HospitalInspections.org

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Based on interviews, email communications, review of central log and medical record documentation for 5 of 28 encounters of individuals who presented to the hospital for emergency services (Patients 16, 19, 20, 27, and 28 ), review of P&Ps, and review of grievance and other documentation, 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:
* For Patients 16 and 20, to not dissuade patients from staying at the hospital to receive MSEs, and to obtain or attempt to obtain written and informed refusal of MSEs in accordance with its P&Ps.
* For Patients 19, 27, and 28, to affect appropriate transfers to other hospitals for further examination and stabilizing treatment that was not within the hospital's capacity at the time, that included physician certification of patient specific benefits and risks of transfer and use of appropriate medical transportation with qualified personnel.

Findings include:

1. Refer to the findings cited under Tag A-2406 for Patients 16 and 20.

2. Refer to the findings cited under Tag A-2409 for Patients 19, 27, and 28.

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Based on interviews, email communications, review of central log and medical record documentation for 2 of 10 individuals who presented to the hospital for emergency services and left prior to completion of an MSE (Patients 16 and 20), review of P&Ps, and review of grievance and other documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured that individuals who presented to the hospital for emergency services were not dissuaded by hospital staff from staying at the hospital to receive a MSE within the hospital's capabilities and capacity.
* A patient brought into the ED by their representative was taken from the hospital by their representative prior to an MSE as result of failure by ED staff to respond to the representative's reports of the patient's worsening condition. The patient's representative drove the patient to a second hospital where they were found to have a life-threatening condition.
* For an individual who was outside in the ED entrance driveway it was unclear whether hospital staff did or said anything to dissuade the patient from staying, they were not informed of the risks of leaving the hospital without an MSE, and there was no indication that attempts to obtain informed written refusal for a MSE had been made.

Findings include:

1.a. The P&P titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated as "Last Revised 02/2022" was reviewed. It included the following information:
* "This policy applies to all patient populations presenting to an ED (including pediatric patients), L&D/Perinatal Department, or anywhere on hospital property with an emergency medical condition needing treatment or transfer to or from any Providence hospital."
* An MSE "is an exam completed by qualified medical personnel to determine whether an EMC or active labor exists ... A complete and appropriate MSE will be performed on all individuals who come to the hospital requesting examination or treatment or attempts will be made to advise the patient of the risk of leaving before an MSE can be completed."
* "If a patient presenting to ED(s) or L&D/Perinatal department(s) and while waiting for medical screening decides to leave without examination (AMA/LWBS) the following steps should be taken if possible:
a. Explain to the patient it is important to have the medical screening to rule out whether they have a medical condition that needs treatment; and
b. Use an interpreter if the patient has limited English proficiency, or use an alternate means of communications; and
c. Inform the patient of the risks of not having the medical screening; and
d. Ask the patient to sign the AMA form acknowledging they understand the risks of leaving without the medical screening; and
e. Document on the medical record the above information and if they refuse to sign the AMA, document that on the record as well."

1.b. The P&P titled "ED Patients leaving AMA, Eloped or LWBS" dated as "Last Revised: 02/2021" was reviewed. It included the following information:
* "Left without being seen (LWBS): occurs when a registered patient leaves the ED before or after triage but before a [MSE] is initiated by a [LIP] or other individual qualified to perform an MSE ..."
* "LWBS: When a patient leaves and/or decides to leave prior to an MSE, the circumstance should be documented: ...
- A reasonable effort should be made to locate the patient. Document specific attempt(s) to locate the patient. Notify security and/or law enforcement of patients who leave before treatment is initiated and for whom it is determined that they might be at risk for harm to self and/or others. Document the notification in the medical record. Consider telephoning the patient at home and/or alerting authorities, if appropriate.
- If possible, provide information to the patient on the potential risks and benefits of leaving prior to a MSE and attempt to have patient sign a LWBS/AMA form ..."

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2.a. A "Formal Grievance" form for Patient 16 was reviewed and reflected [Patient 16's spouse] had telephoned the hospital on 02/08/2023 with concerns about a 12/31/2022 PSVMC ED visit. The documentation included the following:
* "Description" of concern was that the spouse "called to let us know that on [12/31/2022] [they] brought in [Patient 16] to the ED with horrible chest pains into [the] jaw."
* "Brief description of concern" was written as "Triage nurse did an EKG on [Patient 16] and said it is not a heart attack go sit in the lobby. While still in the triage [Patient 16] became worse and more painful. [Spouse] said something to the nurse and [nurse] said 'I said go wait in the lobby till you are called'. Again it was awful and even to look at [Patient 16,] you and everyone else could see [they were] not ok. [Spouse] went to tell the [staff person] behind the desk (registrar) and [they] came out behind the desk and said go sit down in the lobby. The triage nurse looked at [spouse] and turned around and left. Very rude. [Spouse] took [Patient 16] to [LMPMC] where they did a EKG and a cat [sic] scan and found [Patient 16] to have a Aortic disection [sic] and was immediately taken to [LEMC] and had open heart surgery at 6 a.m. This means [Patient 16] could have died in the PSVMC lobby waiting. They are not happy with PSVMC and believe some education and discussion should be had with staff. More needs to be done and staff needs to listen to the patient and family."
* "Investigation Findings/Follow-up Notes" included an entry by a "Patient Liaison" that was dated 02/08/2023 and reflected "I received a telephone call from the spouse of [Patient 16] that presented to the ED at PSVMC on [12/31/2022]. [Patient] was in extreme pain in [their] chest to [their] jaw. Triage nurse did an EKG and said to them, 'Well it is not a heart attack, go sit in the lobby and someone will call you back in a while'. [Spouse] said to the nurse the pain is getting worse. [Nurse] turned and looked at [spouse] and left. [Spouse] went to the desk and said something to the [staff person] there (registrar, I believe), and [they] came out around the desk and said 'Go sit in the lobby'. [Spouse] took [Patient 16] to [LMPMC] after this and calling to make sure there was no wait. They did an EKG and cat [sic] scan; [Patient 16] had an Aortic dissection and was transferred to [LEMC] and had open heart surgery by 6 a.m. They are very upset with PSVMC and the attitudes and rudeness of the staff. This could have been [Patient 16's] demise if [they] had sat in the waiting room at PSVMC. Please review this and let me know your results of the review."
* "Investigation Findings/Follow-up Notes" dated 02/28/2023 reflected that an investigation had not yet occurred as of the date of this survey that was initiated on 02/27/2023.
* The 02/28/2023 notes reflected "we have been unable to follow up with the caregiver involved from the Patient Access Team since [they have] been on a leave of absence since we were notified of this situation."
* There was additionally no reference to attempted follow-up with the Triage Nurse involved in the encounter.
* The "Investigation" section of the grievance form was blank. None of the "Investigation Components - Please choose all that apply: __ Conducted Interview(s) __ Discussed with Care Team __ Discussed with Patient __ Examined Physical Location __ Reviewed Policies/Procedures __ Reviewed Chart __ Other" had been checked to indicate an investigation in progress.

