HospitalInspections.org

Based on observation, interview, review of documentation in the medical record of a pregnant patient who was having contractions and was transferred from WVMC to another hospital (Patient 16), review of documentation in the medical record of a critically ill pediatric patient with diabetes and vomiting who was transferred from WVMC to another hospital (Patient 15), review of documentation in 13 of 13 other medical records of patients who were transferred from WVMC to other hospitals for specialty services not available at WVMC (Patients 1, 2, 5, 9, 10, 11, 12, 13, 14, 17, 18, 19 and 20), 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:
* Appropriate transfers of patients.
* On-call physician responsibilities.
* Required posting of EMTALA signs.

Findings include:

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

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

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

Based on observations, interview, and review of policies and procedures it was determined the hospital failed to develop and enforce EMTALA policies and procedures to ensure that EMTALA signage was posted conspicuously in places and areas that could be seen by all individuals who presented to the hospital for emergency services, and where individuals waited for examination and treatment.

Findings include:

1. The policy and procedure titled "Emergency Screening, Stabilization and Transfers (EMTALA), dated as revised "1/06," was reviewed. It stipulated:
* "Signage Requirement...The Emergency Department and those places likely to be noticed by all individuals entering the Emergency Department, as well as those individuals waiting for examination and treatment in areas other than traditional Emergency Department (that is, entrance, admitting area, waiting room, and treatment areas) should have a sign that informs individuals of the hospital's participation in the state's Medicaid program and specifying the right of individuals under EMTALA with respect to examination and treatment for emergency medical conditions and women in labor."

2. The ED was toured on 03/14/2019 at 1745 with the EDD and CNO. Observations made during the tour revealed:
* The ED was comprised of approximately 22 exam/treatment rooms including one seclusion room, one isolation room and three trauma rooms.
* The main waiting area had one EMTALA sign with the required language posted on the wall near the room entry. The waiting room was large and had approximately 28 chairs. The writing on the sign was not conspicuous and clearly readable from the chairs positioned at the opposite end of the room from the sign.
* There was one other sign posted near the registration desk and main waiting area entry that was also not visible and readable from all chairs in the waiting area.
* Observation of the inside of the ED near the bathrooms reflected a smaller waiting area with approximately 2 chairs. There was no EMTALA sign posted in that area.
* There was no other EMTALA signage observed posted in the ED, including observations of two nurse station areas, hallways, the triage room, exam/treatment room 9, and trauma room 3.
* There was no EMTALA signage posted in the ED ambulance entry.

These observations were confirmed during an interview with the EDD on 03/14/2019 at the time of the observations. The EDD stated he/she did not believe there were any EMTALA signs posted in any of the patient exam/treatment rooms. The EDD acknowledged that patients who arrived to the ED by ambulance would not see EMTALA signage.

3. The L&D unit was toured on 03/14/2019 at 1800 with the BCM and CNO. Observations made during the tour revealed:
* The L&D unit had two entrances, an entrance from outside the hospital and an entrance from inside the hospital.
* The entrance from inside the hospital lead directly into the L&D unit.
* The entrance from outside the hospital lead directly into a breezeway and an adjacent L&D patient/family waiting room. The breezeway and the L&D patient/family waiting room each had EMTALA signage posted.
* No other EMTALA signs were observed posted in the L&D unit including observations of the inside entrance to the L&D unit, nurse station, hallways, triage area and exam/treatment rooms including observation of rooms 1 and 6 where patients waited for exam and treatment. For patients who entered the L&D unit from the entrance inside the hospital, there was no EMTALA signage posted and likely to be noticed by individuals waiting for exam and treatment.

During interview on 03/14/2019 at the time of the observations, the BCM and CNO confirmed no EMTALA signage was posted in the areas identified above.

Based on interview, review of documentation in the medical record of a critically ill pediatric patient with diabetes and vomiting who transferred from WVMC to another hospital (Patient 15), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and enforce its physician on-call policies and procedures to ensure the on-call specialty physician responded and was available to consult and/or to come in to the hospital at the request of the ED physician to provide further evaluation and/or treatment necessary to stabilize the patient's EMC.

