HospitalInspections.org

Based on observation, interview, review of a transfer center audio recording and documentation for 2 of 9 transfer center calls from other hospitals seeking to transfer patients to LEMC (Patients 21 and 29), review of documentation in 2 of 4 medical records of patients for whom the central log reflected were transferred from LEMC ED to another hospital (Patients 8 and 9), review of central log documentation, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and enforce EMTALA policies and procedures to ensure compliance in the following areas:
* Recipient hospital responsibilities;
* On-call physician responsibilities;
* Appropriate transfers of patients;
* Maintenance of a central ED log; and
* Required posting of EMTALA signs.

Findings included:

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

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

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

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

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

37081

Based on observation, interviews, and review of policies and procedures it was determined the hospital failed to ensure that EMTALA signage was posted conspicuously in those places that could be seen by all individuals, including women in labor, who enter the emergency department, and by those who wait for examination and treatment in areas other than the traditional department. EMTALA signage was only posted at the main ED registration area and was not posted in any other ED waiting or treatment area, not in the pediatric ED, nor in L&D.

Findings include:

1. A tour of the LEMC pediatric ED was conducted on 05/19/2016 beginning at 1040 with the RCH Nurse Executive, Director of Pediatric Critical Care, and RCH ED Manager. Staff present during the tour indicated that the ED had a waiting area, reception area, triage area, one primary ambulatory entrance, one separate ambulance entrance, 22 treatment rooms, 2 seclusion rooms, 1 isolation room, and 4 trauma rooms.

Observations during the tour revealed that there were no EMTALA signs posted at either entrance, in any waiting areas, in any treatment rooms, or anywhere else in the department. These observations were confirmed with the management staff present during the ED tour.

2. A tour of the L&D department was conducted on 05/19/2016 beginning at 1133 with the L&D Nurse Manager. The Nurse Manager confirmed that patients may present to L&D from the ED, or directly to the L&D department upon arrival. The tour included but was not limited to observations made in the one and only patient entrance to L&D, the L&D family waiting area, triage room, and one LDR room. No EMTALA signage was observed during the tour.

During the tour the Nurse Manager stated, "I know exactly what sign you are talking about, and I haven't seen any since I started here."

3. A tour of the LEMC adult ED was conducted on 05/19/2016 beginning at 1105 with the ED Nurse Manager, Assistant Nurse Manager, and the Trauma Program Manager. Staff present during the tour indicated that the ED had 2 ambulatory entrances, 1 ambulance entrance, 29 treatment rooms, 4 seclusion rooms, 4 isolation rooms, and 4 trauma rooms.

Observations during the tour revealed that there was one EMTALA sign posted at the registration desk in English and Spanish, and one similar sign posted on the wall amongst other signs next to the registration desk. The sign was posted at a height that required a person to stand close to the wall with head tilted back in order to read it, even doing so it was not easily readable. There were no other signs observed in any other areas or rooms in the ED. Staff present during the tour confirmed that those were the only two signs in the department.

On 05/20/2016 at 1640 the Accreditation and Clinical Compliance Coordintor reported that LEMC staff had measured the EMTALA sign posted on the wall near the ED registration desk to be approximately 11X14 inches in size, and the distance from the floor to the bottom of the 14 inch tall sign was measured to be six foot and one inch.

4. Review of the hospital's EMTALA policies and procedures revealed no reference to the posting of EMTALA signs.

5. During an interview on 05/20/2016 at 1200 with the Accreditation and Clinical Compliance Coordinator it was confirmed that the hospital's EMTALA polices and procedures contained no reference to the required posting of EMTALA signs. No such policies and procedures were provided during the survey.

Based on interview, review of a transfer center audio recording and documentation for 2 of 9 transfer center calls from other hospitals seeking to transfer patients to LEMC (Patients 21 and 29), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to enforce its 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 on-call physicians refused to provide phone consultation, refused to come into the hospital, and declined to accept patients from other hospital EDs for whom LEMC had capability and capacity to treat.

