HospitalInspections.org

29708

Based on observation, review of recorded video footage, interviews, review of medical records or other documentation for 18 of 24 patients who presented to the hospital for emergency services (Patients 4, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 and 24), review of central log documentation, and review of policies, procedures and other documents, it was determined the hospital failed to develop and enforce its EMTALA policies and procedures in the following areas:
* Provision of MSEs;
* Appropriate transfers;
* Maintenance of a central log;
* Hospital reporting responsibilities; and
* Required posting of EMTALA signs.

Findings included:

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

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

3. Central Log: Refer to the findings identified under Tag A2405, CFR 489.20(r)(3), which reflects the hospital's failure to develop and enforce its EMTALA policies and procedures related to a central log.

4. Hospital EMTALA policies and procedures were reviewed and contained no reference to the requirement that receiving hospitals must report to CMS or the State survey agency suspected incidences of patients with EMCs who were transferred in violation of CFR 489.24(e).

5. Hospital EMTALA policies and procedures were reviewed and contained no reference to the required posting of EMTALA signs.

6. During an interview with the Regional Director of Hospital Quality Management on 08/28/2015 at 1600, he/she confirmed the hospital had no policies and procedures that addressed the required EMTALA reporting requirements, and EMTALA signage requirements.

Based on observation, review of recorded video footage, interviews, review of central logs and medical records or other documentation for 17 of 24 patients who presented to the hospital for emergency services (Patients 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 and 24), and review of policies, procedures and other documents, it was determined the hospital failed to develop and enforce its EMTALA policies and procedures to ensure maintenance of a central log which contained complete and accurate information about each patient who presented to the hospital for emergency services:
* Not all patients who presented to the hospital were entered on the logs;
* The logs did not include provisions to ensure all of the elements required by policy were recorded;
* The logs did not clearly reflect for each patient whether the patient refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged as required by this regulation; and
* The logs had numerous omissions.

Findings included:

1. The policy and procedure titled "Central Log for Labor and Delivery" dated as last revised "06/13" was reviewed and reflected "A record of patients that present to labor and delivery is kept to meet regulatory expectations...Emergency and Labor and Delivery departments must maintain centralized department logs of patient visits. Logs must document...The patient name, date, time of arrival, MRN # and room assignment...Reason for coming to L&D...Time of discharge, if applicable and where patient discharged to...Admission to hospital and what room...The log must note the primary provider's name...Logs must be instantly retrievable and must be kept in a central location for at least 5 years."

During an interview on 08/28/2015 at 1630 the Regional Director of Hospital Quality Management stated that the hospital had no additional central log policies and procedures specific to the ED.

2. An untitled electronic ED log, reviewed for the period of November 2014 through July 2015, contained 6 columns of the following information: "HRN", "Admit Date", "Year and Month", "ED Discharge Disposition - Name," "Encounter Class - Name" and "Discharge Count."

A second untitled electronic ED log reviewed contained 5 columns of primarily different information: MRN, patient name, two unlabeled or unspecified dates, and medical condition. The medical conditions entered were incomplete and were only entered on the log for some of the patients. For example, one page of the log with a date range of 08/02/2015 through 08/07/2015, had 78 patient names entered but only 14 patient names had a corresponding medical condition. Additionally, the numbers of patients entered onto the log were not consistent with the numbers of patients entered onto the first ED log above. For example, on 04/21/2015 the second log reflected that 32 patients presented on 04/21/2015. However on the first log above there were entries for at least 106 patients who presented on that same date.

A third electronic ED log, reviewed for the period of 08/27/2015 through 09/22/2015, was titled "KPNW Emergency Department, Labor & Delivery Patient Log...Arrived Department: [Sunnyside Medical Center ED]." The log contained columns of the following information: MRN, patient name, arrived date and time, means of arrival, departed date and time, departed from, reason for visit, and disposition. The log contained approximately 3,770 patient entries for that time period. 375 of those entries lacked documentation in the "reason for visit" column. 74 of those entries lacked documentation in the "disposition" column, and included but were not limited to patients whose "reason for visit" was recorded as "Suicidal", "Overdose", "Chest Pain", "Bleeding", and "Seizures".

