HospitalInspections.org

Based on observation, interview, review of documentation of 4 of 4 declined requests from other hospitals to transfer patients to PMMC for specialty services (Patients 10, 11, 16 and 23), review of documentation in 6 of 22 medical records of patients who presented to the hospital for emergency services (Patients 1, 2, 9, 12, 20 and 24), 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:
* Required posting of EMTALA signs.
* On-call physician responsibilities.
* Provision of MSEs.
* Appropriate transfers of patients.
* Recipient hospital responsibilities.

Findings included:

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

2. Regarding on-call physician responsibilities refer to the findings identified under Tag A2404, CFR 489.20(r)(2) and CFR 489.24(j)(1-2).

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).










40575

Based on observation and interview it was determined the hospital failed to develop and enforce EMTALA policies and procedures that ensured the posting of signage that specified patients' EMTALA rights in all areas likely to be noticed and where patients waited for examination and treatment.

Findings include:

1. The policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated as last reviewed "03/2018" included a section titled "General Policies" that included the following: "Signage. Each Hospital will post signage in the dedicated emergency department and perinatal department specifying the rights of individuals with emergency medical conditions and women in labor who come to the dedicated ED or perinatal department for health care services, and indicate on the signs whether the hospital participates in the Medicaid program."

The policy lacked an assurance that the language on the signs would specify the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor. Further, the policy lacked an assurance that the signs would be posted in all places individuals wait for examination and treatment.

2. Observations during tour of the ED on 09/26/2018 at 1645 revealed one EMTALA sign posted next to the main ED entrance door across from the ED registration desk. There were no EMTALA signs observed to be posted in the large waiting room, at the ED registration desk, in the two triage rooms, in the six "fast track" rooms, in the 16 treatment rooms, in the trauma bay, near the mental health treatment room or any other observed location in the department.

3. Observations during tour of the OB Department on 09/26/2018 at 1650 revealed one EMTALA sign posted at the OB main entrance. There were no EMTALA signs observed to be posted in the OB waiting area, in the two triage rooms, in the 8 LDRP rooms or any other observed location in the department.

4. During interview with the QC on 09/26/2018 at 1700 he/she confirmed that the only signs in the ED and the OB department were the ones observed next to each department entrance.

40575


Based on interview, review of documentation of 4 of 4 declined requests from other hospitals to transfer patients to PMMC for specialty services (Patients 10, 11, 16 and 23), 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 its on-call physicians fulfilled their on-call duties and obligations to provide consultation, to come into the hospital, and to accept patients the hospital had capability and capacity to treat.

Findings include:

1. Refer to the findings identified under Tag A2411, CFR 489.24(f) that reflects urology on-call specialty Physician H failed to accept Patients 10, 11 and 16 in transfer from other hospitals' EDs. PMMC had capability and capacity to treat Patients 10, 11 and 16.

2. Refer to the findings identified under Tag A2411, CFR 489.24(f) that reflects neurology on-call specialty Physician O failed to accept Patient 23 in transfer from another hospital's ED. PMMC had capability and capacity to treat Patient 23.

Based on interview, review of documentation in 2 of 22 medical records of patients who presented to the hospital for emergency services (Patients 9 and 12), and review of policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that all patients were provided a complete and appropriate MSE, or that attempts were made to advise the patients of the risks of leaving before an MSE was completed.

Findings include:

1. a. The policy and procedure titled "EMTALA: Medical Screening Examination" dated as implemented "01/2018" contained five "policy" elements. Those stipulated that:
"A. Patients who present to the ED requesting medical services will receive a Medical Screening Examination, regardless of their ability to pay, to determine if an emergency medical condition exists. This examination is performed by qualified medical personnel as defined by Oregon Medical Staff policy."
"B. If an individual who is not a hospital patient comes elsewhere on hospital property...employees will ensure they arrive to the Emergency Department where a Medical Screening Exam is offered..."
"C. The Medical Screening Examination should not be delayed in order to obtain insurance or payer information."
"D. The Medical Screening Examination may include diagnostic studies and interventions necessary to determine if an emergency medical condition exists."
"E. The LIP may refer the patient for ongoing care, which may include, but not be limited to, admitting the patient to the hospital, transferring the patient to another facility or follow-up with a community provider."