Based on interview, review of documentation in 1 of 4 medical records of patients for whom the central log reflected were transferred to another hospital (Patient 9), review of central log documentation, and review of policies and procedures, it was determined the hospital failed to develop and enforce EMTALA policies and procedures to ensure maintenance of a central log that contained accurate information about the disposition of each patient who presented to the hospital for emergency services.

Findings included:

1. Refer to the findings identified under Tag A2409, CFR 489.24(e) that reflects for Patient 9 the central log disposition was not accurately documented. The log reflected that a 4 year old Patient 9 was transferred to another hospital, however, the medical record reflected the patient was formally discharged. The parents of the child were provided with written discharge instructions and were directed by ED staff to drive the child to another hospital.

Based on interview, review of documentation in 2 of 4 medical records of patients for whom the central log reflected were transferred from LEMC ED to another hospital (Patients 8 and 9), review of central log documentation, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and enforce EMTALA policies and procedures to ensure that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved:
* Transfers were conducted for further examination and observation where LEMC had the capability and capacity to provide the further examination and observation;
* Physician certification of medical benefits vs risks was not documented;
* Appropriate transportation was not utilized;
* Medical records were not sent.

Findings include:

1. The central log for Patient 8 reflected that he/she presented to the ED on 04/21/2016 at 0941 and was "Transferred to Another Facility" on 04/21/2016 at 1238.

The demographics, admission and discharge information section of the ED medical record of Patient 8 reflected that he/she presented to the ED on 04/21/2016 at 0941 by ambulance with a chief complaint of nausea. The discharge date and time was recorded as 04/21/2016 at 1238, the discharge disposition was recorded as "[Discharge] to home or self care," and the discharge destination was recorded as "Home."

ED Physician J filed the following note on 04/21/2016 at 2327: "History: ...54 y.o...presenting to the ED by EMS with complaints of nausea and vomiting over the last couple of days...To EMS [he/she] has complaints of CP...Also has complaints of a HA...[He/she] does have new lateral neck pain. 09:57 RN at bedside when pt began having an atypical appearing tonic clonic sz...Primary Associated Symptoms: Positive For: headaches (chronic, unchanged), chest pain, neck pain (lateral), nausea and vomiting...ED Course: 54 y.o...with hx of seizures here with cough, nausea, and vomiting. Unable to take [his/her] meds for 3 days given [his/her] emesis. Pt had a seizure once roomed here...tachycardic and hypertensive. Rhonchi noted bilaterally...BP 229/83...DDX includes, but is not limited to: PNA, meningitis, intracranial hemorrhage, brain mass, medication non-compliance, viral illness, amongst others. Labs as ordered. Will also check head CT...EKG with U wave concerning for hypokalemia...11:15 CT head with left parietal low-density changes concerning for occult lesion. Review of records shows that [his/her] last head CT was in 6/2015 and was normal. Will obtain MRI to evaluate further...11:25 Spoke to [Kaiser hospital physician] from Kaiser regarding further workup here vs transferring. [Kaiser physician] accepts [Patient 8] for transfer, and would prefer transfer occur now for MRI at Kaiser rather than further workup at Emanuel. Meningitis not ruled out at this time, although no fever or neck pain to support this diagnosis at this time. Will defer consideration of LP until after MRI given concern for mass lesion. 11:33 Pt updated on the plan. [He/she] is agreeable to transfer and MRI at Kaiser. [He/she] continues to be hypertensive...Head CT here remarkable for possible mass effect of L parietal area, pt without antecedent AMS or weakness prior to seizure to suggest clinical hx consistent with stroke. Will plan for transfer to Kaiser pending MRI confirmation of head CT...Diagnosis and Disposition: 1. Convulsions...2. Nausea and vomiting...3. Brain Mass."..

The head CT report reflected the exam was conducted on 04/21/2016 at 1047. The "Impression" was "Left parietal low-density changes worrisome for underlying occult lesion. Consider also left watershed distribution ischemic changes. MRI is recommended for further evaluation." The report was authenticated by a physician on 04/21/2016 at 1111.