A fourth electronic log, reviewed for the period of 08/27/2015 through 09/22/2015, was titled "L&D Patients" and contained columns of the following information: Patient name, MRN, age, admit date, admit time, admit Dx, discharge date, and disposition. The log contained 154 patient entries for that time period. Two of those entries did not contain the admit Dx.

A fifth electronic log, reviewed for the period of 08/27/2015 through 09/22/2015, was titled "KPNW Emergency Department, Labor & Delivery Patient Log...Arrived Department: [Sunnyside Medical Center L&D]." The log contained columns of the following information: MRN, patient name, arrived date and time, means of arrival, departed date and time, departed from, reason for visit, and disposition. The log contained approximately 395 patient entries for the same time period as in the third log above that was also for L&D. One hundred and five (105) of those entries lacked documentation in the "reason for visit" column, 48 of those entries lacked documentation in the "disposition" column, and 14 of those entries where a disposition was documented lacked the "departed" date and time.

3. Refer to Tag A2406, CFR 489.24(a) and (c) Medical Screening Exam, which reflects that Patient 6 presented to the L&D and was not entered on the L&D log, and that Patients 23 and 24 presented to the ED and were not entered on he ED logs.

4. The entry on the electronic log for Patient 9 was reviewed and reflected a medical record number but did not reflect the patient's name. The log reflected an admit date of 11/23/2014 and no arrival time, and no room assignment. The ED discharge disposition was reflected as "Unknown Code." There was no time of discharge or where the patient discharged to. There was no entry for Patient 9 on the other electronic log provided.

5. The entry on the electronic log for Patient 10 was reviewed and reflected a medical record number for the patient but did not reflect the patient's name. The log reflected an admit date of 11/23/2014 and no arrival time, and no room assignment. The ED discharge disposition was reflected as "Expired" but there was no disposition/discharge time. There was no entry for Patient 10 on the other electronic log provided.

6. The entry on the electronic log for Patient 11 was reviewed and reflected a medical record number for the patient but did not reflect the patient's name. The log reflected an admit date of 02/21/2015 and no arrival time, and no room assignment. The ED discharge disposition was reflected as "Unknown Code." There was no time of discharge or where the patient discharged to.

7. An entry on the electronic log for Patient 12 was reviewed and reflected a medical record number for the patient but did not reflect the patient's name. The log reflected an admit date of 08/05/2015 but no arrival time, and no room assignment. The ED discharge disposition was reflected as "Discharge to...Hospital" but there was no discharge time. Patient 12 was also on the other electronic log provided but that log lacked an arrival time, room assignment, discharge time, and where the patient discharged to.

Similar findings were identified during review of electronic logs for Patients 13, 14, 15, 19, 20, 21 and 22.

8. An entry on the electronic log for Patient 16 was reviewed and reflected a medical record number for the patient but did not reflect the patient's name. The log reflected an admit date of 04/21/2015 but no arrival time, and no room assignment. The ED discharge disposition was reflected as "AMA/Refused Treatment" but there was no disposition/discharge time. Although the electronic log included a disposition/discharge of AMA, review of the medical record for Patient 16 reflected the discharge disposition was "eloped" which was inconsistent with the electronic log.

Similar finds were identified during review of electronic logs and medical records for Patients 17 and 18.

9. During an interview conducted with the Regional Director of Hospital Quality Management on 08/27/2015 at 1500, he/she stated "We don't have a central log. I see this as our biggest issue."



29708

29708

Based on observation, review of recorded video footage, interviews, review of medical records or other documentation for 3 of 3 patients who presented to the hospital's ED or L&D for emergency services (Patients 6, 23 and 24), and review of policies and procedures and other documents, it was determined the hospital failed to enforce its policies and procedures to ensure that each patient who presented for emergency services received a MSE to determine whether or not an EMC existed.

Findings included:

1. Review of hospital medical staff "Bylaws and Rules and Regulations of the Professional Staff Kaiser Foundation Hospital...Clackamas, Oregon" dated February 2015 reflected the following: "...Attendance of Patients in Emergency Situations. An appropriate medical screening examination within the capability of the hospital (including routinely available ancillary services) shall be provided to all individuals who come to the emergency department and request (or on whose behalf a request is made) examination or treatment. Such medical screening shall be provided by qualified medical professionals...Emergency services and care shall be provided to any person in danger of loss of life or serious injury or illness or to prevent serious permanent disfigurement, or to provide care of a woman in her labor where delivery is imminent whenever there are appropriate facilities and qualified personnel available to provide such services or care..."