There was no other procedural information or direction to ensure the provision of appropriate MSEs contained in the document.

b. The "Policies and Procedures Professional Staff" dated as revised 05/28/2018 included the following information contained within "Article XVII. Additional Policies:"
* "Medical Screening Examinations: Medical screening examinations within the capability of the Hospital will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition."
* "Against Medical Advice (AMA) Discharges: When a patient requests discharge AMA the attending Member shall determine whether the patient is competent to understand and appreciate the risks of leaving the Hospital without further treatment...If the patient is determined competent by the attending Member...whenever possible, the risks of the decision should be explained to the patient by the attending Member or designee. The explanation should be witnessed when possible and the name of the witness and the fact that the explanation was given shall be documented in the patient's medical record. The patient shall be asked to sign a release form that is filed with the medical record. If the patient refuses to sign the release form the refusal shall be document in the patient's medical record...When the patient leaves the Hospital without an opportunity to be given an explanation of the risks of leaving, the medical record should include any attempts to explain the risks and to request that the patient sign a release form."
* "Emergency Medical Record...If a patient leaves the Hospital against medical advice (AMA), this shall also be noted..."

2. The ED record of Patient 9 reflected that he/she presented to the ED on 09/04/2018 at 0612. The record reflected the patient's course through the ED as follows:
* At 0615 an entry by the DO reflected "Provider Contact Initiated."
* At 0626 the next entry was recorded at by an RN and reflected "ED Disposition set to LWBS before Triage."
* At 0627 an entry reflected "Patient discharged."
* The next and last entry in the record written at 1602, approximately ten hours later, was an "ED Provider Note" recorded and electronically signed by the DO and reflected "Patient eloped before physician evaluation."

The patient's course in the ED was unclear, including that the reason the patient presented was not recorded. Although the record reflected that the DO made contact with the patient, there was no documentation in the record to describe efforts to encourage the patient to stay for a MSE, and no documentation that the risks of leaving the hospital prior to the completion of an MSE had been reviewed with and understood by the patient.

3. The ED record of Patient 12 reflected that he/she presented to the ED on 09/11/2018 at 2115. The record reflected the patient's course through the ED as follows:
* At 2116 an entry recorded by laboratory staff reflected an unspecified lab specimen was "Collected: 09/11/2018 2116...Status: Preliminary result."
* At 2120 an entry reflected that "Registration completed."
* At 2207 the next entry recorded was entered by an RN and reflected "Patient dismissed" and "ED Disposition set to LWBS before Triage."
* The last entry in the record written on 09/12/2018 at 1347, approximately 16 hours later, was a "Telephone Encounter" note recorded and electronically signed by a PA that reflected "Called and spoke with patient. [He/she] states that [he/she] left without being seen before [he/she] checked in because [he/she] was having problems with [his/her] infusion pumps however this was fixed. [He/she] has no questions or concerns at this time and will follow-up if any further concerns."

Although there was documentation that a PA called the patient the following afternoon, the patient's ED encounter documentation and patient's course in the ED was unclear, including that the reason the patient presented to the hospital was not recorded at the time the patient was in the ED; the type of lab specimen collected and the results were not specified; and events that transpired during the approximately 50 minutes between "Registration Completion" and "Patient Dismissed" were not recorded. There was no documentation in the record to describe efforts to encourage the patient to stay for a MSE while he/she was in the ED, and no documentation that the risks of leaving the hospital prior to the completion of an MSE had been reviewed with and understood by the patient.


40575

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Based on interview, review of documentation in 4 of 4 medical records of patients who were transferred from PMMC to another hospital for specialty services PMMC did not have capability or capacity to provide at that time (Patients 1, 2, 20 and 24), and review of hospital policies and procedures, it was determined that the hospital failed to enforce its 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 as the physician certification that the benefits of transfer outweighed the risks of transfer did not reflect that patient specific, individualized risks of transfer had been identified.

Findings include:

1. The policy and procedure titled "Emergency Treatment and Active labor Act (EMTALA) Patient Transfers Between Facilities" dated as last revised "03/2018" was reviewed.
* The applicability of the policy was not clear as the "Policy Statement" reflected "This policy applies to all patient populations presenting to an Emergency Department (including pediatric patients) or Perinatal Department with an emergency medical condition needing transfer to or from a Providence hospital" whereas the "Procedure:" indicated "Transferring a patient from a Providence hospital to any other hospital (Providence or non-Providence)."
* The policy and procedure included the following: "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 Patient Transfer Form or physician documentation in the medical record."