There was no evidence to reflect that an MRI was conducted at LEMC.

The Patient Transfer form reflected that the "Reason for Transfer" was "Kaiser insurance." The "Benefits" of the transfer were recorded as "insurance benefits...Personal physician can care for at receiving hospital...Health insurance coverage will be better at receiving hospital." There were no medical benefits identified. The "Risks" of the transfer were recorded as "recurrent seizure, MVC." ED Physician J signed the "Provider Certification...I certify that the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risk, if any, to the individual's medical condition from being transferred." The certification was dated as 04/21/2016. The "Transfer Consent" section of the form read: "I acknowledge that my medical condition has been evaluated and explained to me by the physician who has recommended that I be transferred..." The consent was signed by the patient but not dated or timed. The "Transfer Demand" section of the form contained language for a patient to sign to indicate that they requested and insisted on a transfer to another hospital. That section was blank.

The untitled list of services provided by LEMC confirmed that the hospital provides and conducts extensive imaging services, including MRI.

Although an EMC for Patient 8 had not been ruled out or resolved, and LEMC had the capability to provide an MRI for further examination, the record reflected that the LEMC ED Physician J initiated a transfer to another hospital solely for insurance purposes. There was no documentation in the record to reflect that the patient had initiated the request for a transfer to another hospital.

No additional information about the inappropriate transfer of this patient for insurance purposes was provided during the survey.

2. The central log for Patient 9 reflected that he/she presented to the pediatric ED in LEMC RCH on 04/22/2016 at 0757 and was "Transferred to Another Facility" on 04/22/2016 at 1223.

The demographics, admission and discharge information section of the ED medical record of 4 year old Patient 9 reflected that he/she presented to the pediatric ED on 04/22/2016 at 0757 via a car with a chief complaint of seizures. The discharge date and time was recorded as 04/22/2016 at 1223, the discharge disposition was recorded as "Children's Hospital Or Cancer Ctr (Doernbecher, Randall, Knight Cancer Institute)" and the discharge destination was recorded as "Other."

ED Physician H filed the following note on 04/22/2016 at 1704: "History: 4 y o [child] here with [parents]. [Parent] is a NP - states heard a thud in [child's] room, arrived and [child] was seizing. R side only and lip smacking. Duration 2-5 min. 'Foaming at mouth' but no emesis. On arrival EMS, sz ceased. Now with headache and nausea...Positive for nausea and abdominal pain...R UE with intermittent 'ratcheting' movements...plan for CT and labs and neuro consult..8:38 AM RN reports that when IV went in, R hand twitched rhythmically for a few beats...CT is nl. Labs are normal...9:41 AM discussed with [Pediatric Neurologist I]. Recommends obs here, OP EEG...10:34 AM...Still with stuttering R arm when [he/she] raises it or tries to push buttons on the side of the bed...1138 AM Spoke with [Kaiser physician], Kaiser Hospitalist. Discussed my concern about continued R arm findings. [He/she] called back, with recommendation that pt be observed at OHSU for an additional few hours. No bed available now but expect one in a few hours. Suggest parents go home, pick up overnight items and go to DCH. Pt discharged from [pediatric ED] with plan for obs at DCH later today...Diagnosis and Disposition: New onset sz To DCH for further observation."

The head CT report reflected the exam was conducted on 04/22/2016 at 0820. The "Impression" was "Unremarkable unenhanced brain CT. Consider MRI of the brain with contrast for further workup of seizure focus." The report was authenticated by a physician on 04/22/2016 at 0855.

A note recorded by ED Physician H on 04/22/2016 at 1211, under the discharge instructions section of the ED record reflected "To OHSU for admission."

An RN note recorded on 04/22/2016 at 1219 reflected "IV wrapped with coban for discharge from our ER to go to OHSU admitting. [OHSU physician] from OHSU states no bed are available at this time, [OHSU physician] wants [parents] to go home and [OHSU physician] will call and tell them when to come to OHSU to be admitted for EEG today."