2.b. The PSVMC central log for Patient 16 reflected that they presented to the ED on 12/31/2023 at 0237 with a "Chief Complaint" of "Pleuritic Chest Pain (Adult)." The "ED Disposition" date and time space on the log was blank and the type of disposition was "Lwbs After Triage."

2.c. The PSVMC medical record for Patient 16's 12/31/2023 ED encounter was reviewed. The ED medical record, including the "ED Care Timeline," described the course of the patient's ED encounter as follows:
* On 12/31/2022 at 0237 PAS 1 recorded "Patient arrived in ED."
* At 0238 RN 1 generated entries for "Risk of New Infection ... Infectious Risk Screening ... Infectious Risk Audit ... Custom Formula Data Infections Symptoms ... "
* At 0238 PAS 1 generated an entry for "ED [Facility Charge Calculator] Start"
* At 0238 the record reflected that "ED Information Exchange Resulted."
* At 0238 RN 1 entered "Chief Complaints Updated Pleuritic Chest Pain (Adult)."
* At 0239 RN 1 recorded "ED Triage Notes" as:
- "Narrative of Chief Complaint: Right sided muscle pain
- Onset, Characteristics, location of pain or symptoms, what makes it worse or better: Pt here with right sided muscle/chest pain that started while [they were] playing guitar. Pt states pain rates [sic] to [their] arm.
- Isolation initiated on arrival?: NONE
- Arrive with anyone? family member(s)
- Residence: Private residence
- Mobility: Ambulatory/Independent
- Arrival Transport Type: private vehicle
- Presenting with Behavioral Health Concerns?: No
- Additional information: [Nothing entered, space was blank]"
* At 0240 RN 1 recorded "Airway WDL ... Respiratory WDL ... Patient Acuity: 2 [Emergent] ... Short Triage Completed: YES ... We ask all patients, do you feel safe in your living/school environment?: Patient denies concerns ... Triage Completed."
* At 0240 RN 1 recorded a NIO for "ekg ordered ECG 12 lead."
* At 0243 an EDT entry reflected they performed an "ECG 12 Lead" procedure.
* At 0248 an EDT recorded "Vital Signs" of "Temp: [98.1 degrees Fahrenheit] - Pulse: 56 - Resp: 24 - BP: 165/81 - SpO2: 99%."
* At 0249 RN 1 recorded "Patient Acuity: 3 [Urgent]"
* At 0253 RN 1 recorded NIOs for "Lab Ordered Troponin I, Comprehensive Metabolic Panel, CBC with Differential."

* (The 0253 entry was the last entry in the record until 0618, three hours and 25 minutes later.)

* At 0618 RN 2 recorded "Arrival Documentation ... Triage Call: Call 1x (0617)"
* At 0639 RN 2 recorded "Arrival Documentation ... Triage Call: Call 2x (called for pt in triage area, no answer)"
* At 0710 RN 2 recorded "Arrival Documentation ... Triage Call: Call 3x"
* At 0832 RN 3 recorded "Arrival Documentation ... Triage Call: Call 3x"
* At 0833 RN 3 recorded "Patient dismissed ... ED Disposition set to LWBS after Triage" and the following "Comments":
- "Described events prior to LWBS ... : unknown, not found in lobby
- Explanation of risk and benefits reviewed with patient? Yes
- Reason for leaving without being seen: unknown
- Vital Signs & Reassessment completed & charted? NO
- Is patient identified as At Risk (follow debrief steps)? NO
- Notify ED Charge Nurse: No
- Notify House supervisor? No
- Notify Security? No"
* At 1033 an "automatic" entry reflected "Orders Discontinued CBC (12/31/22 0254); Comprehensive Metabolic Panel (12/31/22 0254); Troponin I (12/31/22 0254)"
* At 1300 an ECG report reflected "ECG 12 lead Resulted Collected: 12/31/2022 02:43 ... Status: Final result ... Ventricular rate EKG: 51 PM ... P-R interval 218 ms ... Interpretation Text: Sinus bradycardia with 1st degree A-V block - Nonspecific T wave abnormality - Abnormal ECG ... Confirmed by [Cardiology MD] on 12/31/2022 [1300]."

2.d.i. During interview with the QMC and EDD on 02/27/2023 beginning at 1630 the following information was provided:
* On 12/31/22 at the time of Patient 16's presentation the ED rooms were full and there were ~ 23 patients who had checked in and were waiting for an ED room.

2.d.ii. During interview with staff that included the COO, DQM, CMO, QMCs, and DAR on 02/28/2023 beginning at 0915 the following information was provided:
* Video recordings of the ED entrance, registration and triage area, and waiting areas for 12/31/2022 were no longer available. On 02/28/2023 video recordings for those areas were only available back to 02/09/2023.