2. The ED record for Patient 1 reflected he/she presented to the ED on 08/05/2018 at 0900 with a chief complaint of "Groin Swelling." The record reflected that the patient's course through the ED included the following:
* An MSE that included labs and imaging was conducted, and stabilizing treatment provided included initiation of IV antibiotics.
* An ultrasound result electronically signed by a DO at 1312 reflected "Impression: Complex fluid collection with mobile debris and surrounding hyperemia in the LEFT lateral posterior scrotum extending through the soft tissues to the gluteal crease suggestive of abscess. 2. Small RIGHT hydrocele."
* At 1545 the ED MD documented "Ultrasound of the scrotum and testes showed an 8.3 x 4 cm abscess tracking toward the gluteal cleft. Give the extent, location, anticipated complexity of the procedures, and concern for ability to achieve adequate pain control, I feel that the patient requires urologic consultation. Unfortunately we do not have a urologist on call, attempts were made to transfer the patient..."
* The documentation reflected that multiple hospitals were contacted and found to lack capacity or otherwise "refused to accept patient," until a note recorded at 1932 reflected that the patient was accepted for urology specialty services by SHRB.
* On 08/05/2018 at 1927 the ED MD completed and electronically signed the "Patient Transfer" form that included the physician certification of risks and benefits under which the "Patient specific transfer risks" were recorded as: "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death." There were no patient specific, individualized risks identified either on the form or in other documentation in the ED record.
* The "Patient Transfer" form reflected that Patient 1 was transferred to SHRB in Springfield, Oregon by ALS transportation.

An on-line distance calculator reflected that SHRB in Eugene, Oregon is 169 miles and three hours and 16 minutes drive time from PMMC in Medford, Oregon.

3. The ED record for Patient 2 reflected he/she presented to the ED on 08/19/2018 at 1150 with a chief complaint of "Hematuria." The record reflected that the patient's course through the ED included the following:
* An MSE that included labs and an EKG was conducted, and stabilizing treatment provided included initiation of blood transfusions.
* At 1417 the ED MD documented "[Pt.]...presents to the ED for evaluation of hematuria and weakness. Pt was evaluated by a urologist on 8/16/2018 and revealed bleeding from the prostate. Pt underwent cystoscopy on 08/16 which showed a considerate amount of obstruction and inflammation of the urethra. A 24 inch, three way catheter was inserted after cystoscopy...Pt currently reports intermittent SOB. Denies fever, [Spouse] reports near syncopal episode. Denies chest pain...Patient's weakness I believe is secondary to blood loss anemia. [His/her] hemoglobin on 13 August was 14.4. [His/her] hemoglobin on August 16 was 11.1...Today it is 7.4. I will begin transfusing the patient but at this point we have no urology coverage and given the patient's age and other medical problems he will need to be admitted by hospitalist with consultation to (sic) [his/her] urologist. I will attempt contact [ARRMC] and see if they're willing to accept the patient...Spoke with urologist..." The documentation further reflected that the patient was accepted by ARRMC for urology specialty services.
* On 08/19/2018 at 1420 the ED MD completed and electronically signed the "Patient Transfer" form that included the physician certification of risks and benefits under which the "Patient specific transfer risks" were recorded as "Risks." There were no patient specific, individualized risks identified either on the form or in other documentation in the ED record.
* The "Patient Transfer" form reflected that Patient 2 was transferred to ARRMC in Medford, Oregon by ALS ambulance.

An on-line distance calculator reflected that ARRMC in Medford, Oregon is approximately 3 miles and 10 minutes drive time from PMMC in Medford, Oregon.

