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Based on interview, review of documentation in the medical records for 5 of 20 patients who presented to the hospital for emergency services (Patients 9, 10, 11, 12 and 16), and review of hospital policies and procedures, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure compliance in the following areas:
* On-call physician responsibilities;
* Appropriate transfers of patients; and
* Recipient hospital responsibilities.

Findings include:

1. 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)

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

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

Based on interview, review of documentation of a request from another hospital to transfer a patient to WVMC for specialty services (Patient 10), 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 for whom 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 WVMC's Surgical on-call specialty Physician C failed to accept Patient 10 in transfer from another hospital's ED for whom WVMC had capability and capacity to treat.

Based on interview, review of documentation in the medical records of 4 of 5 patients (Patients 9, 11, 12 and 16) who were transferred from WVMC to other hospitals for services not available at WVMC, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and 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:
* Physician certification of medical benefits vs risks were not documented or were not patient specific and individualized for Patients 9, 12 and 16.
* There was no documentation that patient medical records were sent to the receiving facility for Patient 11.

Findings include:

1. a. The policy and procedure titled "EMTALA - Transfer Policy" dated approved "8/30/2018" was reviewed. It reflected:

* "Each hospital must have written guidelines outlining the requirements for an appropriate transfer to another facility in accordance with federal and state laws. Any transfer of an individual with an Emergency Medical Condition must be initiated by a physician order with the appropriate physician certification."

* "The hospital may not transfer a patient with an Emergency Medical Condition that has not been stabilized unless ... a physician must have signed a certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual ... The certification form must list specific benefits to be expected from appropriate care at the receiving facility and specific risks associated with the transfer."

* "The certification form must list specific benefits to be expected from appropriate care at the receiving facility and specific risks associated with the transfer."

b. The policy and procedure titled "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions" dated approved "8/30/2018" was reviewed. It reflected:

* "Physician Certification refers to the pre-transfer written certification by the physician ordering the transfer, that based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual with an unstablilized emergency medical condition and, in the case of a woman in labor, to the unborn child, from effecting the transfer. The certification shall include a summary of the specific risks and benefits upon which the certification is based and the reason(s) for the transfer."

2. The ED record for Patient 9 reflected he/she presented to the ED on 09/25/2019 at 1115 with a chief complaint of "right side pain." The record reflected that the patient's course through the ED included the following:
* A MSE was started at 1152 by an MD with a resulting "Clinical Impression: Abdominal pain, Fever, Leukocytosis." The patient transfered to LEMC ED for pediatric surgical services not available at WVMC.
* On 09/25/2019 at 1623 the physician completed and signed the "EMTALA Transfer Record" for transfer to LEMC ED that contained the following entries:
-The "Risks And Benefits For Transfer: Medical Risks:" was recorded with 3 prechecked boxes that reflected: "Deterioration of condition in route, Worsening of condition or death if you stay here, and Risk of traffic delay/accident resulting in condition deterioration or death." The fourth checked box reflected the preprinted word "Other" with the word "death" handwritten next to it. There was no documentation of the risks of transferring to another facillity that were specific to the patient's medical condition.

* During interview with the EDM on 12/17/2019 at the time of Patient 9's medical record review, he/she confirmed there was no documentation of patient specific individualized risks of transfer for the patient.

3. The ED record for Patient 12 reflected he/she presented to the ED by police on 09/07/2019 at 0037 with a chief complaint of "Medical Clearance." The record reflected that the patient's course through the ED included the following:
* A MSE was started at 0040 by an MD with a resulting "Clinical Impression: Symptomatic sinus bradycardia, ST elevation, Seizure." The patient transfered to OHSU for neuro/cardiac ICU care not available at WVMC.
* On 09/07/2019 at 0200 the physician completed and signed the "EMTALA Transfer Record" form for transfer to OHSU that contained the following entries:
- The "Risks And Benefits For Transfer: Medical Risks:" section had 3 prechecked boxes that reflected: "Deterioration of condition in route, Worsening of condition or death if you stay here, and Risk of traffic delay/accident resulting in condition deterioration or death." The fourth box was also preprinted with the word "Other" with "death" handwritten next to it. There was no documentation of the risks of transferring to another facillity that were specific to the patient's medical condition.

