT TO RECEIVE, within the capabilities of this hospital's staff and facilities:
* An appropriate MEDICAL SCREENING EXAMINATION
* Necessary STABILIZING TREATMENT (including treatment for an unborn child) and, if necessary,
* An appropriate TRANSFER to another facility EVEN IF YOU CANNOT PAY or DO NOT HAVE MEDICAL INSURANCE or YOU ARE ENTITLED TO MEDICARE OR MEDICAID.
This hospital DOES NOT participate in the Medicaid Program."

The language in the sign was not clear or accurate as follows:
* It did not clearly reflect that the requirements applied to individuals who presented to the hospital seeking medical or psychiatric emergency services and were not inpatients of the hospital already.
* The language stated that individuals had the right to an appropriate transfer regardless of ability to pay. However, it did not reflect the hospital's obligation to provide MSEs and stabilizing treatment regardless of individuals' ability to pay.
* The sign reflected that services would be provided if individuals' were "entitled to medicare of medicaid." However, it then stated that the hospital did "not participate in the Medicaid Program."

2. Review of policies and procedures revealed none related to EMTALA signage.

3. During interview on 04/19/2019 at 0940 the DCS stated that the hospital did accept Medicaid clients.

Based on interview, central log and medical record documentation for 10 of 12 individuals reviewed who presented to the hospital for emergency services without a scheduled appointment (Patients 13, 20, 27, 28, 34, 35, 36, 37, 38 and 39), review of three different logs provided 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 a central log was maintained to reflect complete and accurate information about the individuals who presented to the hospital for emergency services. There were three logs maintained that did not accurately and consistently identify those individuals that presented to the hospital on an unscheduled or "walk-in" basis and the dates and times they presented.

Findings include:

1. The policy and procedure titled "Hospital to Hospital Transfer, IP" dated as last reviewed 06/22/2017 was reviewed and also was not clear to applicability as the content of the policy included processes other than transfers including MSEs and a Central Log. It reflected "This policy applies to all individuals who are at Cedar Hills Hospital...for examination, emergency care, or treatment..."

The policy reflected that its purpose was to "ensure that Cedar Hills Hospital...is in compliance with the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA)...in providing for the evaluation, treatment and/or transfer of persons presenting for examination or treatment for an emergency medical condition (EMC)."

In regards to the Central Log the policy reflected that:
* "Each individual presenting at CHH for examination or treatment of an emergency medical condition (EMC) will be provided a Medical Screening Examination."
* "A central log is maintained in the Assessment Center noting each individual who comes to the hospital seeking treatment. Log entries document whether the individual: Refused treatment; Was refused treatment; Was transferred, admitted and treated, or stabilized and transferred; Was discharged; and Any other significant related information."

2. Documentation that identified all individuals who presented to the hospital on an unscheduled or "walk-in" basis was presented in three "log" formats. Those were:
* An "EMTALA Log."
* An "Intake Activity Log."
* A printed, electronic "appointment calendar."

3. The "EMTALA Log" contained the following columns: Date, Arrival Time, Arrival Mode, Complaint, Emergency Medical/Psych Condition, Departure/Admit Time, Disposition, Departure Mode, MOT.

* The log did not contain all of the elements required by the policy and procedure identified under Finding 1 above.

* The log did not clearly identify those individuals who presented on an unscheduled or "walk-in" basis.
- The log identified individuals under "Arrival Mode" as "walk-in."
- The log identified individuals under "Arrival Mode" as "car/pedestrian." During interview with staff they indicated those entries reflected both scheduled and un-scheduled appointments.
- The log identified individuals under "Arrival Mode" as "secure transport" and "Military transport." During interview with staff they indicated that those entries reflected scheduled appointments or planned admissions from other hospitals, military installations or facilities.

* The log did not clearly reflect the individual's chief complaint. Under the "Complaint" column the entries were either "CD," "PSY," or "PSY/CD."

* The "Emergency Medical/Psych Condition" column entries were either "yes" or "no." During interview with the DCS on 04/16/2019 at 1115 he/she indicated that if the individual was admitted to CHH staff enter "yes" on the log. If the individual was "referred out" back to the community the staff enter "no." The DCS acknowledged that those answers did not reflect whether an EMC existed but rather whether the individual met "admission criteria."

4. Information about individuals who presented to the hospital on an unscheduled or "walk-in" basis was inconsistently reflected on the three logs. For example:

a. For the CY 2018 the total number of individuals identified as "walk-in" were:
- EMTALA Log recorded 320
- Intake Activity Log recorded 151
- Appointment calendar recorded 513

b. For the month of May 2018 the number of individuals identified as "walk-in" on each log were:
- EMTALA Log recorded 33
- Intake Activity Log recorded 10
- Appointment calendar recorded 39

c. For the month of June 2018 the number of individuals identified as "walk-in" on each log were:
- EMTALA Log recorded 39
- Intake Activity Log recorded 18
- Appointment calendar recorded 40

d. For the month of November 2018 the number of individuals identified as "walk-in" on each log were:
- EMTALA Log recorded 26
- Intake Activity Log recorded 9
- Appointment calendar recorded 41

e. For the month of December 2018 the number of individuals identified as "walk-in" on each log were:
- EMTALA Log recorded 43
- Intake Activity Log recorded 4
- Appointment calendar recorded 42

5. Refer to Tags A2406 regarding MSEs and A2409 regarding transfers that include findings related to inaccuracies and omissions on the logs for Individuals and Patients 13, 20, 27, 28, 34, 35, 36, 37, 38 and 39.

Based on interview, review of documentation in 31 of 31 medical records of patients who presented to the hospital for emergency services without a scheduled appointment during CY 2018 (Patients 10 - 16 and 18 - 41), review of medical staff bylaws and rules and regulations, review of job descriptions, review of appointment and intake logs and review of policies and procedures it was determined that the hospital failed to develop and enforce policies and procedures to ensure the provision of complete, accurate, and appropriate MSEs by LIPs to all individuals who presented without regard of ability to pay:
* MSEs for individuals who presented to the hospital for services, as unscheduled or "walk-in" patients, were not conducted by LIPs, but rather by RNs and QMHPs not qualified to perform MSEs.
* Attempts were not made to advise patients of the risks of leaving the hospital before the evaluation for an EMC was completed.
* There was lack of assurance that staff did or said nothing to dissuade patients from staying at the hospital to be evaluated for an EMC, including inquiring about financial status or payment source.

Findings include:

1. Policies and procedures and bylaws and job descriptions did not contain a clear MSE process that ensured each individual who presented to the hospital on an unscheduled or "walk-in" basis for emergency services received an appropriate MSE by a LIP to determine whether an EMC existed, without regard of ability to pay, and further received stabilizing treatment within the hospital's capabilities and capacity. Those documents contained inaccuracies and contradictions and omissions related to the EMTALA MSE requirements and were not followed.

a. The policy and procedure titled "Emergency Medical Screening, IP" dated as last reviewed 11/11/2016 reflected it applied "to any person on the Cedar Hills Hospital...campus who is seeking services...It is the policy of Cedar Hills Hospital to perform an emergency medical screening on persons presenting at the hospital seeking services." The procedures were described in their entirety as follows:
* "Each person presenting at the hospital seeking services, upon arrival, will be asked to complete the Intake Assessment Patient History Form."
* "The completed form is reviewed to triage the individual's need for emergency medical care."
* "If the individual seeking care answers 'Yes' to any of the following screening questions, they will be immediately assessed by a Registered Nurse:
- Do you have any wounds or sores right now?
- Are you having any other physical problems right now?
- Have you had the flu or been in contact with anyone with the flu in the last two weeks?"
* If the individual seeking care answers 'Yes' to any of the following screening questions, they will be immediately assessed by an Assessment Counselor:
- Are you feeling suicidal?
- Are you feeling like hurting anyone else?
* Based on this assessment, the assigned clinician will initiate interventions to assure that the individual's need for emergency medical care is met. These interventions include but are not limited to:
- Arranging for the individual to be transferred to an appropriate medical facility should the individual's need for emergency medical care be beyond the scope of services offered at Cedar Hills Hospital [example: the individual is reporting symptoms suggestive of a heart attack or stroke.];
- Initiating appropriate precautions if the individual is reporting symptoms of infectious illness; and
- Initiating safety protocols for individuals who are potentially suicidal or homicidal."
* References / Citations - Emergency Medical Treatment & Active Labor Act (EMTALA).

The "Intake Assessment Patient History Form" specified in the policy was not evident in the records reviewed during this survey. There were no requirements for completion of vital signs or other assessment data by the RN.

The policy and procedure described a partial triage process by RNs and QMHPs and not a MSE by LIPs that included medical history, physical exam and diagnostic testing. Although the policy and procedure referred to an "assigned clinician" to initiate interventions, it did not specify what was meant by "assigned clinician," what the credentials of a "clinician" were, how they were "assigned," where they were located and what role they had in an MSE prior to determining "interventions."

b. The policy and procedure titled "Hospital to Hospital Transfer, IP" dated as last reviewed 06/22/2017 was reviewed and also was not clear to applicability as the content of the policy included processes other than transfers including MSEs and a Central Log. It reflected "This policy applies to all individuals who are at Cedar Hills Hospital...for examination, emergency care, or treatment, with the following exception: This policy does not govern the transfer of a stable patient (who also remains stable during transport to and from hospitals and during testing) transferred from Cedar Hills Hospital to another hospital for tests and/or diagnostic procedures if the understanding and intent of both hospital is that the patient is going to the second hospital only for tests, the patient will not remain overnight at the second hospital, and that the patient will return to Cedar Hills Hospital."