4. The ED record for Patient 20 reflected he/she presented to the ED on 09/23/2018 at 1215 with a chief complaint of ""Flank Pain; Testicle Pain." The record reflected that the patient's course through the ED included the following:
* An MSE that included labs and imaging was conducted, and stabilizing treatment provided included initiation of IV fluids and IV pain medication.
* At 1628 the ED MD documented "[Pt.]...presented to the ED with left-sided flank and testicular pain due to a 6 mm obstructing stone in the left proximal ureter. Has been very difficult to control this patient's pain. [Pt.] received fentanyl, nitrous, Toradol and ketamine prior to arrival as well as more Toradol and several doses of Dilaudid while here...is still in pain...Unfortunately, we do not have urology coverage here today. I discussed this case with [ARRMC Urologist] who has accepted the transfer."
* On 09/23/2018 at 1629 the ED MD completed and electronically signed the "Patient Transfer" form that included the physician certification of risks and benefits under which the "Patient specific transfer risks" were recorded as "Worsening of [his/her] condition or accidents during transfer leading to disability or even death." There were no patient specific, individualized risks identified either on the form or in other documentation in the ED record.
* The "Patient Transfer" form reflected that Patient 20 was transferred to ARRMC in Medford, Oregon by ALS ambulance.

An on-line distance calculator reflected that ARRMC in Medford, Oregon is approximately 3 miles and 10 minutes drive time from PMMC in Medford, Oregon.

5. During interviews with staff present at the time of the EHR reviews for Patients 1, 2 and 20 on 09/28/2018 they confirmed the lack of documented patient specific, individualized risks of transfer.

6. The ED record for Patient 24 reflected he/she presented to the ED on 10/27/2018 at 1950 by ambulance with a chief complaint of "Altered Mental Status." The record reflected that the patient's course through the ED included the following:
* An MSE that included labs and imaging was conducted, and stabilizing treatment provided.
* At 2018 the ED MD documented that the patient was "...found unresponsive at 1900 at [workplace]...intubated at the scene...taken directly to the CT scanner on arrival...found to have a large subarachnoid bleed with extension into the midbrain. I was in the CT scanner looking images (sic) as patient was being assessed and immediately made phone calls to [ARRMC] and [PSVMC]...Due to patient's critical illness and severe subarachnoid patient required assessment by neurosurgery for possible EVD placement."
* At 2103 the ED MD documented that a phone call from ARRMC was received and ARRMC had accepted the patient for neurology specialty services.
* On 10/27/2018 at 2110 the ED MD completed and electronically signed the "Patient Transfer" form that included the physician certification of risks and benefits under which the "Patient specific transfer risks" were recorded as "All transfers have the risk of traffic accidents, bad weather and/or road conditions as well as limitations of personnel and equipment during transport. There is also potential for worsening of medical condition during transport resulting in possible disability and/or death." There were no patient specific, individualized risks identified either on the form or in other documentation in the ED record.
* The "Patient Transfer" form reflected that Patient 24 was transferred to ARRMC in Medford, Oregon by ALS ambulance.
* An entry recorded by the ED MD at 2300 reflected that the neurosurgical services required for this patient were not available at PMMC.

An on-line distance calculator reflected that ARRMC in Medford, Oregon is approximately 3 miles and 10 minutes drive time from PMMC in Medford, Oregon.

Based on observation, interview, review of documentation of 4 of 4 declined requests from other hospitals to transfer patients to PMMC for specialty services (Patients 10, 11, 16 and 23), 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 its compliance with recipient hospital responsibilities to accept patients from referring hospital EDs, without delay, for whom it had capability and capacity to treat. In addition, the failure to accept patients for transfer created a delay in the provision of further examination and stabilizing treatment, particularly in the cases where patients had to then be transferred to hospitals that were located at a distance farther away than PMMC.

Findings include:

1. a. The policy and procedure titled "Emergency Treatment and Active labor Act (EMTALA) Patient Transfers Between Facilities" dated as last revised "03/2018" was reviewed. It included the following direction:
* "EMTALA regulations provided that a hospital that has the capability or facilities to treat a patient with an emergency medical condition must accept the transfer of an individual needing those capabilities from a referring hospital lacking those capabilities, if the sending hospital is anywhere within the boundaries of the United States."
* "Transfers are made physician-to-physician. Reasons for transfer include, but are not limited to: Patient requests to be hospitalized elsewhere...Resources do not exist at the sending hospital for best medical care for this type of patient...When a hospital Emergency Department or Perinatal Department has exhausted all of its capabilities in attempting to resolve the patient's emergency medical condition."
* "On-call coverage. The hospital will maintain a list of physicians who are on-call to come to the hospital to consult or provide treatment necessary to stabilized an individual with an emergency medical condition. If a physician is listed as on-call and requested to make an in-person appearance to evaluate and treat an individual, that physician must respond in person in a reasonable amount of time. If the physician is on the hospital's on-call list; has been requested by the treating physician to appear at the hospital; and fails or refuses to appear within a reasonable period of time then the hospital and the on-call physician may be subject to sanctions for violation of the EMTALA statutory requirements."
* "Receiving a patient who is present in another facility's emergency department or perinatal department who has been stabilized within the limits of that facility's current capabilities to a Providence hospital...Any hospital department receiving a request to transfer a patient to a Portland Service Area hospital transfers the call to the Providence Transfer Center..."