2.d.iii. During interview with staff that included the CMO, QMCs, DAR, EDD, EDCNS, and SAS on 02/28/2023 beginning at 1000 information provided included the following:
* The CMO stated that regarding Patient 16's condition their VS were "not terribly elevated" and the "ECG showed nothing actionable ... no tachycardia, no ST elevation ..."
* Regarding the review of ECG results the workflow process was for the EDT to show the strip to an ED physician but that review was "not necessarily documented."
* The EDD stated that "only short triage was done" for Patient 16, and confirmed there was no pain assessment for Patient 16 other than what Patient 16 stated for the chief complaint.
* Regarding triage, a "short triage" was conducted when the ED was "very busy" and the "full triage may occur when the patient is roomed in" to an ED treatment room.
* Regarding blood draws for lab tests, the RNs perform the blood draws and blood draws may occur in triage, in the waiting area, or in an ED treatment room. The RNs wouldn't necessarily document attempts to locate the patient to perform lab draws.
* The SAS stated that regarding PAS processes the PAS would not document interactions with patients or patient representatives beyond the initial registration entries. If a patient or their representative approached the PAS after the initial registration to report worsening condition the PAS would direct them to the triage RN but they would not document that interaction or information in the medical record.
* The SAS stated PAS 1 was on leave and was scheduled to return to work the following day on 03/01 at 1730.
* Staff reported that the RN 1 was also on FMLA leave and not available for interview at the time of the survey.

2.d.iv. During interview with the CMO and EDD on 03/01/2023 beginning at ~ 1200 information provided included the following:
* The ED capacity is 58 total, with 33 "adult" beds, a secure 8-bed behavioral health section, four "safe rooms," and a 13-bed pediatric section.
* The EDD stated that they spoke to RN 2 who had documented calling for Patient 16 on 12/31/2022 three times between 0618 and 0710. The EDD stated that RN 2 didn't recall the patient.
* The EDD stated that they spoke to RN 3 who had documented that they had explained to Patient 16 the risk and benefits of leaving without an MSE on 12/31/2022 at 0833. RN 3 stated they did not recall a lot about that, hadn't seen the patient, and that it "wouldn't be normal practice" to generate the disposition comments for a patient they didn't know.

2.d.v. Email communications with the QMC beginning on 03/02/2023 through 04/07/2023 reflected the following LOA information for PAS 1:
* PAS 1 had been on FMLA leave since 02/16/2023.
* PAS 1 "was not able to return to work [03/01/2023] as planned. [Their] leave of absence has been extended to 3/21/23."
* " ... leave of absence has been extended so [they] will not be returning to work [03/21/2023]."
* " ... expected return to work date on 3/28/23."
* " ... new information we received on [PAS 1's] leave of absence. [Their] new return to work date is set for 4/21/23."

2.d.vi. During interview with PAS 1 on 04/21/2023 beginning at ~ 1815 they provided the following information:
* They did not remember the encounter with Patient 16.
* Their usual practice when a patient presented was to ask the patient if they have identification. If the patient did not have identification they would ask the patient's name and look for them in the "system," then they would generate a wristband for the patient. The patient would be directed to the RN who sat next to the PAS at the registration/triage desk to tell the RN their chief complaint and why they were there. The RN and EDT would take over from there.
* If a patient approached the PAS again to report they were leaving the ED, or for any other reason, the PAS would refer them to the RN.
* They don't document anything other than the initial registration entries.

2.d.vii. Email communications with the QMC beginning on 03/02/2023 through 05/18/2023 reflected the following LOA information for RN 1:
* RN 1 had been on FMLA leave since 01/10/2023 which was expected to be through 04/17/2023.
* " ... return date was moved to 5/21 ... LOA extension."

2.d.viii. During interview with RN 1 on 05/24/2023 beginning at 1815 they provided the following information during review of Patient 16's medical record:
* RN 1 was CN and lead triage RN on the 12/31/2022 night shift.
* They did not remember the encounter with Patient 16.
* The usual process when patients would present to the registration desk was the PAS would ask "pre-registration" information, then the triage RN who would be sitting at the desk next to the PAS would ask "what brings you in ... gets chief complaint and assigns [ESI acuity] based on that."
* "Short triage" was a "brief assessment" of acuity, why the patient was there, infection information, abuse information, and VS.
* For all cardiorespiratory complaints, the triage RN "orders an EKG under [NIOs]." After the EKG, triage would be completed and the patient moved to an ED treatment room or to the waiting room/area if there were no available treatment rooms.
* Regarding the usual EKG process, the EDT who performed the EKG was to take the strip to the ED physician who was to review and write the result on the strip with their initials: For example: "no stemi" or "repeat" or "next." After the physician review, the EKG strips were to be reviewed by the RN who was to then place them in a "to be scanned" basket to be forwarded for scanning into the EHR.
* Regarding the decreased "acuity" change for Patient 16, RN 1 indicated that after the ED physician reviewed the EKG strip, the RN would have changed the patient's acuity to "level 3" and then placed the [NIOs] for labwork.
* Regarding the usual blood collection process for labwork, the ED RNs would perform the blood draws. If a patient was not in a treatment room, the blood draw would be done in the waiting room/area. RN 1 would normally enter the labwork NIOs and then go to the waiting area where the patient was and draw the blood there. The RN stated that on 12/31/2022 it was a "busy night and there was no time to draw."
* When a patient or their representative would reapproach the registration/triage desk to report worsening pain or symptoms it would be "typical that they be reassessed and vitals retaken." They would be told to "go wait in the waiting room" for an EDT who was to be sent out to take their VS.

2.d.ix. Regarding ED physician review of the EKG for Patient 16:
* In an email from the QMC on 06/02/2023 at 1236 they responded to the surveyor request for a copy of the original EKG strip for Patient 16 that included the ED physician's initials and note described by RN 1 during the 05/24/2023 interview above. In the email they wrote that the "ECG read by [ED physician]" was attached to the email. However, the attachment was a copy of the final EKG report from the EHR that had been read by the "[Cardiology MD] on 12/31/2022 [1300]" and which contained no indication of review by an ED physician on 12/31/2023.
* In a follow-up email from the QMC on 12/01/2023 at 1707 regarding the original EKG strip for Patient 16, they again attached the final EKG report from the EHR that had been read by the "[Cardiology MD] on 12/31/2022 [1300]" and which contained no indication of review by an ED physician on 12/31/2023.
* In a follow-up email from the CMO on 12/05/2023 at 1017 they wrote that "The PSVMC ED process is that an RN enters a NIO, the EKG is done then shown to one of the ED providers. The provider assesses the EKG for STEMI then documents this on the EKG - this has been a long-standing workflow for us. Without a scanned EKG, there is unfortunately no indication which ED provider was shown the EKG."