An RN note recorded on 04/22/2016 at 1223 reflected that discharge instructions were reviewed with the parents and that the patient "Has ride home; with parents."

The After-Visit Summary or discharge instructions reflected that it was generated on 04/22/2016 at 1224. Page 2 of the 4 page form was titled Discharge Instructions and the only verbiage recorded on that page was "To OHSU for admission." There were no other discharge instructions, precautions, or other relevant information related to the intact IV access and the reason the patient was seen in the ED.

A note recorded by ED Physician H recorded on 04/22/2016 at 1500 reflected "called [parent] to check in. Patient with no bed assigned as yet but in EEG."

There was no evidence of a transfer form or a certification by Physician H that reflected the medical benefits of transfer to OHSU outweighed the risks. There was no evidence that medical records were sent to OHSU. There was no evidence that appropriate transportation was used.

The untitled list of services provided by LEMC confirmed that the hospital provides pediatric neurology services.

During an interview with staff present at the time of the electronic record review on 05/20/2016 at 1520 they confirmed that LEMC provides pediatric neurology services and conducts EEGs.

During an interview on 05/23/2016 at 1530 the RCH ED Manager stated that the practice demonstrated in the record of Patient 9 is "consistent with Kaiser patients."

Although an EMC for Patient 9 with new onset seizures had not been ruled out or resolved, and LEMC had the capability to provide observation services and an EEG for further examination, the record reflected that the LEMC ED Physician H "transferred" the patient by discharging the 4 year old, with IV access in place, to the care of his/her parents and instructed the parents to transport the child to another hospital. There was no transfer form, no physician certification that benefits outweighed the risks, no evidence that medical records were sent, and appropriate transportation was not provided. There was no documentation in the record to reflect that the patient's parents had initiated the request for a "transfer" or discharge to another hospital.

No additional information about the inappropriate "transfer" of this patient was provided during the survey.

3. During an interview on 05/20/2016 at 1200 the Accreditation and Clinical Compliance Coordinator stated that the Director of Medical Staff Services had reported that EMTALA training has not been provided to any of the medical staff.

4. The hospital's policy and procedure titled "Medical Screening Examination; EMTALA Requirements" dated as originated "06/93" and last reviewed "04/16" was reviewed. The purpose and policy was described as related to the provision of MSEs. However, it contained the following verbiage related to transfers: "'Transfer' means the movement of an individual outside a hospital's facilities at the direction of any person employed by, affiliated with or associated with the hospital, but does not include such a movement of an individuals who (i) has been declared dead, or (ii) leaves the facility without the permission of any such person...The Legacy Facility shall provide, within the capabilities of the staff and facilities available, further examination and treatment required to stabilize the patient's medical condition...Necessary stabilizing treatment will not be delayed in order to obtain insurance or payer information or seek prior authorization...If the Legacy Facility does not have the capability to provide necessary stabilizing treatment for the patient, the Legacy Facility may transfer the patient to another medical facility which has the capability to provide the required treatment and has accepted the patient. All relevant sections of the Patient Transfer Form must be completed to ensure that the transfer is an 'appropriate transfer.'"

There were no other EMTALA policies and procedures related to appropriate transfers, and Medical Staff Rules and Regulations lacked requirements related to EMTALA transfers.

5. During an interview on 05/20/2016 at 1640 with the Accreditation and Clinical Compliance Coordinator it was confirmed that no other policies and procedures related to appropriate transfers as required under EMTALA could be located. No such policies and procedures were provided during the survey.