Although the policy and procedure contained extensive directions related to receiving a patient from another hospital, those directions were specific to requests to transfer to Providence "Portland Service Area" hospitals that did not include PMMC located in Medford, Oregon. An on-line distance calculator reflected that Medford, Oregon is 273 miles and approximately five hours and 22 minutes drive time distance from Portland, Oregon.

b. The document titled "The Plan for the Provision of Care Providence Medford Medical Center" dated as last reviewed "11/2017" reflected that in the hospital's ED "Care provided includes trauma care, patients requiring resuscitative and definitive initial care of acute or chronic problems in the following areas: medical, surgical, cardiac, orthopedic, psychiatric, poisoning, gynecological, urological, obstetrical, respiratory, neurological, otolaryngical, ophthalmologic, regardless of age."

c. The "Policies and Procedures Professional Staff" dated as revised 05/28/2018 included the following information contained within "Article XVII. Additional Policies:"
* "Emergency Call: Each MEC will designate appropriate specialties for the published Emergency Call List. All Active and Active provisional Physician Members of the Professional Staff who hold core privileges in their specialty areas are required to take emergency hospital call. Such call shall include emergency situations within the Emergency Departments...On-call physicians may be on simultaneous call at another hospital or perform elective surgeries while on-call but must maintain reasonable provider back-up to still meet the intent for emergency call responsiveness of being available by phone, and when clinically indicated in person, to the Hospital(s) within thirty (30) minutes. The on-call physician shall arrange ahead of time for another member of the Medical Staff ('Substitute Physician'), with comparable privileges, to be responsible to respond to emergencies in the event that the on-call physician is unable to respond to an emergency call within thirty (30) minutes because he or she is taking simultaneous call or performing an elective surgery...Members must be available to respond by phone, and when clinically indicated in person, to the Hospital(s) within thirty (30) minutes when on the published emergency call schedule...Continued membership on the Professional Staff is contingent upon satisfying emergency call responsibilities."

The policies and procedures for the professional staff contained no references to the obligations of on-call specialty physicians to accept patients with EMCs from other hospitals that request transfer of those patients for whom the other hospital lacks capability or capacity to provide necessary services.

d. The "New Professional Staff/Allied Health Professionals Orientation" document identified as effective August of 2017 included the following:
* "Prohibited On-Call Practices...The statutes and the regulations for EMTALA provide that any participating hospital which has 'specialized capabilities or facilities' or which is a 'regional referral center' my (sic) not refuse to accept a patient in transfer, if it has the capacity to treat the individual."

2. a. The PMMC Medical Staff Roster provided reflected that Physician H's specialty was urology, he/she had been on staff at PMMC since June 2008, and his/her current status was "Active."

b. A "Professional Staff Expectations of Behavior, Conduct and Performance" document signed and dated by Physician H on 12/21/2016 included the following:
* " Members...shall work cooperatively and respectfully with members of the community. Members shall serve and fully complete all emergency call requirements, as befitting their Professional Staff status, as defined by the Professional Staff. This includes but is not limited to the following:
a. Ensure timely availability for emergency room call, if applicable;
b. Ensure that coverage of emergency call, if applicable, is by another Member with similar privileges;
c. Agree to see and treat all patients assigned regardless of age, race, gender, sexual orientation, creed, disease state, or ability to pay as is appropriate to the Member's privileges."and dated

c. The PMMC on-call "Specialty Backup" list for September 2018 reflected that Physician H was scheduled for urology call the week of 09/10/2018. "Weekly coverage" on the list was defined as from "Monday to Monday."