2.e. The ED record for Patient 16 was not clear or complete to fully describe this patient's encounter. Examples include, but may not be limited to:
* "Short triage" assessment of the patient's pain was minimal and reflected only that it radiated to their arm. There was no other subjective information about other pain characteristics such as pain intensity, quality, and timing. Further, there was no objective information about the patient's physical presentation and whether the patient demonstrated non-verbal signs of pain such as moaning, grimacing, slumping, holding their arm/chest, sweating, etc.
* There was no objective or subjective assessment documentation or narrative to reflect why RN 1 downgraded the patient acuity from 2, Emergent, to a 3, Urgent, at 0249.
* There was no evidence that the lab tests ordered at 0253 had been drawn, or that attempts had been made to locate the patient to draw the ordered labs prior to 0618, three hours and 25 minutes after they were ordered.
* There was no evidence that attempts had been made to locate the patient who had complaints of chest pain prior to 0618 when RN 2 called the patient for "triage."
* Although by 0833 in the morning it was established that Patient 16 was no longer in the ED, RN 3 who had not seen the patient documented that "Yes", they explained to the patient the risk and benefits of leaving without being seen.
* The description of the encounter in the medical record is not consistent with the description provided by Patient 16's spouse, including that the record did not reflect that the Patient's spouse reapproached the PAS and RN 1 to report the patient's worsening symptoms.

2.f. Patient 16's condition was not fully or clearly assessed during "short triage," and by failing to respond to the reports of Patient 16's worsening condition hospital staff dissuaded the patient's representative from staying at the hospital for an MSE. Hospital staff did not attempt to respond to Patient 16, who had presented with "pleuritic chest pain" at 0237 and for who the spouse had reported worsening condition, until they began to call for the patient in the waiting area at 0618.

Based on the interview with RN 1 it is reasonable to conclude that Patient 16's spouse, as described in their 02/08/2023 report to the hospital, had reported the patient's worsening condition and was told by RN 1 to go to the waiting area as RN 1 described was "typical" practice. It was unclear whether RN 1 told Patient 16's spouse that an EDT would be sent out to evaluate the patient. However, if the RN had told the spouse that, under the circumstances of Patient 16's worsening condition the spouse had not been assured of an immediate response. Further, if the RN had told the spouse that an EDT would be sent to the waiting area to evaluate the patient, there was no evidence in the record to reflect that had occurred as the first attempt to locate the patient for any reason was documented at 0618, ~ three and 1/2 hours later.

2.g. Medical journal articles about pleuritic chest pain were reviewed.

2.g.i. The National Institutes of Health, National library of Medicine website contained an article titled "Pleurisy" with the notation "Last update: January 23, 2023." The article included the following information:
"Pleuritis is characterized by sharp and localized thoracic or shoulder pain. It is exacerbated by respiratory movements, coughing, sneezing, or chest wall/trunk movement. Pain characteristics can be dull aching, burning, or simply as a "catch." Duration and recurrence of symptoms may be helpful in determining the cause. As in the other causes of chest pain, diagnosis of the cause of pleurisy relies heavily on the history and physical exam. The acuity of the onset (e.g., hyperacute - pulmonary embolism, primary spontaneous pneumothorax, and traumatic pleural inflammation/traumatic pneumothorax), duration, and progression of symptoms are useful in establishing a differential diagnosis ... Because chest pain is the most common symptom at presentation, it is left-sided, then evaluation for an acute coronary syndrome is important. A careful history, electrocardiogram, and serum troponin should be considered if clinical suspicion prevailed. Though pleuritic chest pain is not the typical presentation of ischemic heart disease, it can occur in acute pericarditis and aortic dissection, both of which can cause localized substernal pain or referred pain to the shoulder ... The most important disease states to evaluate in the setting of pleuritic pain are acute coronary syndromes, aortic dissection, pneumothorax, pericardial effusion/tamponade, and pulmonary embolism ..."

2.g.ii. The American Academy of Family Physicians website contained an article published in its "peer-reviewed journal" American Family Physician titled "Pleuritic Chest Pain: ..." dated 09/01/2017. The article included the following information:
"Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. Pulmonary embolism is the most common serious cause, found in 5% to 21% of patients who present to an emergency department with pleuritic chest pain. A validated clinical decision rule for pulmonary embolism should be employed to guide the use of additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography. Myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax are other serious causes that should be ruled out using history and physical examination, electrocardiography, troponin assays, and chest radiography before another diagnosis is made."

2.h. EPIC EHR Care Everywhere records were reviewed.

2.h.i. Patient 16's encounter at LMPMC reflected that on 12/31/2022 at 0315 Patient 16 was physically present in that ED.
* At 0319 an RN triage note reflected that "Pt was playing guitar ... and developed right upper chest pain that radiates to [their] jaw that started about an hour ago. Pt is moaning in pain, unable to find a position of comfort."
* At 0321 an EKG was performed with nearly same result as at PSVMC: "Sinus rhythm with 1st degree A-V block."
* At 0327 Lab specimens were collected for D-Dimer, Troponin I, Comprehensive Metabolic Panel, and CBC.
* At 0335 Lab specimens were received in the lab and results included D-Dimer that was elevated to 597 (ref. range 0-229), and CBC and CMP with "Abnormal" values.
* At 0440 "CTA Chest PE With and Without Contrast" was performed with findings of "Impression: 1. Type A aortic dissection is incompletely and poorly evaluated. 2. Evidence of pulmonary embolism."
* At 0515 AMR was at the bedside for transfer to LEMC.
* At 0517 LMPMC ED physician electronically signed an ED note that was initiated at 0325 and reflected that Patient 16 "... presents with chest pain ... Location: R upper chest - Quality: intense - Associated with: jaw pain - Worsened by: not sure - Relieved by: nothing - took nsaid - imilar [sic] episodes in the past: no ... BP 136/97 | Pulse 65 | Temp [98.4 degrees Fahrenheit] | Resp 20 | SpO2 98% ... ED Course: ... presents with intense R upper chest pain that started at 0215 radiates to the jaw, with no other sxs. [Patient] is moaning and appears uncomfortable. No prior hx of this. Will obtain cardiac labs, cxr, obs on tele. Asa and sl nitro for pain ...With elevated [D-dimer], will obtain CTA instead. Night shift [radiologist] called about the critical finding ... Pt's case/impression summarized and discussed with: pt and [cardiothoracic surgeon] who would like pt to be transferred to CVICU as soon as possible ... Likely Dx given clinical picture: type 1 ascending aortic dissection with trace hemopericardium ..."