Findings include:
1.a. The "Willamette Valley Medical Center Medical Staff On-Call Policy," dated "August 2015 Revision" reflected:
* "On-Call Schedule...Each specialty represented on the Medical Staff will be responsible for developing an on-call coverage commitment plan each year that reflects the services to be provided by the individuals in that specialty. In developing the plan, each specialty shall consider all relevant factors, including but not limited to...how the plan may affect the Medical Center's ability to comply with applicable regulatory requirements, including the Emergency Medical Treatment and Active Labor Act."
* "Specific on-call schedules will include the name and contact information of each physician in a specialty who is required to fulfill on-call duties...On-call schedules will be maintained in the Emergency Department..."
* "Responses to Call Guidelines...When an on-call physician is contacted by the Emergency Department, the general guidelines for the physician's response are as follows...by telephone within 15 minutes of being paged; and...Tier 1 providers...will be personally in the Medical Center within 30 minutes of being requested to do so...Tier 2 providers...will be personally in the Medical Center within 60 minutes of being requested to do so..."
* "Enforcement...An on-call physician's unavailability when on call, refusal to respond to a call from the Emergency Department, or any other violation of this Policy is a serious matter. Such violations can result in an investigation of the Medical Center and the physician involved, significant monetary fines per incident, civil lawsuits, and/or exclusion from participation in the Medicare and Medicaid programs for the Medical Center and/or the physician...A complaint about a physician's failure to comply with this Policy shall be referred to the Chief of Staff and the Chief Executive Officer for a preliminary review. These individuals shall review the complaint and may discuss it with involved individuals. The complaint and related information shall then be referred to the MEC, unless the Chief of Staff and the Chief Executive Officer agree that there is no need for such a referral..."

b. The policy and procedure titled "Emergency Screening, Stabilization and Transfer (EMTALA)," dated last revised "1/06" was reviewed. It stipulated:
* "On-Call Physician Requirement...The hospital must maintain a list of physicians who are on-call after the initial examination to provide further examination and/or treatment necessary to stabilize an individual with an emergency medical condition. The on-call list identifies and ensures that the emergency department is prospectively aware of those physicians, including specialists and sub-specialists, who are available to provide care...The hospital will maintain the on-call list of physicians to meet the needs of individuals receiving EMTALA services in accordance with the resources available to the hospital, including the availability of on-call physicians...The physician shall determine whether the additional stabilizing services of the on-call physician are necessary. The on-call physician is required to respond to the Emergency Department within 30 minutes...If an on-call physician fails to arrive within the response time established by the hospital policies...the hospital and that physician may be in violation of EMTALA...When a physician is on-call, the physician must respond to the hospital...A determination as to whether the on-call physician must physically assess the patient in the Emergency Department is the decision of the treating emergency physician, whose ability and medical knowledge of managing that particular medical condition will determine whether the on-call physician must come to the emergency department...If an on-call physician does not fulfill the obligation to come to the hospital once called, the hospital should attempt to arrange for another staff physician in that specialty to assess the individual...The on-call physician's refusal or failure to timely respond must be reported immediately to the Chief of Staff and the hospital Chief Executive Officer, or designee, who shall review the matter..."

2. Refer to the findings identified under Tag A2409, CFR 489.24(e) that reflects the hospital's failure to ensure the pediatric on-call physician, Physician B responded and was available to consult and/or come in to the ED on 03/02/2019 at the request of the ED physician to provide further evaluation and/or treatment necessary to stabilize pediatric Patient 15's EMC.

3. The WVMC medical staff roster with the heading "List Providers By - Initial Appointment Date," printed 03/13/2019 reflected that pediatric on-call physician, Physician B had been on staff at WVMC since 08/01/2018, and Physician B's "Department" was "OB/Pediatrics."

4. The "Peds March 2019" and "Peds Admits-March 2019" physician on-call calendars reflected Physician B was scheduled on-call for pediatric services on 03/02/2019. Physician B's contact information, a pager number and a secondary home cell phone number were listed on the calendar.