2. The policy and procedure provided titled "EMTALA (Emergency Medical Treatment and Active Labor Act) dated as last reviewed "07/2014" was reviewed. The policy section reflected "The hospital will provide a medical screening examination (MSE) by a qualified medical provider to any individual who comes to the hospital seeking emergency medical treatment (or requested on their behalf); determine if the individual seeking care has an emergency medical condition (EMC); and, if an EMC exists, provide the individual with further medical examination and treatment as required to stabilize the emergency medical condition or arrange for transfer of the individual to another medical facility..." The Definitions section of the policy reflected "Labor: The process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in labor unless a physician or clinical nurse midwife certifies, after a reasonable period of observation that the woman is not in labor."

3. The policy and procedure titled "Divert Policy for Labor and Delivery" dated as last revised "06/13" was reviewed and reflected the following: "When the census/acuity of patients in Labor and Delivery exceeds the capability to manage safe care, diversion should be initiated...Per EMTALA, all patients whether via ambulance, phone, or clinic, who need evaluation for possible medical emergency or active labor will come to the closest facility regardless of divert status for evaluation and stabilization."

4. The policy and procedure titled "Triaging Obstetrical Patients to Labor and Delivery," dated as last revised "09/13" was reviewed The policy reflected "...Labor and Delivery triage services will be available 24 hours per day, seven days per week...In accordance with hospital policies and the Emergency Medical Treatment and Active Labor Act (EMTALA), Labor and Delivery will...
Provide a medical screening exam by a Physician or Certified Nurse Midwife (CNM) to any pregnant woman who comes to Labor and Delivery seeking examination or treatment; and, if it is determined that labor or an emergency medical condition exists, provide the pregnant woman with further medical examination and treatment as required to stabilize her condition..."

The policy and procedure continued and was not clear or consistent in its direction regarding where the OB patient with a gestational age of more than 20 weeks was to be evaluated. It stipulated that "Obstetrical patients with a gestational age of more than 20 weeks will be evaluated in the Labor and Delivery Unit." However, it further directed that "Any obstetrical patient who's (sic) chief complaint is not pregnancy related is to be evaluated in the Emergency Department and treated appropriately. The Emergency Department physician will notify the OB/GYN staff physician and the ED Charge RN will notify the L&D CN." And also "Patients over 20 weeks gestation may be treated in Emergency Department/Medical Procedures Unit if the problem is not directly related to the existing pregnancy. The OB will consult with ED MD prior to sending the patient as well as the L&D CN will discuss patient the (sic) ED CN."

5. The policy and procedure titled "Standards of Care: Obstetric Patient," dated as last revised "06/14" was reviewed The policy reflected that for patient triage, vital signs were to be collected upon patient arrival and based on "admitting diagnosis, medical therapy, or procedure." The policy identified the triage assessment as a "Review of prenatal record, if available...Complete perinatal observation assessment including assessment of labor status...Complete targeted physical assessment including heart/lung exam...Fetal monitoring...Document prior to discharge...Psychosocial needs assessment and patient/family teaching prior to discharge."

6. An interview was conducted with the Manager of Regional Hospital Quality on 08/27/2015 at 1545. He/she stated that after learning of a potential EMTALA violation involving Patient 6, the hospital conducted an investigation and analysis of the incident. The report of that investigation was provided. The report was reviewed and described that Patient 6 who was pregnant and experiencing contractions, presented to the hospital's L&D on 08/05/2015 at 2245. The report reflected that Patient 6 was "registered", signed a "Conditions of Admission" document, and was then told by a US that L&D was on divert. The report reflected that Patient 6 left the hospital based on the direction received from the US and did not receive a MSE.

The report reflected "After leaving [KSMC Patient 6's family member] made calls from [his/her] car to find a hospital. [Family member] 'googled' [KWMC] and went there...[Patient 6] was admitted to [KWMC] at 12:16 AM on August 6, [2015]. [Patient 6] delivered baby at 7:18 AM the same day."