The policy reflected that its purpose was to "ensure that Cedar Hills Hospital...is in compliance with the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA)...in providing for the evaluation, treatment and/or transfer of persons presenting for examination or treatment for an emergency medical condition (EMC)."

The policy contained the following referenced to MSEs:
* "Each individual presenting at CHH for examination or treatment of an emergency medical condition (EMC) will be provided a Medical Screening Examination."
* "The Medical Screening Examination is performed by a physician who is present in the hospital at the time the individual presents for care, by a physician who is on-call and available to arrive at the hospital within one hour, by an Nurse Practitioner (NP) who subsequently consults wit a physician; or by a Registered Nurse who subsequently reviews their assessment findings with the on-call physician by telephone."
* "The purpose of the Medical Screening Examination is to determine" included "Is the individual presenting with an unstable emergency medical condition."
* "After conducting a Medical Screening Examination an/or receiving the report from the Registered Nurse regarding the subject's condition, if the physician determines that an immediate transfer is medically appropriate and necessary the physician may provide orders for the transfer."

c. The undated CHH "Medical Staff Bylaws" were reviewed. Interview with the CEO on 04/16/2019 at 1000 revealed that the "Medical Staff Bylaws" were last approved and signed as adopted in 2015. Those bylaws included the following:
* Article 5.3.5 reflected "only Physicians, Licensed Psychologists, Psychological Associate, Licensed Masters Social Workers, Licensed Professional Counselors, Psychiatric Mental Health Nurse Practitioners, Registered Nurses, Licensed Social Workers, Licensed Marriage and Family Counselors, (collectively, 'Qualified Mental Health Professional') and Physician Assistants shall have the Prerogative to perform assessments as appropriate to their license and Privileges. All Qualified Mental Health Professionals and Physician Assistants may perform pre-admission assessments. Final determination of the need for services may be assessed by appropriately privilege Staff Members only."

There were no references in the bylaws to provision of services to unscheduled or "walk-in" patients who presented to the hospital with medical or psychiatric complaints, no references to EMTALA requirements, and no references to the provision of MSEs, including the credentials and qualifications of LIPs approved to provide MSEs.

d. The undated CHH "Rules and Regulations of Medical Staff" were reviewed. Interview with the CEO on 04/16/2019 at 1000 revealed that the "Rules and Regulations of Medical Staff" were last approved and signed as adopted in 2015. Those rules and regulations included the following:
* Article 2.3 reflected "Patients whose illness cannot be treated with the capability of the Facility shall not be admitted to the Facility. If such a patient presents with an 'emergency medical condition' as defined in the Facility's EMTALA policy, such patient will be stabilized to the extent possible and, transferred to a facility equipped to treat their condition, in accordance with the Facility's policies with respect to EMTALA."
* Article 2.4 reflected "'Emergency' in this context means a condition in which serious or permanent harm could result to an individual or an unborn child or in which the life of an individual or unborn child is in imminent danger."
* Article 2.9 reflected "Persons who present to the Facility with an 'emergency medical condition,' as set forth in the Facility's EMTALA policy, shall be seen immediately by a Qualified Medical Person ('QMP'), as defined in the Facility's Medical Staff Bylaws. If the QMP giving the medical screening exam is not a physician, the QMP shall contact the physician on call, to request that the physician come to the hospital to see the person if necessary, or authorize immediate admission of the person to the Facility, or initiate a transfer of the patient to another facility if the facility does not have capability to treat the person."
* Article 5.4.3 reflected "Only Physician's, APRNs and PAs with privileges may write orders..."
* Article 9 titled "On-Call" reflected "There is a psychiatrist on-call to the Facility on a 24-hour basis to cover assessments, admissions and emergencies...Each attending Member is responsible for arranging adequate medical coverage in his absence...On-call Members are required to respond to calls/pages by the Facility within 15 minutes and, if necessary, to be physically present at the Facility within 30 minutes."
* Article 17.1 reflected "Persons presenting at the Facility potentially seeking treatment for an emergency medical condition (an 'Emergency Patient') shall be appropriately medically screened and treated in accordance with the Facility's EMTALA policy, to the extent of the Facility's capabilities."
* Article 17.2 reflected "Physicians or Allied Health professional who are on-call are responsible for returning to the Facility when requested by a Qualified Medical Person to provide necessary screening and stabilizing treatment to Emergency Patients. All transfers of Emergency Patients shall be in accordance with the Facility's EMTALA policy. The decision to transfer a person who has presented to a Facility with an 'emergency medical condition' (as such term is defined in the Facility's EMTALA policy) that has not been stabilized shall in all cases remain with a physician Member of the Medical Staff, and a written order will be obtained."
* Article 17.3 reflected "Following assessment and treatment to address an emergency medical condition, the physician or Allied Health Professional attending to the Emergency Patient shall complete an assessment of the patient's diagnosis/recommendations and implement appropriate orders for follow-up treatment."
* Article 21 reflected "Definition of Qualified Medical Person - In addition to physicians, the following classes of practitioners are granted authority, within the scope of clinical privileges or prerogatives for which they have been approved, to conduct medical screening examination as required under the facility's EMTALA policy as a 'Qualified Medical Person' or 'QMP': nurse practitioners, physician assistants, RNs with specified training."

Article 2.9 of the rules and regulations required that each individual who presented "be seen immediately" by a QMP as defined in Article 21 above, and if the QMP was not a physician, that the on-call physician be called to come into the hospital or authorize admission or initiate transfer.

e. The "Medical Screen" form was described as the documentation of the MSE. That form did not contain documentation to reflect an adequate MSE to determine whether a medical or psychiatric EMC existed for individuals who presented, rather the form reflected a "triage" process.
* The first two pages of the form was to be "Completed by Patient or Patient Representative" and was a questionnaire with the following headings:
- "Reason for Assessment / Admission"
- "Recent Substance Use History"
- "Medical Issues - Using the table below, identify all medical conditions you are experiencing or have experienced in the past."
* The third page of the form was to be "Completed By Assessment Center Staff" and consisted of two sections:
- "Vital Signs"
- "Details of Affirmative Responses / Issues Noted in Medical Screen (Part 1)."

f. Review of the "Assessment Center Nurse" Job Description dated "Revised 1.21.15" reflected the following:
* "The Assessment Center Nurse is a registered professional nurse with demonstrated experience in the triage and assessment of potential patients with mental health and/or chemical dependency treatment needs. The RN must possess the ability to assess the medical stability and appropriateness of the patient for admission to Cedar Hills Hospital. The Assessment Center Nurse must have working knowledge of the functions of the Assessment Center and provide back-up clinical assessments as directed when not engaged in nursing functions."
* "Required Knowledge, Skills, Licensure and Training" were identified as:
- "Education: Graduate from an accredited program of professional nursing required; Bachelor's Degree preferred."
- "Experience: A minimum of three (3) years experience in a psychiatric healthcare facility preferred."
- "Licensure: Currently licensed to practice as an RN by the Oregon State Board of Nursing."
- "Additional Requirements: Must pass a medication administration exam. Must have a working knowledge of the DSM-V and the Mental Status Exam. Must have a working knowledge of the Addiction and Recovery field."
- "Training: Successful completion of the CPR, Crisis Management and Service Excellence Training must occur within 90 days of employment and prior to assisting in any restraining procedures."
* "Essential Job Functions" identified included, but were not limited to:
- "Conduct medical screenings on all potential patients within 15 minutes of their arrival at Cedar Hills Hospital and evaluate them for: urgent medical issues requiring intervention, and medical appropriateness for admission to the hospital's programs."
- "Facilitate and document hospital-to-emergency room transfers for: patients with suspected medical conditions requiring treatment prior to admission, and patients needing medical clearance prior to admission."
- "Conduct nurse-to-nurse medical reviews of potential patients transferring from/to other hospital emergency rooms."
- "Call medical providers to obtain/document the various admission orders."
- "Conduct a skin assessment and contraband search on admitting patients prior to transferring the patient to the care of the Unit Nurse."
- "Communicate relevant clinical information on admitting patients with the Unit Nurse accepting the patient at the time of the patient hand-off."
- "Take direction of the Assessment Center Lead Counselor in triaging and prioritizing the needs of both patients and the Assessment Center."
- "Patients are clinically assessed and stabilized prior to leaving the hospital...or...the patient's admission to a hospital is arranged."
- "Conduct / document thorough and knowledgeable intake assessments to assure appropriate disposition."
- "Conduct/document appropriate safety plans for patient that are referred out from Cedar Hills Hospital."

The Job Description contained no references to provision of services to unscheduled or "walk-in" patients who presented to the hospital with medical or psychiatric complaints, no references to EMTALA requirements, and references to the provision of "medical screenings" and the other essential functions identified were contrary to, not consistent with, nor ensured compliance with, the EMTALA requirements.