2.h.ii. Patient 16's encounter at LEMC reflected that on 12/31/2022 they were in the operating room from 0749 until 1454 for "Repair of Ascending Aortic dissection, hypothermic circulatory arrest, Transesophageal ecocardiogram (Cardiac)."

2.i. The "Policies and Procedures Professional Staff Providence Health & Services ... Providence St. Vincent Medical Center" dated as "Revised 8/29/22" were reviewed. Article XII, Sections 7.B. and 7.F. reflected that the PSVMC "Surgery Division" included "Cardiothoracic surgery." A PSVMC organizational chart reviewed reflected that "Critical Care Services" included "Cardiovascular Intensive Care." Review of a PSVMC document that contained a list of "Key Clinical Services" reflected the PSVMC "Heart Institute" included "Cardiac Surgery ... Cardiac Critical Care Unit." The PSVMC internet website reflected that "Surgical Services" included "Heart and vascular surgery" and "Thoracic surgery," and that the "Providence Heart Institute of Oregon" at PSVMC included the "Comprehensive Aortic Center" where areas of expertise included "Abdominal aortic aneurysm" and "Aortic dissection."

2.j. Internet/GPS distance calculators reflected that LMPMC in Tualatin, Oregon was ~ 10 miles, primarily freeway, and ~ 15 minutes drive-time at posted speed limits in early morning hours, from PSVMC in Portland, Oregon. As Patient 16 was physically inside the ED at LMPMC at 0315 they would have needed to leave PSVMC ED by ~ 0300.

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3.a. The central log for Patient 20 reflected that they presented to the ED on 01/10/2023 at 1307 with a "Chief Complaint" of "Burns." The "ED Disposition" on the log was " Lwbs Before Triage" on 01/10/2023 at 1333.

3.b. The medical record for Patient 20's 01/10/2023 ED encounter was reviewed and included the following:
* On 01/10/2023 at 1307 "Patient arrived in ED" was recorded.
* At 1314 an RN recorded "Infectious Risk Screening" information, "Infectious Risk Audit ... Data" information, and "Screening complete."
* At 1314 the RN recorded "Chief Complaints Updated - Difficulty Breathing - Leg Pain - Burn (Adult - Major [greater than] 5% Of Body Surface)"
* At 1315 the RN recorded "Patient Acuity: 2"
* At 1323 a second RN recorded "Triage Started"
* At 1326 the RN recorded "RN retrieved pt from ED turn around, pt presents [with friend], pt states loudly--'get me to a [expletive] burn center right now', pt demanding, loud, & belergerent [sic]. Pt has extensive burns to RLE that do not appear fresh, pt states burns occurred on Jan 1st. Pt asked RN to provide address directions to burn center, RN provided address to [LEMC], RN DID let pt know that [PSVMC] can eval & treat as well but pt demanded a 'burn center'. Pt left [with] friend in a W/C."
* At 1331 the RN recorded the following "ED Notes:"
- "Describe events prior to LWBS or Elopement including behavior and statements: see 13:26 note
- Explanation of risk and benefits reviewed with patient? No
- Reason for leaving without being seen: [Nothing entered, space was blank]
- Vital Signs & Reassessment completed & charted? NO [sic]
- Is patient identified as At Risk (follow debrief steps)? NO [sic]
- Notify ED Charge Nurse? No
- Notify House Supervisor? No
- Notify Security? Security present due to pt being loud & belegerent [sic]
- NIOs completed? no ...
- Method of leaving the ED: walked and Wheelchair
- Additional Comments: [Nothing entered, space was blank]"
* At 1333 the RN recorded "Patient dismissed ... ED Disposition set to LWBS before Triage"

3.c. The medical record did not clearly describe the ED encounter for Patient 20 who presented with difficulty breathing, leg pain, and major burns, and reflected the hospital's P&Ps had not been followed. Although the RN documented that they "DID" let the patient know they could be treated, it was unclear whether anything else had been done or said to dissuade the patient from staying. For example:
* The sequence of events for Patient 20's encounter was unclear. The record reflected that Patient 20 arrived "in ED" at 1307, that minimal triage information was obtained, and then at 1326 the patient was "retrieved ... from ED turn around," or the driveway outside of the ED entrance. It was unclear whether the patient was ever inside the ED, or whether the patient had been in the ED and then went outside and what those circumstances were. It was unclear what "retrieved" meant as in did the RN bring the patient into the ED.
* It was unclear how and when the RN observed "extensive burns to RLE," what "extensive" meant, and what was meant by they "do not appear fresh."
* The RN documented that they did not inform the patient of the risks of leaving the hospital without an MSE as required by the hospital's P&Ps.
* There was no documentation to reflect that attempts to obtain informed written refusal of an MSE had been made as required by the hospital's P&Ps.

3.d. During interview with staff that included the DQM, CMO, QMCs, DAR, EDD, and EDCNS at the time of the ED record review on 02/28/2023 beginning at 1330 they confirmed that the record reflected that Patient 20 had not been info

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Based on interviews, review of central log and medical record documentation for 3 of 7 individuals who presented to the hospital for emergency services and were transferred to other hospitals for further examination or stabilizing treatment not within its capacity at the time (Patients 19, 27, and 28), and review of P&Ps, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that it effected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved:
* Patients were transferred to other hospitals without a physician certification that included identification of what the patient specific and individualized benefits and risks of transfer were.
* Patients were transferred to other hospitals in POVs by family members, contrary to section (2)(iv) of this CFR that requires "The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer." Medical transportation with qualified personnel and equipment was not used for transfer to ensure proper monitoring and response to changes in patient condition. It was not clear whether hospital staff or the patients initiated discussions about transport by POV, and what additional risks secondary to transport by POV without qualified personnel and emergency equipment had been identified and discussed.