5. An email from the CQO dated 03/19/2019 at 1543 confirmed the hospital failed to ensure on-call Physician B responded to the ED physician's attempts to contact him/her regarding Patient 15. The email reflected "...[Physician B] was paged at 1102 and 1111 on 3/2/19...we just discovered our paging system was down...the on call [physician] did not get the pages...The secondary number was not called..."

Based on interview, review of documentation in the medical record of a pregnant patient who was having contractions and was transferred from WVMC to another hospital (Patient 16), review of documentation in the medical record of a critically ill pediatric patient with diabetes and vomiting who was transferred from WVMC to another hospital (Patient 15), review of documentation in 13 of 13 other medical records of patients who were transferred from WVMC to other hospitals for specialty services not available at WVMC (Patients 1, 2, 5, 9, 10, 11, 12, 13, 14, 17, 18, 19 and 20), and review of hospital policies and procedures, 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:
* For Patient 16, there was no documentation that reflected the receiving facility had accepted the patient for transfer and had all available resources necessary to care for the patient and unborn child.
* Physician certification of medical benefits versus risks were not documented or were not patient specific and individualized for Patients 1, 2, 5, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20.
* Appropriate mode of transfer was not effected and documented for Patient 16.
* There was no documentation that patient medical records were sent to the receiving facility for Patient 16.
* For Patient 16, there was no documentation that the receiving facility's physician accepted the patient for transfer as required by hospital policy.

Findings included:

1. The policy and procedure titled "Emergency Screening, Stabilization and Transfer (EMTALA)," dated last revised "1/06" was reviewed. It stipulated:
* "Purpose...To comply with requirements of the Emergency Medical Treatment and Active Labor Act ("EMTALA")..."
* "Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman is in true labor unless a physician or qualified medical person certifies that, after a reasonable period of observation, the woman is in false labor."
* "Transfer means the movement (including discharge) of an individual outside the hospital's facilities at the direction of any person employed by (or affiliated with) the hospital, but does not include such a movement of an individual who has been declared dead, or leaves the facility without the permission of any such person."
* "...Women in labor should be considered to be suffering from an Emergency Medical Condition until delivery of the baby and placenta, unless the woman is in 'false labor.' If the specially trained registered nurse determines a woman is in 'false labor' a physician must certify the diagnosis..."
* "If the medical screening examination reveals that an emergency medical condition exists, the hospital must provide such further examination and treatment necessary to stabilize the individual's emergency medical condition prior to discharge or transfer, unless an appropriate transfer to another medical facility is medically necessary or requested by the individual..."
* "Stabilizing Treatment Requirement...With respect to woman in labor, the individual is not stabilized until both the baby and placenta are delivered."
* "Transfer Restrictions...If the medical screening examination reveals the individual has an emergency medical condition, the hospital may not transfer the individual prior to stabilizing the individual's condition, unless either (i) the individual requests the transfer, or (ii) a physician certifies that the transfer is medically necessary because the hospital lacks the capability or capacity to stabilize the individual."
* "An individual with an emergency medical condition who requests a transfer prior to receiving stabilizing treatment must be fully informed of the risks of the transfer and the hospital's EMTALA obligation. The individual must sign and complete the Transfer Request Form, which must include the reason(s) for the request, a statement of the hospital's EMTALA obligation, and the risks associated with the transfer. The signed form should be made a part of the medical record."
* "If a transfer is necessary because the hospital lacks either the capacity or capability to stabilize the individual's emergency medical condition, the treating physician must sign a certification that, based upon 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 or unborn child from effecting the transfer, including the time away from an acute care setting necessary to effect the transfer...The physician certification must be signed by the physician and contain a summary of the risks and benefits upon which it is based...The certification should be specific to the condition of the patient upon transfer...should 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 away from an acute care setting necessary to effect the transfer."
* "The following four requirements of an appropriate transfer must be met before the hospital may transfer an individual pursuant to the individual's request or physician certification...The transferring hospital must provide treatment for the individual's condition within its capabilities to minimize the risks to the health of the individual or unborn child during transfer...The receiving hospital and receiving physician must accept the transfer and have the capability and capacity to provide appropriate treatment. The transferring hospital should document its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer...The transferring hospital must provide the receiving hospital with copies of appropriate medical records available at the time of transfer (including a copy of the physician certification or the individual's informed request for transfer)...Any follow-up test results or copies of records not available at the time of transfer must be sent to the receiving facility as soon as practicable...The individual must be transferred through the use of qualified personnel and transportation equipment, including those life support measures that may be required during transfer. The physician at the transferring hospital has the responsibility to determine the appropriate mode, equipment, and personnel necessary for transfer..."