The report reflected "...the allegation that EMTALA was violated is substantiated. [Patient 6] presented to [KSMC] complaining of contractions. In fact, a nurse had told [Patient 6] to come in via phone call prior to [his/her] arrival. The patient left the hospital based on statements made by [US] and did not receive a medical screening exam."

A document titled "Telephone Encounter Kaiser Foundation Health Plan" electronically signed and dated 08/05/2015 at 1709 by an RN was reviewed. The document reflected that Patient 6 called the L&D on 08/05/2015 at 1702, prior to his/her arrival to the hospital on 08/05/2015, to report he/she was having contractions.

A document titled "Conditions of Admission - Hospital", with a date of service of 08/05/2015, was reviewed. The document was signed by a registration staff person and Patient 6, and was electronically dated "11:28PM 8/5/2015."

The hospital's L&D central log was reviewed. There were no central log entries reflecting that Patient 6 presented to the hospital on 08/05/2015.

There were no other documents related to Patient 6's 08/05/2015 arrival and encounter at the hospital. There was no documentation in accordance with hospital policies and procedures to reflect that Patient 6 was triaged, vital signs collected, a review of prenatal records completed, a perinatal observation assessment of labor status, a complete physical assessment including heart/lung exam, fetal monitoring performed, and psychosocial needs assessed. There was no documentation reflecting the hospital provided Patient 6 a MSE to determine whether or not an EMC existed. This was confirmed during an interview conducted with an L&D RN on 08/27/2015 at 1315.

An interview was conducted with the L&D Charge Nurse on 08/28/2015 at 0815. The Charge Nurse indicated he/she was aware of the 08/05/2015 EMTALA incident involving Patient 6. The Charge Nurse stated he/she was on duty in L&D on 08/05/2015 when Patient 6 came to the hospital. The Charge Nurse stated that on 08/05/2015 at about 2200 to 2300, Patient 6 called the L&D and spoke with a L&D RN. The Charge Nurse stated "[Patient 6] told the L&D RN that [he/she] was in labor" and "[Patient 6] was calling about [his/her] contractions." The Charge Nurse stated that about a half hour later, Patient 6's family member called the L&D. The Charge Nurse stated that Patient 6's family member stated "we'll be there in a few minutes." The Charge Nurse stated he/she told Patient 6's family member "We'll be expecting you." The Charge Nurse stated he/she then told the US "[Patient 6] will be here in a few minutes. Get a chart ready." The Charge Nurse stated that about 20 minutes later, the US told him/her that Patient 6 was not coming.

An interview was conducted with the L&D US on 08/26/2015 at 1310. The US stated he/she was on duty in the L&D when Patient 6 presented to the hospital on 08/05/2015. The US stated that sometime in the evening of 08/05/2015 he/she went to a L&D waiting area and Patient 6 was there with another person. The US stated that Patient 6 looked like he/she was pregnant and he/she asked Patient 6 and the other person if they knew what "divert" meant. The US stated "I didn't think they understood so I explained to them that divert means there are a lot of patients and not an adequate number of staff to provide real safe care." The US stated "I probably made them feel very uncomfortable. They just turned around and walked out." The US stated Patient 6 never went inside the L&D unit and stated "I saw them walk out the doors and leave." The US stated "It was inappropriate and I know it. I should've just taken them back to a room." During the interview the US stated that he/she had been working in the hospital's L&D for about 2 1/2 years. The US stated he/she never received any EMTALA training from the hospital.

Hospital video footage recording around the time frame in which Patient 6 was reported to have presented to the hospital was reviewed with the Regional Director of Hospital Quality Management on 08/26/2015 at 1730. The video recording was of the area outside of the entry doors to the L&D. The video recording reflected that at 2156 Patient 6 and another person walked through the entry doors and into the hospital. The video recording reflected that approximately 4 minutes later, at 2200, Patient 6 and the other person exited the building.

Mapquest reflects KWMC in Hillsboro, Oregon is 26 miles and 32 minutes drive time from KSMC in Clackamas, Oregon.

7. The Hospital Compliance Officer and Quality and Patient Safety Managers and staff were interviewed on 09/23/2015 at 1200 regarding a report of a potential EMTALA violation involving Patient 23 on 08/28/2015. A document titled "EMTALA issue at KSMC ED on August 28, 2015" was reviewed and reflected that Patient 23 spoke to a registration clerk upon entry to the ED and reported complaints of fever, headache and cough. The document reflected that the registration clerk directed Patient 23 to go to an off-campus Kaiser clinic and the patient left the ED.