Findings include:

1.a. The P&P titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated as "Last Revised 02/2022" was reviewed. It included the following information:
* An MSE "is an exam completed by qualified medical personnel to determine whether an EMC or active labor exists."
* "A LIP or qualified medical personnel will perform a MSE to determine whether an EMC exists and treat the patient or stabilize the patient's condition within the capability and capacity of the ED or L&D/Perinatal Department."
* "Prior to transfer, an explanation of the need to transfer and the alternative to transfer will be made to the patient. Individualized risks and benefits will be summarized verbally and documented on the EMTALA Patient Transfer Form in the electronic medical record (EMR)."
* "Stabilized patients may be transferred to another hospital if the patient so desires. Patient may be transferred (1) at their own request, (2) at the request of a legally responsible person on the patient's behalf or (3) if physician or qualified medical personnel certifies in writing that the benefits of transferring the patient to another facility outweigh the risk. 1. Arrangements for proper conveyance will then be made; a LIP or qualified medical personnel will determine the safest method of transport. 2. If a LIP or qualified medical personnel feels it is necessary for the patient's safety, they or their qualified designee will accompany the patient during transfer."
* "The referring and receiving LIP share the responsibility for patient transfer and they should consult regarding the arrangements and details of patient transfer, including the method of transportation. The LIP or qualified medical personnel arranging transportation is responsible for determining what additional care is required before transfer. The LIP or qualified medical personnel will also determine what transportation equipment is needed, including the use of necessary and medically appropriate life support measures during the transfer."
* "Documentation of patient transfer will be completed electronically for each transfer. The EMTALA transfer form needs to be printed from Epic after completion, signed by the patient, and sent to HIM to be included in the EMR. A copy of the form should be sent with the patient to the accepting facility."

1.b. There was no reference or acknowledgement in the EMTALA P&P that an "appropriate transfer" for patients with EMCs that had not been ruled out, removed, or resolved included, as required by section (2)(iv) of this CFR, that "The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer." Further, the P&P provided no assurance that staff would not offer POV transport as an option; there were no provisions or steps for managing cases where patients refused medical transportation and insisted on using a POV without qualified personnel and equipment; and it did not recognize the additional risks of transfer that exist in the stress-filled scenario where a lay-person, caregiver, family member drives an individual with an EMC that has not been ruled out, removed, or resolved through the city during rush hour or in the middle of the night in their private vehicle.

1.c. The P&P titled "Transfer of Maternal Perinatal Patient" dated as "Last Revised "10/2021" was reviewed. It included the following information:
* "... the transfer shall be effected through qualified personnel and transfer equipment."
* "A woman experiencing contractions is in true labor unless a qualified medical person (as defined in a hospital's medical staffing bylaws) certifies that after a reasonable time of observation the woman is in false labor."
* "The transferring LIP will determine what additional care is required before transfer, mode of transfer and what equipment and capabilities should be available en route."
* "Notify appropriate personnel per facility to arrange transportation ... PSVMC: Notify nursing supervisor ..."

1.d. The "Transfer of Maternal Perinatal Patient" P&P reflected that "The transfer is effected through qualified personnel and transportation equipment" as required by section (2)(iv) of this CFR. Similar to the EMTALA P&P, this P&P also included no provisions for transfer by POV, and no steps for managing cases where patients refused medical transportation and insisted on using a POV without qualified personnel and equipment.

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2.a. The central log for OB Patient 19 reflected that they presented to the L&D unit on 01/07/2023. The time was not specified. The space on the log for chief complaint was blank. The disposition on the log was "Short Term General Hospital" on 01/07/2023 at 0238.

2.b. The medical record for Patient 19's 01/07/2023 OB encounter was reviewed, reflected the patient arrived at 0015, that an MSE was conducted by CNM A, and included the following information:
* On 01/07/2023 at 0049 an RN recorded "Contraction Frequency (min) 2-3 ... Contraction Duration (sec) 60-90 ... Contraction Intensity mild by palpation."
* On 01/07/2023 at 0209 an RN recorded "Contraction Frequency (min) 1-4 ... Contraction Duration (sec) 40-120 ... Contraction Intensity mild by palpation."
* On 01/07/2023 at 0237 an RN recorded "Patient discharged to drive to [KSMC] with spouse for admission for SROM. We are currently Closed to Admissions and unable to accommodate [them] here. Patient understands to report to labor and delivery there, and declines transfer via ambulance. [KSMC CN and physician] have accepted transfer."
* On 01/07/2023 at 0241 CNM A electronically signed an "Obstetrical Triage H&P" that included the following:
- "[Patient 19] ... at 40w5d who presents for contractions and leaking of fluid since 0730 on 1/6/23 which has been clear and blood tinged. Contraction are occurring every 3-4 minutes and rated as 6 out of 10 on the pain scale. [Patient] is using [their] breathing and movement to cope with contractions. Positive fetal movement. No headaches, vision changes, RUQ/epigastric pain, or other concerns ..."
- "Contractions: Frequency: 3 in 10 minutes Strength: Mild"
- "Plan: Confirmed SROM with sterile speculum exam: ... Condition is stable, however recommend pitocin augmentation for prolonged rupture of membranes. Discussed need to transfer care to different facility at this time because both [PSVMC]and PPMC [L&D facilities] are closed to admissions. Patient states understanding and agrees with plan. [Patient's] preference is to transfer to Kaiser Sunnyside ... Patient declined transfer by ambulance. [Patient] opts to have [their] partner drive their private vehicle to Kaiser Sunnyside. Discharged to Kaiser Sunnyside in stable condition. See separate "EMTALA" documentation for further details."
* Final diagnoses included:
- Full-term premature rupture of membranes, unspecified as to length of time between rupture and onset of labor
- Diseases of the respiratory system complicating pregnancy, third trimester

2.c. The electronic two-page "Patient Transfer" form in Patient 19's record contained EMTALA physician transfer certification and other required documentation and included the following:
* Beginning on Page 1 the form reflected:
- In the space for "Reason for Transfer:" was written "No bed available"
- In the space for "Summary of transfer benefits:" was written "Condition"
- In the space for "Patient specific transfer benefits:" was written "Receive time-appropriate care"
- Pre-printed language on the form: "Summary of transfer risks: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport."
- In the space for "Patient specific transfer risks:" was written "discussed"
- Patient 19's signature recorded at the bottom of page 1 was dated and timed as 01/07/2023 at 0233.
* The form continued on Page 2 and reflected:
- Pre-printed language on the form: "The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures. After discussion with the receiving physician, the patient and/or family, the agreed mode of transportation is ___." Written in that space was "Private auto none."
- Pre-printed language on the form: "I discussed the risks and benefits with the patient/patient representative and they verbalized understanding and are in agreement with the decision to transfer. By completing this form, I authorize transfer of this patient."
- CNM A's electronic signature recorded under those entries on Page 2 was dated and timed as 01/07/2023 at 0227.