3. a. Review of "EMTALA transfer in" documentation provided in log format reflected that on 09/16/2018 at 1530 a request to transfer Patient 16 for urology specialty services was received from SLMC in another town. The log reflected "Transfer accepted: [No]."

b. A written summary of the request for transfer of Patient 16 reflected the following:
* PMMC received a request for transfer from SLMC on 09/16/2018 at 1530.
* Paitent described with "...scrotal cellulitus with skin necrosis/gangrene. Suspicious for Fournier gangrene. Surgical debridement recommended."
* The patient was subsequently accepted for transfer to ARRMC.
* On 09/24/2018 Physician H reported to PMMC staff that he/she had received the transfer request for Patient 16 and had confirmed that PMMC had beds. He/she reported that the SLMC LIP indicated he/she had called ARRMC first and was told they had no beds. "At that point, [Physician H] told the transferring provider [he/she] was going to call the [ARRMC transfer center]...when [he/she] called the transfer center...was told they would have beds in an hour. With that, [he/she] called [SLMC] back and instructed them to call [ARRMC] back and request a bed."

c. During interview with HS F on 09/27/2018 at 1415 he/she stated that on 09/16/2018 at approximately 1530 he/she received a call from SLMC requesting a possible transfer for urology services. The HS stated that PMMC did have beds at that time so he/she called the on-call urologist, Physician H, and informed the physician of the request. The HS stated that Physician H expressed that "I don't know why they call here." The HS stated that Physician H told him/her that he/she would call SLMC and call the HS back if he/she accepted the patient. The HS stated he/she did not hear back from Physician H and did not hear back from SLMC.

d. During interview with Physician H on 09/27/2018 beginning at 1615 he/she provided the following information:
* In regards to requests for transfer from other hospitals Physician H stated "What I do for these patients is this. They always call [ARRMC] first. All have transfer agreements with [ARRMC]...I say is this a urology emergency? If they say 'no' I say did you call [ARRMC] first? If they say 'yes' I take them. Then I call [ARRMC] and ask if they have a bed. Then I call [requesting hospital] back and tell them to call [ARRMC] back and if [ARRMC] gives you any grief call me back."
* Physician H expressed concerns about ARRMC "holding beds for elective cases."
* Regarding Patient 16 Physician H received call from answering service and HS confirmed PMMC had beds.
* Physician H called the SLMC ED LIP and stated he/she said to the LIP "Don't tell me about the patient. Is this an emergency that needs to be taken care of?"
Physician H excused him/herself and discontinued the interview at 1640.

e. During further interview with Physician H on 09/28/2018 beginning at approximately 1000 he/she provided the following information:
* Regarding Patient 16 Physician H received call from answering service and HS confirmed PMMC had beds.
* He/she called SLMC and asked the ED LIP "if this is absolute emergency?" He/she stated the response was "no."
* He/she asked the SLMC LIP "Did you call [ARRMC] first?" He/she stated the response was "yes, they didn't have bed."
* He/she told the SLMC "Let me call and see if they really don't have bed."
* Physician H stated that he/she then called the ARRMC "transfer center" and was told that "they might have beds in an hour."
* Physician H called the SLMC LIP back and informed him/her that "I called [ARRMC]. That's where you called first. If you get push back call me back and I'll take the transfer."
* Physician H stated that when he/she talked to ARRMC "I told them they would be getting call from [SLMC]."
* Physician H stated "I didn't call back to [PMMC] that there was no transfer.
* He/she stated that the SLMC LIP "did not tell me anything about the patient at all - just that it was not an emergency."
* He/she stated that "I won't let [him/her] tell me or ask me anything before I asked is this an emergency."
* He/she stated "I never said I will not take this transfer."
* In response to the question "Did [PMMC] have capacity to accept [Patient 16]," Physician H answered "Yes."
* In response to the question "Did [PMMC] have capabilities to provide further exam and stabilizing treatment for [Patient 16]," Physician H answered "I didn't know about the patient so I can't answer that. I know I was on call but this is how it played out."

f. Handwritten notes provided by Physician H about the request to transfer Patient 16 were reviewed with Physician H. Those notes included the following entry "[Discussed with] ED MD [at SLMC] - They called [ARRMC] 1st. 'No beds.' I told to call again. If will not take pt. then call me and I will take pt. - 9/17."

g. During interview with QC, the DES and the DQMS on 09/27/2018 beginning at 0930 they confirmed that PMMC had capability and had capacity to accept Patient 16 when the request for transfer was made.