Further, in regards to Article 21 of the Medical Staff Rules and Regulations that "RNs with specified training" were considered QMPs who could perform MSEs, there was no evidence of written description of that training.

g. Review of the "Assessment Referral Counselor" Job Description dated "Revised 6.28.16" reflected the following:
* "The Assessment and Referral Counselor is responsible for assisting in the process of responding to referrals and other requests for services and information."
* "Required Knowledge, Skills, Licensure and Training" were identified as:
- "Education: Registered Nurse or Master's Degree in a human relations field."
- "Experience: Preferably two or more years experience in intake assessment activities within an acute psychiatric setting. A minimum of two (2) years experience in a psychiatric hospital setting including customer contact."
- "Licensure: Licensed to practice in the State of Oregon as a mental health professional."
- "Additional Requirements: A working knowledge of the DSM-IV and the Mental Status Exam. A working knowledge of the Addiction and Recovery field. Successful completion of Crisis Management and Service Excellence training must occur within 90 days of employment and prior to assisting in any restraining procedures. May be required to work occasional overtime and flexible hours."
* "Essential Job Functions" identified were broad and non-specific and included, but were not limited to: ."
- "Completes pre-certifications as needed."
- "Assist in arranging for admission of patients, including alerting the business office staff to begin the verification of benefits, initiating calls to physicians and other related tasks as directed by the Case Manager. On call doctor is notified and assisted with patient interview."
- "Patient are assessed and stabilized prior to leaving hospital or admission to hospital arranged."
- "Medication is obtained after hours as ordered by the physician with proper documentation of drugs removed and accountability maintained."

The Job Description contained no references to provision of services to unscheduled or "walk-in" patients who presented to the hospital with medical or psychiatric complaints, no references to EMTALA requirements, no references to the provision of MSEs or the Assessment Referral Counselor's role relative to MSEs.

2. a. The "EMTALA Log," the "Intake Activity Log" and the "appointment calendar" reflected Individual 41 presented to the hospital on 12/13/2018 at 0900 and 0905 as an unscheduled "walk-in."

b. The "Face Sheet" form completed by Individual 41 reflected "Arrival Time" was 0900 on 12/13/2018.
The form contained direction for the individual to "Complete ALL Sections" of the form. The sections of the form and information on the form included:
* "Patient Demographics."
* "Guarantor/Legal Guardian" was blank.
* "Primary Insurance Information" was blank.
* "Secondary Insurance" was blank.
* "All requested information must be completed for insurance claims to be correctly processed. Exclusions of insurance policy information may result in an insurance denial in which case you will be totally responsible for your bill."

c. Pages 1 and 2 of the "Medical Screen" form completed and signed by the individual on 12/13/2018 reflected:
* "Are you feeling suicidal or feel like harming yourself in any way?" to which the recorded answer was "Yes."
* "Are you feeling like hurting anyone else?" to which the answer recorded was "Yes."
* The "Medical Issues" section of the form had not been completed.

d. Page 3 of the "Medical Screen" form was signed by an RN and dated 12/13/2018 at 0925 and contained the following:
* The individual's vital signs, height, weight, allergies and medication list.
* A note that "detox" was completed "3 days ago" for "heroine (sic)" and "meth."
* A note that "SI/HI - rageful."
There was no other documentation recorded by the RN.

e. A "Clinical Intake Screen" form completed and signed by a LPC on 12/13/2018 at 1804, nine (9) hours after Individual 41 presented to the hospital, reflected the following:
* The "time" of the "screen" was blank.
* The individual was a "Walk-in."
* "Chief Complaint" included "I want to hurt others...My ex-[boy/girl]friend."
* "The CSSRS information included "I'm thinking about injecting air in my veins. Pt has hx of attempts...Overdoses, 'tried to hang myself.'"
* "Risk Factors" were identified as "History of suicide attempts" and "Possession or access to gun - 'I can get a gun from a gang member.'"
* "Response Protocol" was identified as "Notify provider; Place on Suicide Precautions; Consider increased Level of Observation; Inform Staff During Handoff."
* "High Risk Factors" were identified as "Suicide Ideation" and "Suicide Plan;" and "Homicide Ideation."
* "Issues to Address on Treatment Plan" were recorded as "Pt is not admitting, due to [his/her] presentation, which is at [his/her] baseline...Pt was sent to [his/her] outpatient provider, Lifeworks NW, in a Taxi. [LPC] spoke to [LNW] mental health clinician of the day, who said a clinician would be able to see [Individual 41] when [he/she] arrived."
* The "Level of Care Determination" was recorded as "Outpatient - Referred to Community."
* Although "High Risk Factors" related to suicide and homicide were identified in the "screen," the "High Risk Discharge Issues / Needs" section of the form asked "Are There Any High Risk Issues To Address If Patient Discharges Before Treatment Is Complete?" that was answered with an "N/A."
* A space for "Reviewed w/ Physician" was completed with a physician's name and the date and time 12/13/2018 at 1122.
* The "screen" also reflected "Medical Issues to Address" were "none." However, the individual had not completed the "Medical Issues" section of the "Medical Screen" form and there was no documentation to reflect that a medical history or physical examination by an LIP had been conducted.

The date and time the individual was discharged from the hospital in a Taxi was not recorded and there was no documentation that the individual received written discharge instructions. However, the "Patient Observation Rounds, IP" reflected that the individual "Left" at 1220.

f. There was no documentation in the record to reflect that an MSE had been conducted by a LIP to determine whether an EMC existed, nor that stabilizing treatment for the suicidal ideations and plans, and homicidal ideations had been provided.

g. During interview with the DCS on 04/18/2019 at 1530 he/she confirmed that there were no discharge instructions and there was "No crisis safety plan" that should have been obtained.

3. a. Individual 35 was not identified on the "EMTALA Log" for the dates 11/15/2018 through 11/17/2018. Individual 35 was identified on the "appointment calendar" as a "walk-in" on 11/16/2018 at 1300 and on the "Intake Activity Log" as a "walk-in" on 11/16/2018 at 1448.

b. The only documentation by hospital staff in the record was a "Clinical Assessment" dated and signed by a MS on 11/16/2018. The MS did not record the "Time" of the "Assessment" nor the "Time" of his/her signature. The "Assessment" included the following:
* "Pt. has passive SI and will not safety plan. States that [he/she] can't afford to buy a gun but that Steele (sic) Bridge seems easy enough to jump. Does not want to pick up meds from pharmacy and is not willing to go to OP. Pt. unable to state that [he/she] will remain safe."
* "Overall Assessment of Risk" was identified as "Moderate...Pt expresses persistent SI w/ Hx of a gesture several years ago."
* "Disposition" was recorded as "To Admit to IP Care Today."
* The space for "Case Reviewed with MD / NP" was blank.
* "Discharge Needs Assessment" was recorded as "Exhibits behavior no longer dangerous to self / others."

c. There was no "Medical Screen" form to be completed by the individual and the RN and there was no other documentation by an RN.

d. There was no documentation in the record to reflect that an MSE had been conducted by a LIP to determine whether an EMC existed, nor that stabilizing treatment for the suicidal ideations and plans had been provided.

There was no other documentation related to Individual 35's encounter at the hospital nor the disposition of Individual 35 who "will not safety plan." The date and time the individual left the hospital, the mode of transportation, and where he/she was going was not recorded and there was no documentation that the individual received written discharge instructions.

Further, there was no documentation in the record to reflect that Individual 35 was apprised of the risks of leaving the hospital prior to receiving a MSE by a LIP to determine whether an EMC existed.

e. Documentation on the "appointment calendar" log that was not in the medical record reflected in the "MD" column of Individual 35's entry that he/she was "Sent to [PSVMC]" and an entry in the "Notes" column was recorded as "NO [INSURANCE]."

4. a. The "EMTALA Log," the "Intake Activity Log" and the "appointment calendar" reflected Individual 30 presented to the hospital on 08/30/2018 at 1125 as an unscheduled "walk-in."

b. The "Face Sheet" form completed by Individual 30 reflected "Arrival Time" was 1127 on 08/30/2018.
The form contained direction for the individual to "Complete ALL Sections" of the form. The sections of the form and information on the form included:
* "Patient Demographics."
* "Guarantor/Legal Guardian" was blank.
* "Primary Insurance Information" contained insurance information.
* "Secondary Insurance" was blank.
* "All requested information must be completed for insurance claims to be correctly processed. Exclusions of insurance policy information may result in an insurance denial in which case you will be totally responsible for your bill."

c. Pages 1 and 2 of the "Medical Screen" form completed and signed by the individual on 08/30/2018 that reflected:
* "Reason for Assessment / Admission:" "My [spouse] doesn't believe that I am lucid."
* "Medical Issues" identified included "Current High Blood Pressure" and "Current Frequent Headaches."

d. Page 3 of the "Medical Screen" form was signed by an RN and dated 08/30/2018 at 1145 and contained only the following:
* Vital signs, height and weight.
* The "Details" section of the form was blank.
There was no other documentation by an RN.

e. A "Clinical Assessment" was dated as conducted on 08/30/2018 at 1156 and signed by an LPC at 1408. The "Disposition" documentation reflected "Recommended OP services provided info on finding an appropriate provider. Crisis plan attached." The LPC documented that the "Case reviewed with MD" at 1319.

f. A "Referral Recommendations / Crisis Safety Plan" form was dated 08/30/2018 and signed by Individual 30 and the LPC. The time the information was reviewed and signed was not recorded. The form contained the following:
* "Referral Recommendations" were identified as "Agency/Organization: psychology today.com." There were no other referrals.
* "The manner in which the Assessment and Referral Center recommends referrals for patient is based on clinical judgment, geographic proximity, and any special needs or concerns evidenced in the assessment. Referrals are also made on clinically appropriate rotational basis, from a selected list of providers." However, there were no providers identified for this individual.