"Event" documentation reviewed dated 09/16/2015 additionally reflected "Camera footage at Kaiser Sunnyside does confirm that this allegation is true."

Review of the ED central logs revealed no log entries to reflect that Patient 23 had presented to the hospital for emergency services on 08/28/2015.

There was no evidence of a medical record or any other documentation to reflect that Patient 23 had presented to the hospital for emergency services on 08/28/2015.

Video footage recorded on 08/28/2015 around the time Patient 23 was reported to have presented to the ED was reviewed with hospital staff on 09/23/2015 at 1200. The video reflected that an individual identified by staff as Patient 23 entered the ED at 1010, presented to the ED registration desk at 1011 and had an interaction with the registration clerk, and then left the desk and exited the hospital approximately 30 seconds later.

During interview with the Hospital Compliance Officer on 09/23/2015 at 1215 he/she stated that the registration clerk on duty on 08/28/2015 when Patient 23 presented had been interviewed and the clerk had claimed that he/she could not recall this patient or event.

8. The Hospital Compliance Officer and Quality and Patient Safety Managers and staff were interviewed on 09/23/2015 at 1230 regarding a report of a potential EMTALA violation involving Patient 24 on 09/11/2015. A document titled "EMTALA issue at KSMC ED on September 11, 2015" was reviewed and reflected that Patient 24, who was 38 weeks pregnant, presented to the ED, was triaged by an RN, and was then directed by a registration clerk to drive to the L&D.

"Event" documentation reviewed dated 09/16/2015 additionally reflected "Pregnant patient (38 weeks) presented to the ED at [KSMC] with complaint of red rash covering body that caused severe itching and pain on 9/11/2015. Patient was directed to leave ED and drive to L&D after being registered and triaged in the ED...The medical record reflects a delay in getting this patient treated. The patient did not receive a medical screening exam in the ED."

Review of the ED central logs revealed no log entries to reflect that Patient 24 had presented to the ED on 09/11/2015.

Review of the ED medical record for Patient 24 reflected that the pregnant patient arrived at the hospital on 09/11/2015 at 1704 in a "Car" and had complaints of a rash all over his/her body. The ED record reflected that the patient was triaged by an RN at 1713. At 1723 the RN wrote that he/she "Called L&D. They want patient in their department." The record reflected that at 1728 the RN recorded "Nurse Discharge." The record reflected that Patient 24 was discharged on 09/11/2015 at 1728. The "Discharge Disposition" was recorded as "Home Or Self Care." The "Discharge Destination" and "Discharge Provider" were both recorded as "None." There was no documentation in the record to reflect that the patient was evaluated by a physician in the ED, no documentation to reflect what directions were given to the patient, no evidence that arrangements were made to transport the patient to the L&D, and no documentation to reflect why the patient's disposition was recorded as "Home."

Video footage recorded on 09/11/2015 around the time Patient 24 was reported to have presented to the ED was reviewed with hospital staff on 09/23/2015 at 1245. The video reflected that an individual identified by staff as Patient 24 entered the ED with at least one other individual at 1705, presented to the ED registration desk at 1707, had an interaction with the registration clerk and proceeded to the waiting area at 1711, left the waiting area and proceeded to the triage room at 1717, left the triage room and proceeded back to the waiting area at 1724, left the waiting area and proceeded to the registration desk at 1736, had an interaction with the registration clerk and left the ED at 1737.

The video footage was not consistent with the documentation in the ED record. Whereas the RN documented that the patient was discharged from the ED at 1728, the video footage reflected that the patient did not leave the ED until 1737.

The RN on duty when Patient 24 presented to the ED on 9/11/2015 was interviewed on 09/23/2015 at 1425. The RN confirmed that he/she triaged Patient 24 who was 38 weeks pregnant and had presented with a worsening rash. The RN stated that after the triage exam he/she called the L&D and was told that the patient was supposed to be seen there. The RN did not recall who in the L&D he/she spoke to. The RN indicated that he/she discharged the patient in the computer, then left the triage room and couldn't find the patient. The RN stated that she did not know where the patient went or what happened to her and that she didn't ask registration staff and didn't call the L&D, and that he/she continued on with his/her duties. The RN confirmed that usually a pregnant patient would be escorted from the ED to the L&D by an RN.