* During interview with the EDM on 12/17/2019 at the time of Patient 12's medical record review, he/she confirmed there was no documentation of patient specific individualized risks of transfer for the patient.

4. The ED record for Patient 16 reflected he/she presented to the ED on 11/25/2019 at 0836 with a chief complaint of "Weakness." The record reflected that the patient's course through the ED included the following:
* A MSE was started at 0859 by an MD with a resulting "Clinical Impression: TIA (transient ischemic attack), Carotid stenosis, bilateral." The patient transfered to OHSU for vascular surgery services not available at WVMC.
* On 11/25/2019 at 2358 the physician completed and signed the "EMTALA Transfer Record" that contained the following entries:
- The "Risks And Benefits For Transfer: Medical Risks:" was recorded with 3 prechecked boxes that reflected: "Deterioration of condition in route, Worsening of condition or death if you stay here, and Risk of traffic delay/accident resulting in condition deterioration or death." There was no documentation of the risks of transferring to another facility that were specific to the patient's medical condition.

* During interview with the EDM on 12/17/2019 at the time of Patient 16's medical record review, he/she confirmed there was no documentation of patient specific individualized risks of transfer for the patient.

5. The ED record for Patient 11 reflected he/she presented to the ED on 09/11/2019 at 1730 with a chief complaint of "Seizure Disorder." The record reflected that the patient's course through the ED included the following:
* An MSE was started at 1730 by an DO with a resulting "Clinical Impression: Status epilepticus." The patient transfered to OHSU for neurology services not available at WVMC.
* On 09/11/2019 at 0859 the physician completed and signed the "EMTALA Transfer Record" form.
* The "Accompanying Documentation" section on the form was blank.
* There was no documentation on the transfer form or elsewhere in the record that reflected medical records were sent to the receiving facility.

* During interview with the EDM on 12/17/2019 at the time of Patient 11's medical record review, he/she confirmed there was no other documentation in the patient's chart to reflect that medical records were sent to the receiving facility.

Based on interview, review of documentation of a request from another hospital to transfer a patient to WVMC for specialty services (Patient 10), 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.

Findings include:

1. The policy and procedure titled "EMTALA - Duty to Accept" dated approved "08/30/2019" was reviewed. It reflected:

* "Recipient hospitals must accept the patient with the emergency medical condition only if he/she requires the specialized capabilities or facilities of the hospital. CMS views specialized capabilities very broadly to include the availability of on-call specialists who are not available at the transferring hospital."

* "Each hospital will develop a process for receiving a request for transfer, facilitating communication of the request to the appropriate parties and stakeholders, and escalating any potential inappropriate denial of a transfer. Each hospital should maintain a log of all transfer requests noting details about the request (e.g., what facility requested the transfer, when it was made) and information supporting any decisions to refuse to accept a transfer."

2. The policy and procedure titled "EMTALA - Provision of On-Call Coverage" dated approved "8/30/2018" was reviewed. It reflected:

* "The hospital is responsible for adopting and enforcing an EMTALA policy that ensures compliance with the requirements of EMTALA to maintain a list of physicians who are on call after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an "emergency medical condition." The medical staff bylaws or appropriate policy and procedure should define: the responsibility of on-call physicians to respond, examine and treat patients with emergency medical conditions; and actions to be taken when a practitioner fails to respond, including initiaition of chain of command."

* "Each facility must establish a process to ensure that when a physician is identified as being "On-Call" to the emergency department for a given specialty, it shall be the duty and the responsibility of that physician to assure the following: Immediate availability, at least by telephone, to the emergency department physician for his/her scheduled 'on-call' period, or to secure a qualified alternate in the event he/she is temporarily unavailable and notify the emergency department of the substitution."