The time the individual left the hospital was not documented.

g. There was no documentation in the record to reflect that an MSE had been conducted by a LIP to determine whether an EMC existed.

Further, there was no documentation in the record to reflect that Individual 30 was apprised of the risks of leaving the hospital prior to receiving a MSE by a LIP to determine whether an EMC existed.

5. a. The "EMTALA Log" and the "appointment calendar" reflected Individual 28 presented to the hospital on 08/17/2018 at 0950 as an unscheduled "walk-in." Individual 28 was not entered on the "Intake Activity Log" for the dates of 08/16/2018 through 08/18/2018.

b. The "Face Sheet" form completed by Individual 28 reflected "Arrival Time" was 1014 on 08/17/2018.
The form contained direction for the individual to "Complete ALL Sections" of the form. The sections of the form and information on the form included:
* "Patient Demographics."
* "Guarantor/Legal Guardian" was blank.
* "Primary Insurance Information" was blank.
* "Secondary Insurance" was blank.
* "All requested information must be completed for insurance claims to be correctly processed. Exclusions of insurance policy information may result in an insurance denial in which case you will be totally responsible for your bill."

c. The only other documentation in the record was the following:
* An "Assessment Service Disclosure Statement and Consent to Assessment" form.
* A "Consent to Release Information."
* A "Notice of Privacy Practices."
* A one-page "Leisure Interests Screening" form.
* A "Patient Observation Rounds, IP" form.

d. There was no "Medical Screen" form to be completed by the individual and the RN and there was no other documentation by an RN.

e. There was no documentation in the record to reflect that an MSE had been conducted by a LIP to determine whether an EMC existed.

There was no other documentation related to Individual 28's encounter at the hospital nor the disposition of Individual 28. Although an entry on the "Patient Observation Rounds" form reflected that the individual "left" at 1113, why he/she left, the mode of transportation and where he/she was going was not recorded.

Further, there was no documentation in the record to reflect that Individual 28 was apprised of the risks of leaving the hospital prior to receiving a MSE by a LIP to determine whether an EMC existed.

6. a. The "EMTALA Log" and the "appointment calendar" reflected Individual 27 presented to the hospital on 07/23/2018 at 2024 as an unscheduled "walk-in." Individual 27 was not entered on the "Intake Activity Log" for the dates of 07/22/2018 through 07/23/2018.

b. The "Face Sheet" form completed by Individual 27 reflected "Arrival Time" was 2000 on 07/23/2018.
The form contained direction for the individual to "Complete ALL Sections" of the form. The sections of the form and information on the form included:
* "Patient Demographics."
* "Guarantor/Legal Guardian."
* "Primary Insurance Information" was completed to reflect the individual had State Medicaid coverage.
* "Secondary Insurance" was blank.
* "All requested information must be completed for insurance claims to be correctly processed. Exclusions of insurance policy information may result in an insurance denial in which case you will be totally responsible for your bill."

c. Pages 1 and 2 of the "Medical Screen" form completed and signed by the individual on 07/23/2018 reflected:
* "Reason for Assessment / Admission:" "Anxiety/Panic - Paranoia - Dissasocation (sic)."
* "Medical Issues" were identified as "Current Frequent Headaches."

d. Page 3 of the "Medical Screen" form was signed by an RN and dated 07/23/2018 at 2140 and contained the following:
* The individual's vital signs.
* A note that reflected "Pt declined to stay for assessment. Pt denied SI/HI. Explained to pt that therapist may evaluate appropriateness of admission [after] assessment, however, pt declined to stay."

Although the note also reflected "Pt had friends waiting and wanted to accommodate them," it was unclear whether the EMTALA sign posted in the hospital lobby that reflected "This hospital DOES NOT participate in the Medicaid Program" had any bearing on the individual's decision to leave as the "Face Sheet" he/she completed indicated he/she was a Medicaid client.

e. The "Patient Observation Rounds, IP" reflected the individual "left" the hospital at 2158.

f. Further, there was no documentation in the record to reflect that Individual 27 was apprised of the risks of leaving the hospital prior to receiving a MSE by a LIP to determine whether an EMC existed.

7. a. The "EMTALA Log" reflected Individual 20 presented to the hospital on 03/31/2018 at 2009 by "car/pedestrian" and did not reflect whether he/she had an appointment. However, the "appointment calendar" reflected Individual 20 was a "walk-in" on 03/31/2018 at 2000. Individual 30 was not entered on the "Intake Activity Log" for either 03/30 or 03/31/2018.

b. The "Face Sheet" form completed by Individu

Based on interview, documentation in 3 of 3 medical records of patients who were reviewed for transfers from CHH to another hospital for services not available at CHH at that time (Patients 36, 37 and 38) 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 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 met:
* MSE's were not conducted prior to transfers.
* It was unclear whether stabilizing treatment within the hospital's capability had been provided.
* It was unclear whether the receiving hospital had agreed to accept the patient for further examination and stabilizing treatment.
* There was no certification by a physician that the medical benefits outweighed the risks of transfer and the risks of transfer were not identified.
* Medical records were not sent to the receiving hospital.

Findings include:

1. Policies and procedures did not contain clear transfer criteria and processes that ensured each individual who presented to the hospital on an unscheduled or "walk-in" basis for emergency services and who, after an MSE, required further exam or stabilizing treatment not within the capacity or capability of CHH, received an appropriate transfer to another hospital. Those policies and procedures contained inaccuracies and contradictions related to the EMTALA transfer requirements and were not followed.

a. The policy and procedure titled "Medical Transfers", IP' was dated as last reviewed 11/09/2016 was reviewed. It's applicability was unclear as it reflected it "applies to Inpatient Services at Cedar Hills Hospital" however, it also indicated "Patients who present with the following emergent conditions will be transferred..."

b. The policy and procedure titled "Hospital to Hospital Transfer, IP" dated as last reviewed 06/22/2017 was reviewed and also was not clear to applicability as the content of the policy included processes other than transfers including MSEs and a Central Log. It reflected "This policy applies to all individuals who are at Cedar Hills Hospital...for examination, emergency care, or treatment, with the following exception: This policy does not govern the transfer of a stable patient (who also remains stable during transport to and from hospitals and during testing) transferred from Cedar Hills Hospital to another hospital for tests and/or diagnostic procedures if the understanding and intent of both hospitals is that the patient is going to the second hospital only for tests, the patient will not remain overnight at the second hospital, and that the patient will return to Cedar Hills Hospital."

The policy reflected that its purpose was to "ensure that Cedar Hills Hospital...is in compliance with the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA)...in providing for the evaluation, treatment and/or transfer of persons presenting for examination or treatment for an emergency medical condition (EMC)."

The policy reflected that:
* "Each individual presenting at CHH for examination or treatment of an emergency medical condition (EMC) will be provided a Medical Screening Examination."
* "The purpose of the Medical Screening Examination is to determine" included "Is the individual presenting with an unstable emergency medical condition."
* "After conducting a Medical Screening Examination an/or receiving the report from the Registered Nurse regarding the subject's condition, if the physician determines that an immediate transfer is medically appropriate and necessary the physician may provide orders for the transfer."
* "Transfer of patients who have emergency medical conditions, as determined by a physician/NP, shall be undertaken for medical reasons only."
* "Cedar Hills Hospital shall not transfer a patient who is not psychiatrically stabilized unless:
- The patient or the legally responsible person acting on the patient's behalf, after being informed of the hospital's obligation and of the risks and benefits of transfer, requests transfer to another hospital in writing:
- A physician/NP has provided documentation in the medical record which includes a summary of the risks and benefits of the transfer, i.e. that based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increase risks to the patient if transferred; or
- A qualified medical person documents the summary of risks and benefits after consultation with the physician/NP because the physician/NP who made the determination to transfer a patient with an emergency condition is not physically present in the hospital at the time of transfer."
* "Prior to each transfer, the physician/NP who authorized the transfer shall personally examine and evaluate the patient to ensure that the proper transfer procedures are used."
* "Prior to the transfer, the transferring physician/NP shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and hospital care."
* "A copy of those portions of the patient's medical record which are available and relevant to the transfer and to the continuing care of the patient shall be forwarded (with the patient) to the receiving physician and receiving hospital. At a minimum, the medical record shall contain: the individual's emergency condition; a brief description of the patient's medical history and physical exam; a working diagnosis and recorded observations of physical assessment...; the reason for the transfer; the results of all diagnostic tests; pertinent X-ray films and reports; and any other pertinent information."

The sections of the policy titled "Transfer of Patients Who Do Not Have Emergency Medical Conditions" and "Transfer of Patients Who Are On A Hold / Diversion / Commitment" were additionally unclear as it did not specify whether those were for transfers of patients who presented to the hospital on an unscheduled basis or for transfers of inpatients. Further, regarding the "Transfer of Patients Who Are On A Hold / Diversion / Commitment" section it provided steps and processes that did not clearly include the EMTALA requirements and ensure EMTALA compliance should those patients present to the hospital on a unscheduled basis.