During interview with the Hospital Compliance Officer on 09/23/2015 at 1215 he/she stated that the registration clerk on duty on 09/11/2015 when Patient 24 presented had been interviewed. A report of the interview titled "Interview Questions for [registration clerk]," dated 09/22/2015, was reviewed. The report reflected that the clerk recalled Patient 24 and that the patient was seen by the RN. In regards to the patient's disposition from the ED to L&D the report reflected that the clerk "offered the patient a wheelchair or that [he/she] can drive [to L&D]...told them that [he/she] can be taken in wheelchair, but 'if you don't want to go by wheelchair, then can drive'...tries to prevent them from walking. If don't want to go by wheelchair, then driving car may be better. Nurse escort by wheelchair is preferred...Will tell them that L&D is on opposite side of building so they can be taken in a wheelchair."

The route from the outside ED entrance to the outside L&D entrance was driven on 09/23/2015 and was determined to be one half of a mile.

During interview with the ED Nurse Manager on 09/11/2015 at 1015 he/she stated that if a patient more than 20 weeks pregnant presents to the ED with primarily a medical problem generally the RN would call the L&D and the patient would be transported by an RN to the L&D for the MSE and treatment.

Review of a L&D medical record for Patient 24 reflected that he/she arrived at the L&D as a "Walk-in" on 09/11/2015 at 1740, 12 minutes after begin discharged from the ED. "Admission Type" was recorded as "Urgent." The L&D record reflected that Patient 24 received a MSE in the L&D and was discharged from L&D on 09/11/2015 at 1955.

Based on interview, review of medical records for 7 of 7 patients who presented to the hospital with an EMC and who were transferred to other facilities (Patients 4, 12, 13, 14, 20, 21 and 22), and review of policies and procedures, it was determined that the hospital failed to enforce its policies and procedures to ensure that the physician certification that the benefits of the transfer outweighed the risks of transfer were individualized and documented for each patient.

Findings included:

1. Review of the hospital's policy and procedure titled "Transfer of Patient to Another Facility: EMTALA", dated as issued "08/08" and revised on "10/12" and "07/15", reflected "If the patient has an emergency medical condition which is not stabilized, the patient may not be transferred unless either the patient requests the transfer or the physician caring for the patient certifies the benefits from the transfer outweigh the risks of the transfer...Transfers must be carried out according to the following guidelines...The emergency physician and/or specialty consult responsible for the individual must determine whether, at the time of transfer being considered, the individual's medical condition is "stabilized," i.e., that within reasonable medical probability, the transfer will not result in a material deterioration in, or jeopardy to, the medical condition or expected chances for recovery of the individual (or, with regard to a woman in labor, that the woman has already delivered her baby, including the placenta)...An individual who has a medical condition which is not stabilized may not be discharged or transferred for any reason unless one of the following conditions is met...Request for transfer or discharge from patient or legal representative of the patient. ..The physician caring for the patient certifies the benefits for the transfer outweigh the risks of the transfer...If the physician signs the certification for transfer of an unstable individual, the physician must denote in the chart the exact reason the individual is being transferred, the basis for certification of the transfer, and that the risks and benefits were discussed with the individual and/or responsible legal representative, and recorded. The chart note summarizing the basis for the physician certification for the transfer must give a complete picture of the benefits to be expected from appropriate care at the receiving facility and the risks associated with the transfer, including the time for the transfer...All sections of the Transfer Form must be completed prior to transfer of the patient and a copy of the form must be sent with the patient along with copies of the patient's medical record."

2. The ED record for Patient 14 was reviewed. Documentation on the "IP Encounter Report" reflected the patient presented to the ED on 03/06/2015 at 1252 and the patient's acuity was "3 Urgent."

The RN notes dated 03/06/2015 at 1257 reflected "pt is type 1 dm that had a burn to R foot. on abx but clinic thinks [he/she] is not doing well on abx regiment (sic) now. sent over for further tx."