Based on interview, review of a transfer center audio recording and documentation for 2 of 9 transfer center calls from other hospitals seeking to transfer patients to LEMC (Patients 21 and 29), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and enforce EMTALA policies and procedures to ensure 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 Legacy One Call Transfer Center Manager was interviewed on 05/19/2016 at 1600. He/she described the system for capturing phone calls from other hospital EDs seeking to transfer patients to LEMC and indicated that an electronic database of the calls is maintained. The Manager stated that the calls are recorded and are saved for 30 days. He/she further stated that there is an "unspoken rule" that when the physician from the calling hospital is connected with the LEMC physician an "intake" is created. The electronic intake is a record of the details of the call, and includes all incoming and outgoing calls related to the specific request originating from the calling hospital. He/she further stated that intakes are not created consistently for all calls. He/she stated that it was his/her practice to generate an intake for each call, but staff haven't been trained to do that consistently.

2. An untitled log identified as the One Call Center log for the time period of 02/01/2016 through 05/18/2016 was reviewed. The log entries reflected calls received from other hospitals seeking to transfer patients to LEMC. The log reflected 26 calls from other hospitals where transfers were declined by LEMC during that time period and one call where a phone consult was declined.

3. On 05/19/2016 at 1620 the Legacy One Call Transfer Center Manager played an audio recording of a One Call Center phone call from PPMC ED staff to LEMC to request transfer of Patient 29. The Manager indicated that the recording reflected that PPMC staff called the One Call Center on 05/03/2016 at 0551. PPMC staff, on behalf of PPMC ED Physician K, requested to speak with a LEMC OMFS physician about transfer of a patient who was assaulted and had facial mandible fractures. The One Call Center staff person reported to the PPMC staff person that he/she would contact the physician on-call and call PPMC back. The recording then revealed that LEMC on-call OMFS Physician B called the One Call Center back within a few minutes. Following is the call transcribed from this point through the end between the One Call Center staff and OMFS Physician B:

One Call Center staff: "Hi, so I have [physician] from Portland Prov ED who wants to talk to you...about a patient that might need to be transferred over. Do you want any..."

OMFS Physician B: "Oh, uh is it is Portland?" (sic)

One Call Center staff: "I'm sorry, what was that?"

OMFS Physician B: "It's a ED patient?"

One Call Center staff: "Over at Portland Prov, yes."

OMFS Physician B: "Yeah, uh...we don't...we don't cover Portland Prov anymore."

One Call Center staff: "Oh, you guys don't?"

OMFS Physician B: "No."

One Call Center staff "Oh, ok."

OMFS Physician B: "Thank you."

One Call Center staff: "Thank you, bye."

OMFS Physician B: "Bye."

That was the end of the recording.

This call was not found on the One Call Center log, nor was there a corresponding "Legacy One Call Center Intake Form."

4. A One Call Center Intake Form for Patient 21 was reviewed. The form reflected that a call from PAMC ED Physician A was received by the One Call Center on 02/10/2016 at 1647. The form reflected that the patient had "dog bite to face" and the transfer request reasons were identified as "level of care" and "specialty care." The form denoted that three LEMC physicians were paged to respond to the call and those calls were returned respectively at 1654 by LEMC General Surgeon C, at 1700 by LEMC ED Physician D, and at 1727 by LEMC OMFS Physician E. The form reflected that the "Transfer Status" was "Denied," and the "Denial reason" was "Physician Refusal." The time the last call ended was recorded as 1729. In the narrative section of the form the following was recorded: "Denied transfer. [General Surgeon C] was on another trauma call when this call came in, that was the delay in getting [him/her] on the line. [General Surgeon C] felt the patient did not warrant a trauma transfer, and recommended speaking with an ED MD. [ED Physician D] insisted that they speak with OMFS, despite the long-standing issues between Adventist and the OMFS group." The space on the form contained no room for additional electronic narrative at that point.

A second One Call Center Intake Form for Patient 21 was reviewed. The form reflected that another call from PAMC ED Physician A was received by the One Call Center on 02/10/2016 at 1826. The form reflected that the patient had a "dog bit to face" and additionally, a "lip amputation." The transfer request reasons were identified as "level of care" and "specialty care." The form denoted that two LEMC physicians were paged to respond to the call and those calls were returned respectively at 1832 by LEMC General Surgeon C and at 1838 by LEMC ED Physician G, resulting in LEMC acceptance of the patient as a transfer at 1842.