2. The "EMTALA Log" and the "appointment calendar" reflected Patient 38 presented to the hospital on 11/28/2018 at 2115 as an unscheduled "walk-in." The "Intake Activity Log" reflected the patient presented on 11/28/2018 at 2139 but did not specify whether he/she was scheduled or unscheduled.

The medical record of Patient 38 reflected he/she presented to the hospital on 11/28/2018, however, the time of arrival was not recorded. Documentation on the "Medical Screen" form contained only a set of vital signs, a height and weight, and a notation "'mon', last week." It was not clear what that meant. There was no other documentation on the form and it was not dated or signed. There was no documentation to reflect that the patient was seen by a LIP, that an MSE was conducted and stabilizing treatment provided.

Although there was no documentation to reflect why the patient presented and details about the patient's condition, or that an MSE was conducted, the record contained transfer documents. The handwriting on those forms was the same handwriting on the "Medical Screen" form above. The documentation on the "Memorandum of Transfer" form, signed with an unclear signature, reflected the following:
* "Reason for Transfer" was recorded as "Unavailable Resources...SI and not contracting for safety."
* The patient's "Primary Diagnosis" was recorded as "MDD."
* The "History of Medical Diagnosis" was blank.
* Documentation to reflect that the patient was accepted by the receiving hospital was unclear. The "Name of the Transferring Nurse" was a first name that did not match the unclear signature of the author of the form. Although there was a first name for an "Accepting Nurse," the name of the "Accepting Physician" was blank, and the "time" the patient was accepted was also blank.
* The "Certification of Transfer" reflected that "I certify 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 risk, if any, to the individual's medical condition...This certification is based upon the following risks and benefits of the patient's condition."
* The "Risks" of transfer section under the "Certification of Transfer" was blank.
* The "Benefits" of transfer recorded were "Other: Pt has a bed to stay in due to SI."
* The "Certification" was signed with an unclear signature on 11/28/2018 at 2010.
* The "Documents Transmitted to Receiving Hospital" had not been completed. However, another document titled "Hospital-To-Hospital Transfer" reflected that "Face Sheet / Patient Demographics" was "provided" Yet, there was no evidence of that document found in the patient's record.
* The form was signed with an unclear signature on 11/28/2018 at 2009.
* It was unclear whether the signature belonged to a physician, LIP, RN or other individual.

The time the transfer documents were signed on 11/28/2018 at 2009 and 2010 was prior to the time the logs recorded the patient's arrival to the hospital on 11/28/2018 at 2139 and 2215.

During interview with the DCS on 04/19/2019 at 1700 he/she stated that Patient 38 was "sent to the ED because likely we didn't have a bed."

3. Patient 37 was not identified on the "EMTALA Log" for the dates 11/20/2018 through 11/22/2018. The patient was identified on the "appointment calendar" on both 11/20/2018 and 11/21/2018 at 0033 as an unscheduled "walk-in." The "Intake Activity Log" reflected the patient presented on 11/21/2018 at 0033 as a "walk-in."

The medical record of Patient 37 reflected he/she presented to the hospital on 11/21/2018. The "Patient Observation Rounds, IP" form reflected the patient "arrived" at 0033 on that date. Documentation on the "Medical Screen" form reflected that the patient expressed feeling suicidal and he/she stated "way more homicidal (sic) but I have to watch what I say" and regarding feeling like hurting others he/she stated "If they try to get me." The record contained no vital signs, no history, no physical exam, no mental health assessment. There was no documentation to reflect that the patient was seen by a LIP, that an MSE was conducted and stabilizing treatment provided.

Documentation by the RN dated 11/21/2018 at 0130 reflected that although an MSE was not conducted "CHH did not have an appropriate bed available...MD on-call notified of pt presentation. Pt presenting irritable, aggitated (sic) delusional sounding gang violence and thoughts of 'they' coming to 'get me.' MD suggested attempting to crisis safety plan and arrange for an intake appointment in the A.M. When pt was informed pt continued to yell at staff...Pt demanded to be transferred to Providence for evaluation. This RN notified oncall provider who ordered to be transferred due to no appropriate beds. [Nurse-to-Nurse & Doctor-to-Doctor] completed. Pt. accepted at Providence St. Vincents. Metro West contacted for transfer.

The documentation on a "Memorandum of Transfer" form was completed by an RN and reflected the following:
* The patient's "Primary Diagnosis" was recorded as "N/A."
* The "History of Medical Diagnosis" was recorded as "N/A."
* The name of the "Transferring Physician" and the name of the "Accepting Physician" with a date and time recorded of 11/21/2018 at 0110. However, it was unclear who spoke with the "accepting physician" at 0110 as the RN had documented in the narrative note that he/she had completed the "[Doctor to Doctor]."
* The "Risks" of transfer section under the "Certification of Transfer" was blank.
* The "Benefits" of transfer recorded were "Stabilization of medical condition: Pt demanding to be sent to providence."
* The "Certification" was signed by an RN on 11/21/2018 at 0100 and not by a LIP.
* The "Documents Transmitted to Receiving Hospital" were "Other: Nursing Assessment." However, there was no "Nursing Assessment" found in the patient's record.
* The form was signed by the RN on 11/21/2018 at 0100.
* There was no physician or LIP signature on the form.

4. Patient 36 was not identified on the "EMTALA Log," the "appointment calendar" or the "Intake Activity Log" for the dates 11/17/2018 through 11/19/2018.

The medical record of Patient 36 reflected he/she presented to the hospital on 11/18/2018. The "Patient Observation Rounds, IP" form reflected that patient "arrived" at 2255 on that date. Documentation on the "Medical Screen" form reflected that the patient expressed feeling suicidal, hurting self and hurting others. The "Medical Screen" form dated and signed by the RN on 11/18/2018 at 2330 contained one set of incomplete vital signs that lacked a temperature and a note that reflected "Pt endorsed SI & HI presenting [with] paranoid (sic) delusions surrounding gang violence. Pt. disorganized in speech. MD on call notified ordered to transfer pt due to no appropriate beds at this time. Providence St. Vincents notified [Nurse-to-Nurse] completed." The record contained no history, no physical exam, no mental health assessment. There was no documentation to reflect that the patient was seen by a LIP, that an MSE was conducted and stabilizing treatment provided.

Although a MSE had not been conducted the patient was transferred to another hospital. The documentation on a "Memorandum of Transfer" form was completed by an RN and reflected the following:
* The patient's "Primary Diagnosis" was recorded as "N/A."
* The "History of Medical Diagnosis" was recorded as "N/A."
* The "Certification of Transfer" section of the from that contained transfer risks and transfer benefits had not been completed, was crossed out with a slash mark and "N/A" recorded above the slash mark, and was signed by the RN on 11/18/2018 at 2315.
* The "Documents Transmitted to Receiving Hospital" had not been completed. However, another document titled "Hospital-To-Hospital Transfer" reflected that "Admission paperwork" was "provided" Yet, it was not clear what "Admission paperwork" referred to as there were no documents identified as "Admission" documents.
* The form was signed by the RN on 11/18/2018 at 2315.
* There was no physician or LIP signature on the form.

Based on interviews, review of transfer request documentation for 9 of 9 patients for whom other hospital EDs requested transfer to CHH for specialty psychiatric services who were not accepted for transfer (Patients 1 - 9), review of intake activity 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 its compliance with recipient hospital responsibilities.
* Recipient hospital obligations were not met as patients were not accepted for transfer by CHH in the order in which they were received at the time of the requests, but rather were evaluated for acceptance based on insurance and ability to pay.

Findings include:

Policies and procedures, transfer request documents, job descriptions, training documents, and other documentation did not contain a clear process that ensured the hospital upheld its recipient hospital obligations, and ensured acceptance of patient transfers was not evaluated and based on insurance and ability to pay.