Physician notes dated 03/06/2015 at 1424 reflected "Patient was trying to fix radiator in truck Saturday and a bunch of radiator fluid filled [his/her] boot. Extreme pain...erythema has spread, pain is worse today..."

A physician consult note dated 03/06/2015 at 1911 reflected "...[patient] seen in consultation for "cellulitis and split thickness burn injury...Upon seeing the leg, I was struck by the severity of the situation and called Plastics immediately...there appeared to be dead tissue, this was all over the ankle, and I felt the best place for [him/her] would be the [another hospital] burn unit..." The physician "Recommendations for Today" reflected "Discussed with ED MD that both my and Plastic Surgery recommendation for this patient is that [he/she] be transferred to the Burn Unit at [another hospital]...I will cancel my admit order."

The RN notes dated 03/06/2015 at 2300 reflected "Patient care report to...Burn center at [another hospital]...Patient transferred via [ambulance]."

There was no transfer form in the record. There was no documentation to reflect that a physician had signed a certification that the medical benefits outweighed the increased risks of transfer in accordance with the hospital's policy.

This was confirmed during an interview conducted with the ED Nurse Manager on 08/28/2015 at 1020.

3. The ED record for a pediatric patient, Patient 13 was reviewed. Documentation on the "IP Encounter Report" reflected the patient presented to the ED on 08/06/2015 at 2019 and the patient's acuity was "2 Emergent." The "Arrival Complaint" was "penny stuck in throat."

The record reflected the patient received a MSE. Physician notes dated 08/06/2015 at 2307 reflected Quarter swallowed and stuck in upper throat...CXR showed quarter in the [throat]." The "ED course" section of the physician note reflected "Attempted to manipulate...Unable to get out w initial attempt...sedated...and still unable to dislodge the [foreign body]...Repeat xray showed no change in position..." The "Disposition and Follow-up Plan" reflected "Children's Hospital [another hospital]..."

The RN notes dated 08/06/2015 at 2358 reflected "Pt being transferred to [another hospital]...via [ambulance]."

A form titled "Transfer Form" was reviewed. The top of the form reflected "All Sections Must be Completed Prior to Transfer of the Patient." The form was signed and dated by a physician on 08/06/2015, but not timed by the physician. The form reflected the "Patient's condition/diagnosis" was "Foreign Body Esophagus." In the "Risks of Transfer" section, there was a checkmark in the checkbox preceding the generic language "Additional time delay in receiving treatment."

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

4. The ED record for a pregnant patient, Patient 4 was reviewed. Documentation on the "IP Encounter Report" reflected the patient presented to the hospital on 04/25/2015 at 1403. The "Admission Type" was documented "Urgent."

The record reflected the patient received a MSE. Physician notes dated 04/25/2015 at 1428 reflected "...[Patient] presents to Labor and Delivery at 28 [weeks] 2 [days] with gross PPROM since 6:30AM today. [Patient]...arrives reports leaking fluid just walking into the unit. Gross ROM confirmed on arrival.

The RN notes dated 04/25/2015 at 1440 reflected "Pt arrives to L&D with ROM from approximately 0745 this am...[Physician] at the bedside to evaluate and develop a plan for transfer of care to [another hospital].

The RN notes dated 04/25/2015 at 1548 reflected "[Ambulance] Transport team arrived at 1540...Pt to be transported via ambulance with antibiotics infusing." The record reflected the patient was transferred on 04/25/2015 at 1545.

A form titled "Transfer Form" was reviewed. The form was signed and dated by a physician on 04/25/2015, but not timed by the physician. The form reflected the "Patient's condition/diagnosis" was "PPROM." In the "Risks of Transfer" section, there was a checkmark in the checkbox preceding the generic language "Additional time delay in receiving treatment."

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

5. The ED record for a pediatric patient, Patient 12 was reviewed. Documentation on the "IP Encounter Report" reflected the patient presented to the ED on 08/05/2015 at 2331 and the patient's acuity was "3 Urgent." The "Arrival Complaint" was "abdominal pain, vomiting."

Physician notes dated 08/06/2015 at 0035 reflected "...[Patient's] abdominal pain is concerning for an acute abdomen...I am most concerned about appendicitis vs perforated appy. Will start transfer process to [another hospital], get IV access and initial labs...[family member] (who is a physician) wanted to drive by [private vehicle] and did not want ambulance transfer. [He/she] also did not want to wait to draw labs or establish IV and medications for pain or fluids prior to leaving."