4. a. Review of "EMTALA transfer in" documentation provided in log format reflected that on 09/10/2018 at 2028 a request to transfer Patient 10 for urology specialty services was received from SCH in Northern California. The log reflected "Transfer accepted: [No] - declined by urology."

b. A written summary of the request for transfer of Patient 10 reflected the following:
* PMMC received a request for transfer for urology services from SCH on 09/10/2018 at 2028.
* Physician H was on-call and declined the transfer.
* The patient was subsequently accepted for transfer to MMCR.
* On 09/24/2018 Physician H reported to PMMC staff that he/she received the request and responded to the SCH provider who conveyed that the patient was a prison inmate and was accompanied by two guards. The SCH provider reported to Physician H the patient had an abscess near the kidney, no hydronephrosis and creatinine was normal. "[Physician H] indicated the need for an IR procedure for percutaneous drainage. Indicated this was not a urologic emergency, was not a urology issue and does not need a urologist. [Physician H] indicated he/she stated I'm not refusing the transfer. Went on to say that...the complex needs of the patient could not be met here referencing the prisoner status and security guards, not medical complexity."

c. During interview with Physician H on 09/28/2018 beginning at 1015 he/she provided the following information:
* Regarding Patient 10 Physician H received call from answering service and HS confirmed PMMC had beds.
* He/she called SCH and asked the ED LIP if this was an "absolute urology emergency?" He/she stated the response was "it might be."
* Physician H asked the SCH LIP if he/she had called ARRMC first, to which the response was "yes" and ARRMC didn't have beds.
* Physician H stated he/she then called ARRMC and was told ARRMC did not have beds.
* Physician H called the SCH ED LIP back to get information about the patient. The SCH ED LIP reported that Patient 10 had "one kidney...peri-renal abscesses...no stone...no hydronephrosis...creatinine WNL."
* Physician H stated this was not a urology case and that the patient needed percutaneous drainage and IR and confirmed that was within the capability of PMMC.
* Physician H stated he/she told the SCH ED LIP to call him/her back "if there's an issue."
* He/she stated that "they obviously have IR at [ARRMC]."
* Physician H also stated that information provided about the patient by SCH included that he/she was a prison inmate and was attended by two armed guards. He/she stated that ARRMC is "better equipped to handle [persons] with two armed guards than [PMMC]."
* In response to the question "Did [PMMC] have capacity to accept [Patient 10]," Physician H answered "Yes."
* In response to the question "Did [PMMC] have capabilities to provide further exam and stabilizing treatment for [Patient 10]," Physician H answered "I did tell [SCH ED LIP] that IR was available at [PMMC]." He/she further confirmed that PMMC had capability, "yes, but do they want to [take the patient] under those circumstances."

d. During interview with QC, the DES and the DQMS on 09/27/2018 beginning at 0930 they confirmed that PMMC had capability and had capacity to accept Patient 10 when the request for transfer was made.

e. An on-line distance calculator reflected that PMMC is 110 miles distance and two hours and 50 minutes drive time away from SCH, whereas MMCR is 213 miles five hours and 30 minutes drive time away from SCH.

5. a. Review of "EMTALA transfer in" documentation provided in log format reflected that on 09/11/2018 at 0406 a request to transfer Patient 11 for urology specialty services was received from ATRMC in a nearby town. The log reflected "Transfer accepted: [No] - declined by urology."

b. A written summary of the request for transfer of Patient 11 reflected the following:
* The patient presented to ATRMC on 09/11/2018.
* Primary diagnosis and reason for transfer request: was Acute Kidney Injury and bilateral obstructing ureteral stones.
* ATRMC did not have urology on-call services.
* On 09/11/2018 at 0406 a request for transfer for urology services was made to PMMC and the request was declined.
* The patient was subsequently accepted for transfer by SHRB.
* On 09/24/2018 Physician H reported to PMMC staff that he/she received the request and responded to the ATRMC LIP with "'Don't tell me about the patient' indicating if [he/she] is told, then [he/she] is legally liable for the patient." Physician H reported that ATRMC told him/her that they had called ARRMC and was told they had no beds at that time. Physician H reported he/she instructed ATRMC to call ARRMC back and to "'call be back if you can't get them to accept.'"