An email from the One Call Center Patient Placement Lead to the Accreditation and Clinical Compliance Coordinator dated 05/20/2016 at 0825 was reviewed and found to contain additional information and continuation of the narrative note on the first One Call Center Intake Form above for Patient 21. The email reflected "02/10/2016 at 1647: Portland Adventist ED called requesting transfer of a 21-year-old male with a dog bit to the face. [General Surgeon C], trauma surgeon on call, felt the patient did not warrant a trauma transfer, and recommended speaking with an ED MD. [ED Physician D], ED doc at EH, insisted that they speak with OMFS, despite the long-standing issues between Adventist and the OMFS group. [ED Physician D] said [he/she] would not accept the patient until [PAMC ED Physician A] from Adventist had spoken with OMFS. Paged [OMFS Physician E], OMFS. After the second page, [he/she] did respond, however [he/she] did refuse to speak with anyone at Portland Adventist. Adventist opted to try OHSU. Transfer denied.
Portland Adventist ED called back later at 1741, requesting transfer of a 21-year-old male with a dog bite to the face to [LGSMC]. Earlier, they called OHSU who declined the transfer due to no beds available. [Plastic Surgeon F], plastics on call at [LGSMC], declined to speak with Adventist because [he/she] believed they have their own Plastics service. Transfer denied.
Then, at 1826 the AOC at Adventist called to get [LEMC trauma] on the line for this patient. [PAMC ED Physician A] connected with [General Surgeon C], who agreed to accept the patient as a trauma transfer if all else fails, just to get the patient over. [He/she] expressed frustration at the waste of a trauma transfer for this. One Call interjected that would they (sic) be happy to try the ED MD Again, and connected [ED Physician G]. [Ed Physician G] was willing to accept the patient."

The first call from PAMC ED requesting transfer was made on 02/10/2016 at 1647. LEMC eventually accepted the patient in transfer at 1842, two hours after the original call and only after a PAMC AOC called LEMC. However, LEMC's initial transfer denials and physician refusals, including the OMFS Physician E's refusal to even speak to the PAMC physician, caused PAMC to have to contact two other hospitals and resulted in an unnecessary delay in an appropriate transfer for Patient 21.

5. During an interview on 05/20/2016 at 1200 the Accreditation and Clinical Compliance Coordinator stated that the Director of Medical Staff Services had reported that EMTALA training has not been provided to any of the medical staff.

6. The hospital's "Emergency Department Services Agreement" between LEMC and HNSA (the OMFS and related specialties) was signed and dated in May 2007. "Amendment No. 7" to the agreement was dated and signed 06/08/2015 and referred to a revised attached "Exhibit A." The attached "Exhibit A" stipulated that "HNSA shall arrange, schedule, and provide continuous and adequate coverage 24 hours per day, 365 days per year, for each of the following specialties: Oral maxillofacial surgery, Otolaryngology, Facial plastic surgery, Pediatric oral maxillofacial surgery, Pediatric facial plastic surgery. Such coverage shall include the provision of care to patients in the [ED], admitted through the ED, or accepted via emergent transfer. HNSA shall respond to a request from an ED physician for on-call services within thirty (30) minutes of the request, examine and treat patients referred to HNSA while on-call, regardless of payor or insurance status, and accept patients transferred from Legacy and non-Legacy hospitals for treatment of emergency medical conditions...HNSA shall ensure that all Emergency Services are properly performed by physicians, residents, and fellows who are employed by or under contract with HNSA."

7. Review of the hospital's EMTALA policies and procedures, and the Medical Staff Rules and Regulations, revealed no references to the hospital's obligations as a receiving hospital as required under EMTALA.

8. During an interview on 05/19/2016 at 1715 the Accreditation and Clinical Compliance Coordinator confirmed that although there was a training guide for the One Call Center employee training purposes, which was provided, there were no LEMC policies and procedures related to LEMC's obligations as a receiving hospital. No such policies and procedures were provided during the survey.



37081