A form titled "Transfer Form" was reviewed. The form was signed and dated by a physician on 08/06//2015, but not timed by the physician. The form reflected the patient was transferred to another hospital on 08/06/2015 at 0114 by private vehicle. The "Patient's condition/diagnosis" was "abdominal pain suspected appy." In the "Risks of Transfer" section, there were checkmarks in the checkboxes preceding "Additional time delay in receiving treatment," "Deterioration of medical condition," and "Other traffic accident."

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

6. The ED record for pediatric patient, Patient 20 was reviewed. The record reflected an "Adm Date and Time" of 07/11/2015 at 1923. The record reflected the patient received a MSE. Physician notes dated 07/11/2015 at 2119 reflected "...[Patient] here for intermittent severe abdominal pain x 1 week much worse and constant tonight...intermittent vomiting. Pt not eating today...[ultrasound] done finding [positive] for intussusception...discussed with pediatric surgery and pediatric ER at [another hospital]...and accepted for transfer to the ER at [other hospital] for further eval...Pt transferred via ALS ambulance."

A form titled "Transfer Form" was reviewed. The form was signed and dated by a physician on 07/11/2015, but not timed by the physician. The form reflected the "Patient's condition/diagnosis" was "intussusception." In the "Risks of Transfer" section, there were checkmarks in the checkboxes preceding the generic language "Additional time delay in receiving treatment" and "Deterioration of medical condition."

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

7. The ED record for a pediatric patient, Patient 21 was reviewed. Documentation on the "IP Encounter Report" reflected the patient presented to the ED on 07/18/2015 at 0042 and the patient's acuity was "3 Urgent." The "Arrival Complaint" was "change of mental status, unable to focus, glassy eyes."

The record reflected the patient received a MSE. Physician notes dated 07/18/2015 at 0342 reflected "...[Patient] is a 15 mos [male/female] who presents to the Emergency Department complaining of altered mental status..." The "Initial Assessment and Plan" section of the physician notes reflected "...UDS [consistent with] cannabinoid exposures...[another hospital], accepted in transfer for further evaluation and observation re: AMS and laboratory abnormalities, concern for additional coingestants. EMS transport...Family refusing EMS transport based on financial concerns. Will go to [another hospital] by private vehicle."

A form titled "Transfer Form" was reviewed and was signed and dated by a physician on 07/18/2015, but not timed by the physician. The form reflected the patient was transferred to another hospital on 07/19/2015 at 0405. The "Patient's condition/diagnosis" was documented as "Altered Mental Status, Metabolic Acidosis." The "Transportation/Care" was identified as "Other Private Vehicle (per request)." In the "Risks of Transfer" section, there were checkmarks in the checkboxes preceding "Additional time delay in receiving treatment" and "Deterioration of medical condition."

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

8. The ED record for a pediatric patient, Patient 22 was reviewed. Documentation on the "IP Encounter Report" reflected the patient presented to the hospital on 11/23/2014 at 1724 and the patient's acuity was "3 Urgent." The "Arrival Complaint" was "abd pain, vomiting after eating."

The record reflected the patient received a MSE. Physician notes dated 11/23/2014 at 1900 reflected "...[Patient] presents with nausea and vomiting since about 1400 this afternoon with an extensive history of bowel obstruction due to multiple operations on [his/her] bowels. Pt is actively vomiting upon arrival with diffuse tenderness throughout [his/her] abdomen...Parents state that this is typical presentation during an obstruction."

A form titled "Transfer Form" was reviewed and was signed and dated by a physician on 11/23/2014, but not timed by the physician. The form reflected the patient was transferred to another hospital on 11/23/2014 at 2105. The "Patient's condition/diagnosis" was documented as "[small bowel obstruction]." The "Transportation/Care" was identified as "Other Private Vehicle, parents request." In the "Risks of Transfer" section, there was a checkmark in the checkbox preceding "Additional time delay in receiving treatment."

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

This was confirmed during an interview conducted with the ED Nurse Manager on 08/28/2015 at 1030. The ED Nurse Manager stated "I don't see any individual risks."