1. a. An undated flowsheet document titled "Revised Tracking Form Trial" was provided by the IDI on 03/19/2019 at 1825. The IDI stated the flowsheet reflected the hospital's process for managing transfer requests or "referrals" from other hospital EDs. The flowsheet included steps to be taken in response to yes/no questions as follows:
- "Assessment Counselor Receives Transfer Request"
- "Screen against Admission and Exclusionary Criteria"
- "Questions about Medical Status?" with "Yes" and "No" choices. If "No" response "Meets Criteria?" If "Yes" response Consult with Assessment RN or RN Supervisor"
- "Meets Criteria?" with "Yes" and "No" choices. If "No" response "Decline Transfer." If "Yes" response "Determine Potential Program/Unit."
- "Requires CSU or 1:1..." with "Yes" and "No" choices. If "No" response "Contact MD." If "Yes" response "Consult RN Supervisor re: bed/staffing"
- "Can Accommodate?" with "Yes" and "No" choices. If "No" response "Decline Transfer." If "Yes" response "Contact MD...Send Clinical Documentation to MD...Doc to Doc...MD Calls Assessment RN"
- "Accepted Transfer?" with "Yes" and "No" choices. If "No" response "Notify AOC." If "Yes" response "MD Gives Initial Admit Orders...Assessment RN Does RN to RN...Assessment RN Confirms transport (sic)...Patient Arrives..."

b. The policy and procedure titled "Medical Exclusionary Criteria, IP" dated revised "01/2018" was reviewed. It stipulated:
*"Each potential admission to Cedar Hills Hospital will be screened on an individual case basis to assure they meeting (sic) applicable admission criteria and that the services they require are within the scope of care provided at Cedar Hills Hospital."
* "The following criteria may prevent admission to Cedar Hills Hospital's Inpatient Programs:
"General exclusionary criteria...Younger than 18 years of age...Cognitive exclusions...Diagnosed dementia with mini-mental score [less than] 18...Intellectual capacity that will not allow patient to benefit from process oriented group therapy."
"Functional Exclusions...Inability to independently perform activities of daily living...Requires two people to transfer from bed to chair or bathroom...Requires hospital medical bed (exclusion cannot be waived)..."
"Infectious Disease Exclusions...Active tuberculosis...Conditions requiring isolation or quarantine..Medical Instability Exclusions (requires medical clearance for admission)...Unstable vital signs...Overdose without medical clearance...Current cardiac symptoms...Head injury within past 72 hours without CT...Stimulant abuse with history of cardiac problems or seizures...CBG [greater than sign] (Transfers)...Critical abnormal laboratory values (Transfers)...Care exclusions (Has need of medical devices, equipment, or specialized care beyond the scope of Cedar Hills Hospital)...Less than 48 hrs post-op...Open and weeping wounds...sterile dressings...suctioning...IV therapy...heparin locks...subclavian lines...mediports...implanted medication pump...O2 therapy...dialysis...physical therapy...High Risk for Medical Decompensation Exclusions...severe sleep apnea...and requiring detox from alcohol or opiates...Pregnant, third trimester, and requiring CSU...Behavior Exclusions...If seclusion/Restraint was required in referring agency, must have demonstrated at least 6 hours free of restraint/seclusion prior to transfer."

c. The policy and procedure titled "Admission Criteria, IP" dated revised "01/14" was reviewed. It stipulated:
* "It is the policy of Cedar Hills Hospital to follow criteria for admission to all programs to ensure that each patient is treated in the least restrictive environment that will allow them to attain an optimal functional level."
* "At least one of the following must be met...Behavior which is life threatening, destructive or disabling to self or others...Symptoms/behaviors indicative of need for 24 hours monitoring and assessment of the patient's condition...Active psychiatric disorder with potential to interfere with treatment of serious medical condition...Failure at outpatient or partial hospitalization treatment evidenced by clinical instability of a MD consult indicates a condition which precludes safe treatment at a lesser level of care...Severe deterioration of level of functioning..."

2. a. Undated staff training materials titled "EMTALA Emergency Medical Treatment and [Active] Labor Act" were reviewed and reflected: "...Transfer requests: EMTALA applies. If another hospital has determined an EMC exists and they don't have capability or capacity to treat, then we are obligated to accept the patient as a transfer..."

b. Undated staff training materials titled "EMTALA The Emergency Medical Treatment and Labor Act" were reviewed and reflected: "Medicare-certified psychiatric hospitals are considered 'hospitals with specialized capabilities.' Therefore, they must...Accept appropriate transfers of emergent individuals needing their specialized services when the transferring hospital does not provide those services...Provide the individuals with necessary stabilizing treatment within the Hospital's capabilities; and...Make a decision about whether they can treat the individual without delay or regard to the individual's ability to pay...EMTALA does not allow a hospital to refuse such transfer just because it is not the closest psychiatric hospital to the transferring hospital...All emergency services provided at Medicare-certified psychiatric hospitals must be performed in accordance with written policies and procedures...Be sure you are doing what your policy requires, or if appropriate, revise your policy to correspond to what you are doing (as long as the procedure complies with EMTALA!)...The duty to provide necessary stabilizing treatment is limited to the hospital's capacity to render such treatment...The capacity to render care is not reflected simply by the number of persons occupying a specialized unit, the number of staff on duty, or the amount of equipment on the hospital's premises...Capacity includes whatever a hospital customarily does to accommodate patients in excess of its occupancy limits..."

3. During an interview with the IDI on 03/19/2019 at 1355 a blank "Hospital Transfer Tracking" form was provided. The IDI stated the transfer tracking form was used to document transfer requests, also called "referrals" from other hospital EDs. He/she stated the transfer tracking form was the only documentation that reflected an evaluation and determination of the hospital's capability and capacity to accept a patient for transfer.

4. a. Transfer request documents for Patient 1 that included a "Hospital Transfer Tracking" form and fax'd ED records from KWMC were reviewed.
The "Hospital Transfer Tracking" had an extensive list of approximately 20 items or questions to be completed or answered. Those included:
* "Appropriate Unit (s): with the following choices "CSU(...single)," "South," and "North/West 1"
* "Patient Name:"
* "Open Date/Time:"
* "Hospital:"
* "SW Contact...Nurse Contact...MD Contact:"
* "Info received...Facesheet...Clinicals...Labs... Reconciled med list...NMI/hold"
* "Communication With Hospital:"
* "[Verification of Benefits]"
* "MS4"
* "Appointment Board"
* "Voluntary...Hold...NMI"
* "Seclusion/Restraint/Aggression...Pt in: Seclusion/Restraint? Date/Time In...Time out...Medication Given...Pt Aggressive...YES...NO Details"
* "Level of Care...Dementia with Mini Mental [less than] 18...YES...NO...Developmental Delay/Intellectual Capacity that will not allow Pt to benefit from group?..YES...NO...Can Pt perform their own ADLs?..YES...NO"
* "Closed Status...Accepted...Closed: Date/Time:...Patient D/C...Patient referred elsewhere...Hospital Capacity/Staffing...No Appropriate Bed: M/F/Single Bed...No Appropriate Bed: CSU...Medical Exclusionary: (specify)...Other..."

The only sections on Patient 1's transfer tracking form that contained documented responses were primarily related to insurance verification and initial intake information as follows:
* "Patient Name: [Patient 1]"
* "Open Date/Time: 12/14 [at] 0836"
* "Hospital: [KWMC]"
* "SW Contact: [phone number]
* "...[Verification of Benefit] was not checked and followed by "n/a"
* "MS4" and "Appointment Board" were checked.
* The "Closed Status:" section reflected "...Closed Date/Time: 12/19"
The other sections on the form were blank.

The ED records from KWMC for Patient 1 dated received by fax at CHH on 12/14/2018 at "09:21" reflected:
* The KWMC LCSW "Mental Health Emergency Evaluation" dated 12/13/2018 at 2330 reflected "...Pt endorses SI with plans, reports beliefs that AFH staff are trying to 'overdoes me and kill me,'...found lying face down on the floor...refused to move for hours until EMS arrived...impulsive, irritable...AFH provider...reports pt is 'worse'...Will seek acute inpatient psychiatric admission..."
* The KWMC Physician "ED Notes" dated 12/14/2018 at 0713 reflected "[Patient 1]...with h/o bipolar disorder, schizophrenia...Workup grossly unremarkable with no acute medical process...Suspect psych component..."

b. An electronic "Intake Activity Log" provided in response to a request for the hospital's log, records of calls, and any documentation of calls received from other hospitals seeking to transfer patients from their EDs was reviewed. It reflected the following entries related to Patient 1:
* "Call Date, Time...12/14/2018 8:36"
* "...Referral Source Name...E.D. [KWMC]"
* "Primary Payer" and "Secondary Payer" sections were blank.
* "Assessment Date, Time" reflected "00/00/0000" and "Completed by?" was blank.
* "Disposition/Reason Non-Admit" reflected "[Returned to Referral Source]" and "[Refused Action Other]"
The log reflected the patient was not admitted and the reason was "Refused Action Other." There was no documentation that reflected what was meant by "Refused Action Other." There was no further documentation that reflected the reason this patient who was suicidal and needed inpatient psychiatric services was not accepted for transfer.

c. The electronic "Intake Activity Log" reflected the following entries related to a self "referral" for another patient on 12/14/12018. That request reflected the following:
* "Call Date, Time..." reflected "12/14/2018 18:39"
* "...Referral Source Name" reflected [Referred Self]"
* "Primary Payer" reflected "Medicare Inpatient"
* "Secondary Payer" reflected "Washington Medicaid"
* "ADMT"
* "Admit Date, Time" reflected "12/14/2018 18:45"

The electronic "Intake Activity Log" reflected the following entries related to a transfer request "referral" for another patient on 12/14/12018. That request reflected the following:
* "Call Date, Time..." reflected "12/14/2018 21:08"
* "...Referral Source Name" reflected [PSVMC]"
* "Primary Payer" reflected "BCBS Federal Program"
* "Secondary Payer" reflected "Self Pay After Insur"
* "ADMT"
* "Admit Date, Time" reflected "12/15/2018 [no time recorded]"

The intake activity log reflected the following:
Patient 1 had no payer source (insurance), and was not accepted for transfer. However, the other 2 patients whose transfer/referral requests were received after Patient 1, had a payer source and were accepted for transfer/admission.