2.d. The meanings of the physician certification of transfer benefits written on the transfer form as "Condition" and "Receive time-appropriate care" were unclear.

2.e. There was no documentation on the transfer form or elsewhere in the medical record to reflect what individualized and specific benefits and risks of transfer for this pregnant patient and their unborn child CNM A had "discussed."

2.f. The mode of transport decision and risk discussion for this EMTALA transfer was not clear. The transfer form reflected the "The patient will be transferred by qualified personnel and transportation equipment as required ..." However, it then reflected "Private auto" and "none" as the mode to be used which does not reflect transfer by "qualified personnel and transportation equipment." Although the CNM note reflected the "Patient declined transfer by ambulance" it was not clear whether CNM A or Patient 19 initiated the idea of transport by POV. There was no documentation on the transfer form or elsewhere in the medical record to reflect that CNM A had informed Patient 19 of the additional risks of transfer to themselves and their unborn child secondary to transport by POV without qualified personnel and emergency equipment through the city to the other hospital during the middle of the night.

2.g. Internet/GPS distance calculators reflected that KSMC in Clackamas, Oregon was approximately 19 miles, and approximately 40 minutes drive-time in "light traffic" (dependent on time of day and freeway traffic), from PSVMC in Portland, Oregon.

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3.a. The central log for OB Patient 27 reflected that they presented to the L&D unit on 02/12/2023. The time was not specified. The chief complaint was recorded as "Water Leaking (Possible Membrane Rupture)." The disposition on the log was "Other Health Facility" on 02/13/2023 at "000" or midnight.

3.b. The medical record for Patient 27's 02/12/2023 OB encounter was reviewed, reflected the patient arrived at 2204, that an MSE was conducted by an MD, and included the following information:
* On 02/12/2023 at 2300 "Amniotic Fluid ... pH 7.0 ! ... Ferning Present ! ..." results indicated premature rupture of membranes.
* On 02/12/2023 at 2315 an RN recorded "Contraction Frequency (min) 3-4" and "Contraction Duration (sec) 60-80."
* On 02/12/2023 at 2342 Physician B electronically signed an "Obstetric Admission Note" that included the following:
- "Chief Concern: SROM and elevated pressures."
- "History of Present Condition: Pregnancy complicated by gestational HTN. [Patient] has had a few elevated pressures in the office, but not severe range. Pregnancy otherwise unremarkable. Has hx of IUGR in past pregnancy, [patient] was induced for fetal heart rate abnormalities and gHTN. [Patient] presents to Labor and delivery with grossly ruptured membranes, but is not painfully contracting. [Patient] states [they] started leaking at 3pm, but wasn't sure [they] ruptured until around 7pm. [Patient] feels fetal movement and some cramping."
- "Assessment & Plan: PPROM @ 36w4d."
- "Assessment and plan: PSVMC is closed to admission, so [Patient 27] will need to be transferred to different hospital, then admitted and induced for PPROM. GBS negative."
- "Hypertension affecting pregnancy in third trimester - Assessment & Plan: No severe features at this time Recommend CBC, CMP."
- "MDM [Physician B] Spoke to [PPMC physician], on call for PPMC WHA, who accepts transfer of care."
* On 02/13/2023 at 0018 an RN recorded "Contraction Frequency (min) 3-4" and "Contraction Duration (sec) 60-80"
* On 02/13/2023 at 0031 an RN recorded "Discharge/Transfer Summary Note ... rupture of membranes ... confirmed. We are closed to admissions so we transferred [patient] to PPMC. [Patient] was safe to transfer and rode in private car."
* Final diagnoses included:
- Preterm premature rupture of membranes, unspecified as to length of time between rupture and onset of labor, third trimester
- 36 weeks gestation of pregnancy
- Supervision of pregnancy with history of pre-term labor, third trimester
- Unspecified pre-existing hypertension complicating pregnancy, third trimester

3.c. The electronic two-page "Patient Transfer" form in Patient 27's record contained EMTALA physician transfer certification and other required documentation and included the following:
* Beginning on Page 1 the form reflected:
- In the space for "Reason for Transfer:" was written "No bed available"
- In the space for "Summary of transfer benefits:" was written "Condition"
- In the space for "Patient specific transfer benefits:" was written "No bed"
- Pre-printed language on the form: "Summary of transfer risks: All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport."
- In the space for "Patient specific transfer risks:" was written "Risk of traffic accident, road conditions, potential for worsening medical condition"
- Patient 27's signature recorded at the bottom of page 1 was dated and timed as 02/12/2023 at 2350.
* The form continued on Page 2 and reflected:
- Pre-printed language on the form: "The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures. After discussion with the receiving physician, the patient and/or family, the agreed mode of transportation is ___." Written in that space was "Private auto."
- Pre-printed language on the form: "I discussed the risks and benefits with the patient/patient representative and they verbalized understanding and are in agreement with the decision to transfer. By completing this form, I authorize transfer of this patient."
- Physician B's electronic signature recorded under those entries on Page 2 was dated and timed as 02/12/2023 at 2344.

3.d. The meanings of the physician certification of transfer benefits written on the transfer form as "Condition" and "No bed" were unclear.

3.e. There was no documentation on the transfer form or elsewhere in the medical record to reflect what individualized and specific benefits and risks of transfer for Patient 27 and their unborn child Physician B had "discussed." The physician certification of transfer risks reflected that Physician B had written "Risk of traffic accident, road conditions, potential for worsening medical condition." However, those are all risks inherent to all transfers, and it was not clear what "worsening of condition" meant in the case of this pregnant patient and this patient's unborn child.