3. The policy and procedure titled "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions" dated approved "8/30/2018" was reviewed. It reflected:

* Definitions: "Capabilities of a Hospital provider means the physical space, equipment, supplies and services (e.g., trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry), including ancillary services, available to Hospital patients. The capabilities of the Hospital's staff mean the level of care that the Hospital's personnel can provide within the training and scope of their professional licenses ... Capacity means the ability of the Hospital to accommodate the individual requesting examinaiton or treatment of the transferred individual when the individual needs to receive the emergency treatment. Capacity encompasses number and availability of qualified staff, beds, equipment and consideration of the Hospital's past practices of accommodating additional patients in excess of its occupancy limits. For example, a hospital may have capacity to provide orthopedic services, but may lack capacity to provide such services on an emergency basis, if there is no orthopedist on call on a specific day."

* "Emergency Medical Condition means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual ... in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part ..."

* "On-Call List refers to the list that the Hospital is required to maintain which identifies those physicians who are 'on-call', directly or by arrangement ... to provide further evaluation and/or treatment necessary to stabilze an individual with an Emergency Medical Condition. The purpose of the on-call list is to ensure that the emergency department is prospectively awre of which physicians, including specialists and sub-specialists, directly or by arrangement, are available to provide treatment necessary to stabilize individuals with Emergency Medical Conditions."

4. The "Medical Staff Bylaws, Policies, And Rules and Regulations Of Willamette Valley Medical Center" dated approved "June 2017" was reviewed. It reflected:

* "2.A.3. Responsibilities: Active Staff members must; assume all responsibilities of membership on the Active Staff, including ... providing specialty coverage for the Emergency Department ... accept inpatient consultations during those times when the member is providing coverage for the Emergency Department;"

* "9.B. Other Medical Staff Documents ... All Medical Staff policies, procedures, and rules and regulations shall be considered an integral part of the Medical Staff Bylaws."

5. The document titled "Willamette Valley Medical Center Specialty Roster" reflected "General Surgery," [Physician C]," "Active."

6. The specialty physician on-call list titled "Surgery - October 2019" reflected Physician C was scheduled for General Surgery call on 10/28/2019.

7. During interview and review of an "October 31, 2019 Event" document, with the CQO on 12/17/2020 at 1337, the CQO provided the following information related to WVMC's failure to accept Patient 10 for speciality surgery services.
* Physician C was credentialed on 01/01/2019 and had privileges for surgery services.
* The CQO confirmed that Physician C recieved a call from a PA at PNMC ED regarding Patient 10 who had a SBO. The PA requested to transfer the patient to WVMC for surgical evaluation and treatment of the SBO.
* Physician C stated that since he/she could not see xray images from home at this time, the patient might be better served at another facility.
* The CQO confirmed Physician C was on call for surgery services and did not accept the patient for transfer.
* Physician C did not speak with the surgeon from PNMC about the patient and Physician C did not consult with WVMC ED.
* WVMC did not have a transfer request log in place at the time of the request on 10/28/2019 in accordance with hospital policy.
* Physician C did not have access to radiological images from home due to his/her location and was unaware that he/she could access radiological images from other hospitals prior to accepting a transfer by contacting the on call Radiologist and having them request the images.
* WVMC had the capacity and capability to accept Patient 10 on 10/28/2019 for surgery services. However, the CQO confirmed WVMC did not accept the patient.

8. Review of the "WVMC Bed Control Log," the log that contained the record of transfer inquiries from other hospitals, revealed no entries for Patient 10 on 10/28/2019 as required by hospital policies and procedures. During interview with the CQO on 12/17/2019 at 1337, he/she confirmed the lack of documentation regarding Patient 10 on the transfer inquiry log. He/she stated the hospital did not have a transfer log on 10/28/2019 when PNMC requested to transfer Patient 10 to WVMC. He/she stated the transfer log was recently started and that the House Supervisors documented transfer requests and whether the patient was accepted for transfer or not, with the reasoning if not accepted.

9. Although WVMC had the capability and capacity to provide further exam and stabilizing treatment for Patient 10, on-call specialty Surgery Physician C failed to accept the patient for transfer to WVMC. Further, Physician C failed to ensure he/she had appropriate access and ability to review radiological imaging at home while on - call in accordance with the hospital's policies and procedures. During interview with CQO on 12/17/2019 at 1337, he/she confirmed Physician C could not view the radiological images because he/she "lives out in the country, and the expectation is that the physician will have acess to the images, come into the hospital or call radiology."