Additional entries on the intake activity log for 12/14/2018 reflected:
* The "Caller/Patient Information" and "Referral Information" columns reflected the names of 29 patients referred for admission, including 19 transfer requests from other hospital EDs.
* The spaces for "Primary Payer" and "Secondary Payer" were blank and reflected no payer source for 11 of the patients. All of the other patients had a payer source entered on the log.
* Six of the patients referred for admission were admitted, all of whom had a payer source entered on the log. None of the patients without a payer source were admitted, including patient 1.

d. During an interview with the TC on 03/20/2019 at 1125 the KWMC ED record and "Hospital Transfer Tracking" form for Patient 1 was reviewed. The following information was provided:
* The hospital received a transfer request from KWMC ED for Patient 1 on 12/14/2018.
* The "Hospital Transfer Tracking" form was initiated on 12/14/2018 at 0836. The TC confirmed the tracking form was not completed as reflected above.
* The TC stated Patient 1's diagnosis was SI. The TC stated "I believe we had capability. [He/she] would've been appropriate for our South unit or sometimes we admit psych on West Unit."
* The TC stated the hospital had a bed available but did not accept the patient for transfer because a "pre-arranged VA patient" was planned for admission the next day.
* The TC stated he/she had no documentation that reflected the hospital's "Revised Tracking Form Trial" process was followed.
* The TC confirmed there was no documentation that reflected the hospital lacked capability and/or capacity and therefore was not obligated under EMTALA to accept Patient 1 for transfer.

e. During an interview with the TC and IDI on 03/20/2019 at 1305, the TC stated that "military patient" admits were "pre-arranged, usually 3-5 days in advance." The TC stated "Technically, the bed is held for the military patient even if a psychiatric patient from an ED needs to transfer. The TC stated that "once we've accepted the [military] patient they have priority for that bed."

f. During an interview with the IDI on 03/20/2019 at 1355, the IDI stated that on the "military unit" a patient has to have insurance that is authorized through TriCare or VA in order to be transferred from another hospital's ED to that unit. The IDI stated that if the patient has no insurance "we check with the VA hospital first to make sure they have no available beds...if the VA has available beds, we decline the transfer but then help coordinate the patient's transfer from the requesting hospital's ED to the VA." The IDI stated this was the process even if CHH had capability and capacity to care for the patient.

g. An untitled and untimed electronic "bed board" document with "12/14/18" handwritten on it was provided to demonstrate the hospital's bed availability on 12/14/2018. Review of the document reflected it included patient census and bed activity information such as: "Internal Bed Transfer...Open [beds]...Tentative Pt...Definite Discharge...Possible Discharge...MOT...Waitlist...Military Waitlist...Discharges...No Roommate...pt's with orders to move/UNIT...[Incoming] transfer pt...High aggressivity" However, there was no documentation that reflected the time the report was generated or the times of the various census changes and activities. For example, the "Discharges" section reflected a list of 9 patients but no information that reflected if or when the patients were discharged.

h. During an interview with the TC on 03/20/2019 at 1300, the bed board document above was reviewed. The TC stated that a bed board document was saved and copied once per day from an electronic bed tracking system. The TC acknowledged the "bed availability" information on the daily bed board document was "unclear" and did not provide clear and accurate information about the hospital's capacity throughout the day.

5. a. Transfer request documents for Patient 2 that included a "Hospital Transfer Tracking" form and fax'd ED records from MMC were reviewed.
The "Hospital Transfer Tracking" form had the same 20 items or questions to be completed or answered as reflected above.
The only sections on the transfer tracking form that contained documented responses were primarily related to insurance verification and initial intake tracking information as follow:
* "Patient Name: [Patient 2]"
* "Open Date/Time: 12/17/18 1718"
* "Hospital: [MMC]...SW Contact: [phone number]
* "[Verification of Benefits] Unfunded"
* "MS4" and "Appointment Board" were checked.
* The "Closed Status:" section reflected:
- "...Closed Date/Time: 12/21 [at] 1330"
- "Patient D/C" was checked.
- "...No Appropriate Bed: M/F/Single Bed" had "Unk" hand written above it.
All other sections on the form were blank.

The ED records from MMC for Patient 2 dated received by fax at CHH on 12/17/2018 at "4:49PM" reflected:
* The MMC Physician "Emergency Department Document" dated 12/13/2018 reflected "...patient...presents to the ED brought in by police for suicidal ideation...reports long history of suicidal ideation and was thinking tonight about cutting [his/her] wrist or hanging [himself/herself]..."
* The MMC RN "Patient Notes" on 12/17/2018 at 1526 reflected "...[Physician] has seen and evaluated pt, recommendation is to seek [inpatient] psychiatric care at this time."

b. The electronic "Intake Activity Log" reflected the following entries related to a transfer request "referral" for Patient 2:
* "Call Date, Time..." reflected "12/17/2018 17:21"
* "Agency Name" reflected [MMC]"
* "Primary Payer" and "Secondary Payer" sections were blank.
* "Assessment Date, Time" reflected "00/00/0000" and "Completed by?" was blank.
* "Disposition/Reason Non-Admit" reflected "[Returned to Referral Source]" and "[Refused Action Other]"

c. The electronic "Intake Activity Log" reflected entries related to a transfer request "referral" for another patient on 12/17/2018. That request reflected the following:
* "Call Date, Time..." reflected "12/17/2018 19:23"
* "...Referral Source Name" reflected [PHSJMC]"
* "Primary Payer" reflected "Medicare Inpatient"
* "Secondary Payer" reflected "Medicaid Oregon Open"
* "ADMT"
* "Admit Date, Time" reflected 12/18/2018 19:14"

The intake activity log reflected the following:
Patient 2 had no payer source (insurance), and was not accepted for transfer. However, the other patient whose transfer request was received after Patient 2, had a payer source and was accepted for transfer.

Additional entries on the intake activity log for 12/17/2019 reflected:
* The "Caller/Patient Information" and "Referral Information" columns reflected the names of 27 patients referred for admission, including 19 transfer requests from other hospital EDs.
* The spaces for "Primary Payer" and "Secondary Payer" were blank for 14 of the patients. All of the other patients had a payer source entered on the log.
* Eight of the patients referred for admission were admitted, all of whom had a payer source. None of the patients without a payer source were admitted, including patient 2.

d. During an interview with the TC on 03/20/2019 at 1400 the MMC ED record and "Hospital Transfer Tracking" form for Patient 2 was reviewed. The following information was provided:
* The hospital received a transfer request from MMC ED for Patient 2 on 12/17/2018.
* The "Hospital Transfer Tracking" form was initiated on 12/17/2018 at 1718. The TC confirmed the tracking form was not completed as reflected above.
* The TC stated Patient 2's diagnosis was SI. The TC stated the hospital had capability to care for Patient 2. The TC stated "[He/she] would be appropriate for admission."
* The TC was asked if the hospital had capacity to accept the patient for transfer and he/she stated "I don't know what I had."
* The TC stated he/she had no documentation that reflected the hospital's "Revised Tracking Form Trial" process was followed.
* The TC confirmed there was no documentation that reflected the hospital lacked capability and/or capacity and therefore was not obligated under EMTALA to accept Patient 2 for transfer.

e. An untitled and untimed electronic bed board document provided with handwritten "12/17" on it was reviewed. The document reflected similar unclear bed activity as reflected above. This was confirmed with the TC at the time of the bed board document review.

6. a. Transfer request documents for Patient 3 that included a "Hospital Transfer Tracking" form and fax'd ED records from KWMC were reviewed.
The "Hospital Transfer Tracking" form had the same 20 items or questions to be completed or answered as reflected above.
The only sections on the transfer tracking form that contained documented responses were primarily related to insurance verification and initial intake information as follow:
* "Patient Name: [Patient 3]"
* "Open Date/Time: 12/21 1548"
* "Hospital: [KWMC]"
* "MS4" and "Appointment Board" were checked.
* "[Verification of Benefits] was followed by "N/A"
* The "Communication With Hospital" section reflected "discharged - 12/25"
* The "Closed Status:" section reflected:
- "...Closed Date/Time: 12/25 [illegible time]" and "Patient D/C" was checked.
All other sections on the form were blank.

The ED records from KWMC for Patient 3 dated received by fax at CHH on 12/21/2018 at "17:17" and 12/23/2018 at "09:14" reflected:
* The KWMC Physician "ED Notes" dated 12/21/2018 at 0808 reflected "[Patient 3]...brought to the ED by Hillsboro PD with a behavioral problem and altered level of consciousness...Per PD: Patient has been found wandering the streets multiple times by police...may have schizophrenia...Upon patient's arrival in the ED, [he/she] is yelling...[he/she] 'loves psychedelics, my favorite drug is acid and mushrooms.'...Active Problems...Polysubstance abuse...Hallucinogen psychosis... "
* The KWMC "Mental Health" notes dated 12/23/2018 at 0759 reflected "...psychotic...Psychosocial: homelessness...has been in the ED [approximately] 48 hours...Patient remains on the list for...Cedar Hills..."
* The KWMC RN "ED Notes" dated 12/23/2018 at 0801 reflected "...Pt started...trying to be intimidating...in seclusion until meds help [him/her] relax..."

b. The electronic "Intake Activity Log" reflected the following entries related to a transfer request "referral" for Patient 3:
* "Call Date, Time..." reflected "12/21/2018 13:17"
* "...Referral Source Name" reflected "E.D. [KWMC]"
* "Primary Payer" and "Secondary Payer" were blank.
* "Assessment Date, Time" reflected "00/00/0000" and "Completed by?" was blank.
* "Disposition/Reason Non-Admit" reflected "[Returned to Referral Source]" and "[Not Clinically Qualified Lacks Acuity]"
The intake activity log reflected the patient was not accepted for transfer due to "Not Clinically Qualified Lacks Acuity." However, there was no documentation that reflected how that determination was made for this patient with possible schizophrenia and psychosis who required seclusion.

c. The electronic "Intake Activity Log" reflected entries related to a "referral" for another patient on 12/21/2018. That request reflected the following:
* "Call Date, Time..." reflected "12/21/2018 16:13"
* "Agency" reflected [CHH]"
* "Comments" reflected "Drinking 2 bottles wine daily...also suicidal..."
* "Primary Payer" reflected "BCBS"
* "ADMT"
* "Admit Date, Time" reflected 12/21/2018 19:33"

The intake activity log reflected the following:
Patient 3 had no payer source (insurance), and was not accepted for transfer. However, the other patient whose "referral" was received after Patient 3 was accepted for admission.