3.f. The mode of transport decision and risk discussion for this EMTALA transfer was not clear. The transfer form reflected the "The patient will be transferred by qualified personnel and transportation equipment as required ..." However, it then reflected "Private auto" as the mode to be used which does not reflect transfer by "qualified personnel and transportation equipment." It was not clear in the medical record whether Patient 27 had been initially informed that EMS transport was to be used for this transfer as required, and whether Physician B or Patient 27 initiated the idea of transport by POV. There was no documentation on the transfer form or elsewhere in the medical record to reflect that Physician B had informed Patient 27 of the additional risks of transfer to themselves and their unborn child secondary to transport by POV without qualified personnel and emergency equipment through the city to the other hospital during the middle of the night.

3.h. Internet/GPS distance calculators reflected that PPMC in Portland, Oregon was approximately 12 miles, and approximately 20 minutes drive-time in "light traffic" (dependent on time of day and metropolitan freeway traffic), from PSVMC in Portland, Oregon.

4. During interviews with staff that included the DQM, CMO, QMCs, DAR, LDD, and LDM at the time of the L&D record reviews on 03/01/2023 beginning at 0935 they confirmed the lack of clear transfer risk and POV transport information in the records of Patients 19 and 27.

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5.a. The central log for Patient 28 reflected that they presented to the ED on 02/16/2023 at 1304 with a "Chief Complaint" of "Suicidal." The "ED Disposition" on the log was "Transfer to Another Facility" on 02/17/2023 at 1620.

5.b. The medical record for Patient 28's 02/16/2023 ED encounter was reviewed, reflected that an MSE was conducted by an MD, and included the following information:
* On 02/16/2023 at 1308 an RN recorded "Pt reports [they were] attempting to commit suicide today by jumping off the St. John's bridge ... had previous suicide attempt 3-4 weeks ago where [they] drank gasoline and overdosed on pills. Pt reports [they have] been drinking today, about 6 cans of Mike's Hard Lemonade."
* On 02/16/2023 at 1456 a QMHP recorded that "... patient is at medium to high rescue risk of suicidal behavior if discharged ... Due to patient intoxication, sober re-evaluation with possible voluntary admit is plan, currently I believe the patient meets criteria for Sober Reevaluation ..."
* On 02/16/2023 at 2124 a Physician electronically signed an "Emergency Department Encounter" report that included the following:
- "[Patient 28] ... presents to the emergency department with concern about responding to suicidal thoughts. Patient was parked at the Saint Johns bridge and [they state they] intended to jump off. [Patient's sibling] had placed a tracking device in [patients] car and saw that [patient] was driving toward the bridge and interrupted [them] there."
- "ED Course & Medical Decision Making: ... This patient presents here with concern about suicidal ideation in the context of chronic depression which [they have] suffered from since traumatic brain injury about 5 years ago. Patient also has an alcohol use disorder and states [has] suffered complications from a withdrawal seizure in the past. After conferring with my colleague ... we agreed with the plan of observing the patient closely to see whether [patient] develops any symptoms of alcohol withdrawal, [patient] is placed on CIWA protocol. I do think the patient does have some suicide risk, [their] attempt a month ago was fairly significant ... Patient will be monitored for alcohol withdrawal, care is discussed with my [physician partner] and the patient will be a sober reevaluation in the morning. Final Impression 1. Alcohol intoxication 2. Suicidal ideation."
* On 02/17/2023 at 1054 a QMHP recorded "Due to pt inability to engage in safety planning due to active suicidal ideation, I believe the patient meets criteria for Psychiatric Hospitalization at this time ... The patient's symptoms are considered too severe for a lower level of care as exhibited by depression and suicidal thoughts/threats. Patient is appearing to be an imminent risk of harm to self. Pt has a suicide plan and intent. Patient will remain in the ED boarding model pending final psychiatric disposition. Patient will benefit from admission for purposes of safety, stabilization and medication evaluation."
* On 02/17/2023 at 1120 an RN recorded "Planned Transportation ... [Secure transport company] 2/17 @ 1630."
* On 02/17/2023 at 1414 Physician C electronically signed an "ED Psychiatric Boarder Progress Note" that included the following:
- "Briefly, during my shift patient sobered. [They are] feeling better but continues to endorse some suicidal ideation. No bed availability here but Cedar Hills Hospital does have bed availability ... Plan for transfer to CHH ..."
* On 02/17/2023 at 1620 an RN recorded "Patient discharged."

5.c. The electronic two-page "Patient Transfer" form in Patient 28's record contained EMTALA physician transfer certification and other required documentation and included the following:
* On Page 1 the form included:
- In the space for "Reason for Transfer:" was written "Service unavailable, No bed available"
- In the space for "Patient specific transfer risks:" was written "Worsening sx."
- Patient 28's signature recorded at the bottom of page 1 was dated as 02/17/2023 and the "Time" space was blank.
* The form continued on Page 2 and included:
- Pre-printed language on the form: "The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures. After discussion with the receiving physician, the patient and/or family, the agreed mode of transportation is ___." Written in that space was "Secure transport."
- Pre-printed language on the form: "I discussed the risks and benefits with the patient/patient representative and they verbalized understanding and are in agreement with the decision to transfer. By completing this form, I authorize transfer of this patient."
- Physician C's electronic signature recorded under those entries on Page 2 was dated and timed as 02/17/2023 at 1032.

5.d. There was no documentation on the transfer form or elsewhere in the medical record to reflect what individualized and specific risks of transfer for Patient 28 Physician C had "discussed." The physician certification of transfer risks reflected that Physician C had written "Worsening sx" However, that is risk inherent to all transfers, and it was not clear what "worsening sx" meant in the case of this suicidal patient.

5.e. During interviews with staff that included the DQM, CMO, QMCs, DAR, EDD, and EDCNS at the time of the ED record reviews on 02/28/2023 beginning at 1330 they confirmed the lack of clear transfer risk for information for Patient 28.

5.f. Internet/GPS distance calculators reflected that CHH in Portland, Oregon was approximately 1 mile, and approximately 5 minutes drive-time in "light traffic", from PSVMC in Portland, Oregon.