c. During interview with Physician H on 09/28/2018 beginning at 1030 he/she provided the following information:
* Regarding Patient 11 Physician H received call from answering services and HS confirmed PMMC had beds.
* The HS also indicated that ATRMC had called ARRMC before they called PMMC and was told that ARRMC had no beds.
* Physician H indicated that before he/she called ATRMC to respond to the request for transfer, he/she called ARRMC to check on their bed status and was told ARRMC should have beds in an hour.
* Physician H called ATRMC and asked the ED LIP "Is this an absolute emergency?" He/she stated the response was "no."
* Physician H stated he/she advised the ATRMC ED LIP to "Please call [ARRMC] back because they'll have a bed in an hour. Here's my cell number. I'm not denying transfer I just want you to go to who you called first."
* Physician H stated that he/she had no information about Patient 11's condition "because I asked if it was an absolute emergency."
* In response to the question "Did [PMMC] have capacity to accept [Patient 11]," Physician H answered that they had capacity.
* In response to the question "Did [PMMC] have capabilities to provide further exam and stabilizing treatment for [Patient 11]," Physician H answered that they had capability.

d. Handwritten notes provided by Physician H about the request to transfer Patient 11 were reviewed with Physician H. Those notes included the following entries: "Called by [answering] service. Asante - I called 1st make sure beds [at PMMC] - Called [ARRMC]. [ATRMC] absolute emergency ?? - No...Called [ARRMC]? Yes. Called [transfer center] - on delay beds - Called ER - Back Please call [ARRMC]."

e. During interview with QC, the DES and the DQMS on 09/27/2018 beginning at 0930 they confirmed that PMMC had capability and had capacity to accept Patient 11 when the request for transfer was made.

f. An on-line distance calculator reflected that PMMC is 30 miles distance and 45 minutes drive time away from ATRMC, whereas SHRB is 145 miles distance and two hours and 55 minutes drive time away from ATRMC.

6. a. The undated "PMMC Medical Staff Roster" reflected that Physician O's specialty was neurology, he/she had been on staff at PMMC since 01/15/2016 and his/her current status was "Active."

b. The PMMC specialty backup on-call list for October 2018 reflected Physician O was scheduled for neurology non-stroke call on 10/14/2018.

c. A written summary of the request for transfer received on 10/14/2018 for specialty services for Patient 23 reflected the following:
* PMMC HS received a call from CGH ED with a request to transfer Patient 23 for neurology services secondary to "seizures."
* Physician O was on call for neurology according to the PMMC on call list.
* Physician O failed to respond to the call within 30 minutes and more calls were made to attempt to locate Physician O.
* An hour and 20 minutes after the first call from CGH was placed the HS called CGH back as there had been no communication from Physician O.
* The CGH LIP reported that Physician O "said that [he/she] would not be able to accept the patient and they should send the patient to OHSU."
* "...the response by the PMMC neurologist was that it was beyond our scope of care and recommended OHSU."
* Further meetings and follow up indicated that it was assumed that Patient 23 required continuous EEG monitoring and that Physician O "did not know" PMMC had that capability.
* Physician O was "unclear" if he/she was on call for PMMC or ARRMC when he/she took the call.
* Physician O "did not know the clinical presentation of [Patient 23] because [he/she] did not give the transferring facility an opportunity to provide report."

d. An email from the QC to the medical director dated 11/06/2018 at 1011 reflected "The ability to provide continuous [EEG] monitoring has been in place for more than 2 years...Continuous EEG monitoring is available here on a case by case basis...any request for continuous monitoring must be approved by a neurologist...Based on the clinical presentation of the patient requiring transfer, the service could have been provided."

e. An email from the medical director to the QC dated 11/06/2018 at 1552 reflected in regards to Patient 23: "[Physician O] was not even sure if it was a stroke or seizure patient as the communication [between Physician O] and ED physician from [CGH] was abrupt and ED physician has not (sic) opportunity to give [him/her] entire story regarding patient. [Physician O] is also not aware of continuous EEG monitoring service at [PMMC]."

f. During interview with QC on 12/04/2018 at 1123 he/she confirmed that PMMC had capability and had capacity to accept Patient 23 when the request for transfer was made.

g. An on-line distance calculator reflected that PMMC is 115 miles distance and 3.5 hours drive time away from CGH. OHSU, where Physician O recommended Patient 23 be sent, is 302 miles and 6 hours and 45 minutes drive time away from CGH.


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