Additional entries on the intake activity log for 12/21/2018 reflected:
* The "Caller/Patient Information" and "Referral Information" columns reflected the names of 21 patients referred for admission, including 12 transfer requests from other hospital EDs.
* The spaces for "Primary Payer" and "Secondary Payer" were blank for 9 of the patients. All of the other patients had a payer source entered on the log.
* Six patients were admitted, all of whom had a payer source. None of the patients without a payer source were admitted, including Patient 3.

d. During an interview with the TC on 03/20/2019 at 1435 the KWMC ED record and "Hospital Transfer Tracking" form for Patient 3 was reviewed. The following information was provided:
* The hospital received a transfer request from KWMC ED for Patient 3 on 12/21/2018.
* The "Hospital Transfer Tracking" form was initiated on 12/21/2018 at 1548. The TC confirmed the tracking form was not completed as reflected above.
* The TC stated Patient 3's diagnosis was psychosis and the hospital had capability to care for him/her. The TC stated "We could take [him/her] in CSU."
* The TC was asked if Patient 3 was accepted for transfer and he/she stated "No."
* The TC stated he/she had no documentation that reflected the hospital's "Revised Tracking Form Trial" process was followed.
* The TC confirmed there was no documentation that reflected the hospital lacked capability and/or capacity and therefore was not obligated under EMTALA to accept Patient 3 for transfer.

e. An untitled and untimed bed board document provided with handwritten "12/21" on it was reviewed. The document reflected similar unclear bed activity as reflected above. This was confirmed with the TC at the time of the bed board document review.

7. a. Transfer request documents for Patient 4 that included a "Hospital Transfer Tracking" form and fax'd ED records from OHSU were reviewed.
The "Hospital Transfer Tracking" form had the same 20 items or questions to be completed or answered as reflected above.
The only sections on the transfer tracking form that contained documented responses were primarily related to insurance verification and initial intake information as follow:
* "Patient Name: [Patient 4]"
* "Open Date/Time: 12/18 [at] 1704"
* "Hospital: [OHSU]"
* "SW Contact [phone number]"
* "[Verification of Benefits]" was checked.
* "MS4" and "Appointment Board" were checked.
* The "Closed Status:" section reflected "...Closed Date/Time: [12/19/2018] 1850" and "Patient D/C" was checked.
The other sections on the form were blank.

The ED records from OHSU for Patient 4 dated received by fax at CHH on 12/19/2018 at "12:33:39 AM" reflected:
* The OHSU "ED Provider Notes" dated 12/18/2018 at 0921 reflected "[Patient 4]...h/o depression and SI...reports that [he/she] ingested 4 corona beers and 10 ambien tablets approximately 2 hours prior to arrival..."
* The LCSW "ED Notes" dated 12/18/2018 at 1447 reflected "Suicide Risk: Patient appears at high risk of suicide due to a serious or nearly lethal suicide attempt...Recommendation...Patient will be referred to inpatient psychiatric care, Cedar Hills..."

b. The electronic "Intake Activity Log" reflected the following entries related to a transfer request "referral" for Patient 4:
* "Call Date, Time..." reflected "12/18/2018 17:04"
* "Agency Name" reflected "OHSU ED"
* "Primary Payer" and "Secondary Payer" was blank.
* "Assessment Date, Time" reflected "00/00/0000" and "Completed by?" was blank.
* "Disposition/Reason Non-Admit" reflected "[Returned to Referral Source]" and "[Refused Action Other]"

c. The electronic "Intake Activity Log" reflected entries related to a transfer request "referral" for another patient on 12/18/2018. That request reflected the following:
* "Call Date, Time..." reflected "12/18/2018 21:46"
* "Referral Source" reflected "[LMPMC]"
* "Primary Payer" reflected "Medicare Inpatient"
* "Secondary Payer" reflected "Health Share of Oreg"
* "ADMT"
* "Admit Date, Time" reflected 12/20/2018 23:56"

The intake activity log log reflected the following:
Patient 4 had no payer source (insurance), and was not accepted for transfer. However, the other patient whose transfer request was received after Patient 4 was accepted for transfer.

Additional entries on the intake activity log for 12/18/2018 reflected:
* The "Caller/Patient Information" and "Referral Information" columns reflected the names of 32 patients referred for admission, including 10 transfer requests from other hospital EDs.
* The spaces for "Primary Payer" and "Secondary Payer" were blank for 14 patients. All of the other patients had a payer source entered on the log.
* Eleven patients were admitted, all of whom had a payer source. None of the patients without a payer source were admitted, including the transfer request for Patient 4.

d. During an interview with the TC on 03/20/2019 at 1445 the OHSU ED record and "Hospital Transfer Tracking" form for Patient 4 was reviewed. The following information was provided:
* The hospital received a transfer request from OHSU ED for Patient 4 on 12/21/2018.
* The "Hospital Transfer Tracking" form was initiated on 12/18/2018 at 1704. The TC confirmed the tracking form was not completed as reflected above.
* The TC stated Patient 4's diagnosis was suicide attempt and the hospital had capability to accept Patient 4. The TC stated, "Yes, we were capable of taking [him/her] on the unit."
* The TC stated the hospital had capacity to accept Patient 4. The TC stated, "We had a CSU bed available."
* The TC was asked if Patient 4 was accepted for transfer and he/she stated, "No."
* The TC was asked why Patient 4 was not accepted for transfer. The TC stated, "It doesn't say."
* The TC stated he/she had no documentation that reflected the hospital's "Revised Tracking Form Trial" process was followed.
* The TC confirmed there was no documentation that reflected the hospital lacked capability and/or capacity and therefore was not obligated under EMTALA to accept Patient 4 for transfer.

8. a. Transfer request documents for Patient 5 that included a "Hospital Transfer Tracking" form and fax'd ED records from OHSU were reviewed.
The "Hospital Transfer Tracking" form had the same 20 items or questions to be completed or answered as reflected above.
The only sections on the transfer tracking form that contained documented responses were primarily related to insurance verification and initial intake information as follow:
* "Patient Name: [Patient 5]"
* "Open Date/Time: 3/12/19 1340"
* "Hospital: OHSU"
* "[Verification of Benefits]" was checked.
* "MS4" and "Appointment Board" were checked.
* The "Closed Status:" section reflected:
- "Closed Date/Time: 3/15/19 1706"
- "Patient D/C" was checked.

The ED records from OHSU for Patient 5 dated received by fax on 03/12/2019 at "7:21:45 PM" reflected:
* The OHSU "ED Provider Notes" dated 03/11/2019 at 2011 reflected "[Patient 5]...history of psychosis and depression who presents with suicidal ideation...I placed the patient on a psych hold because of [his/her] suicidal ideation...We considered medical etiologies...There was no indication of significant trauma...no neurologic deficits...no signs/symptoms suggesting infection..."
* The OHSU LCSW "ED Notes" dated 03/12/2019 at 1136 reflected "...Social Worker did not meet with pt due to seclusion...high risk of harm towards others...Pt is living with Schizophrenia, PTSD, chronic SI..."

b. The electronic "Intake Activity Log" reflected the following entries related to a transfer request "referral" for Patient 5:
* "Call Date, Time..." reflected "03/12/2019 13:40"
* "Agency Name" reflected "OHSU ED"
* "Primary Payer" and Secondary Payer" were blank.
* "Assessment Date, Time" reflected "00/00/0000" and "Completed by?" was blank.
* "Disposition/Reason Non-Admit" reflected "[Returned to Referral Source]" and "[Refused Action By Patient]"
The log reflected the patient was not accepted for transfer due to "Refused Action By Patient." However, there was no documentation that reflected how that was determined for this suicidal patient who was on a hold.

c. During an interview with the TC on 03/20/2019 at 1530 the OHSU ED record and "Hospital Transfer Tracking" form for Patient 5 was reviewed. The following information was provided:
* The hospital received a transfer request from OSHU ED for Patient 5 on 03/12/2019.
* The "Hospital Transfer Tracking" form was initiated on 03/12/2019 at 1340. The TC confirmed the tracking form was not completed as reflected above.
* The TC stated Patient 5's diagnosis was schizophrenia. The TC stated "We had a bed for [him/her] but we didn't accept [him/her] because [he/she]