2.a. The ED record for Patient 16 reflected she presented to the L&D unit on 03/04/2019 at 0223 with a significant other for "OB Check/Contractions." The "Mode of Transportation" was wheelchair.
* On 03/04/2019 at 0228 RN triage documentation on the "Willamette Valley Birth Center Triage" form reflected:
- "Reason Pt is presenting...contractions"
- "Arrival From...Home"
- "Pain (0-10 scale)...8...Pain Location...Back"
- "Membranes...Intact"
- "Vaginal Bleeding...Normal show"
- "Care Provider - time notified [OB physician, Physician A] 0245...Notified by...[RN]"

* On 03/04/2019 RN flowsheet documentation from 0229 through 0244 reflected "...MHR: 87...FM: FM % start...BP: 142/90...MHR: 92...MHR: 83...Pt presented to BC c/o contractions q 5 min and increasing in intensity, reports bloody show and pain 8/10. Urine sample given...SVE done...Station: -3...Dilation: 4...Effacement: 80...Consistency: Soft...Position: Posterior...Resp: 16/min...Temp: 98.1 [degrees] F...Pain: 8...Activity: In bed...Position: Semi-fowlers; Right tilt...Contractions: every 3-4 minutes...Contractions duration: 50-70 seconds...Contraction intensity: Moderate...Contractions resting tone: Palp soft between contractions...Accelerations: Absent...Decelerations: Absent...Baseline: 125 (14 min)...Variability: Moderate: 6-25 bpm...

* On 03/04/2019 at 0245 RN flowsheet documentation reflected "...[Physician A] notified of patient status, OK to DC to Newberg per patient request due to divert status here."

* A RN telephone order dated 03/04/2019 at 0245 electronically signed by Physician A on 03/27/2019 at 0754 reflected "Chief Complaint: Contractions...OB Check - including Fetal Monitoring...Ok to take private vehicle to Newberg L&D due to divert status...Diagnosis: Contractions"

* On 03/04/2019 RN flowsheet documentation from 0249 through 0304 reflected "...MHR: 95...MHR: 96...BP: 133/89...MHR: 91...MHR: 88...MHR: 97..."

* RN notes at 0309 reflected "...Newberg L&D notified of patient requesting to come there for labor due to our divert status, spoke with...RN lead and stated there was a bed available. Pt and [significant other] informed, DC paperwork signed and verbalizes understanding of plan MHR 106."

* The "Willamette Valley Medical Center Birthing Center Outpatient Instructions" form dated 03/04/2019 at 0315 signed by the RN and the patient was reviewed. The form included a list of approximately 25 instructions and informational items. The only instructions that were circled or otherwise indicated on the form were "Drink at least eight 8 oz. glasses of water every day" and a handwritten note that reflected "Go to Newberg hospital L&D."

* RN notes at 0315 reflected "...ambulated to private vehicle with [significant other]."

* The untimed "Transfer Chart - Acute" form with "Reg Date: 03/04/19" reflected:
- "Current Diagnoses...False labor at or after 37 completed weeks of gestation (03/04/19)."
- "Discharge Information"
- "Clinical Discharge Date/Time: 03/04/2019 03:15"
- "Clinical Discharge Disposition: Acute Care Hospital 02"
- "Clinical Discharge Comment: to Providence Newberg due to divert status"
- "Instructions:" was blank.
- "Stand-Alone Forms:" was blank.
- "Prescriptions:" was blank.
- "Visit Report" was blank.
- "-Forms:" was blank.

* RN notes at 0400 reflected "...Newberg called requesting a doctor to doctor discussion, paged [Physician A] and gave [him/her] the number for the physician at Newberg." This was the last RN entry in the medical record.

Although the record reflected the current diagnosis was "False labor...", there was no documentation that reflected a physician or QMP certified after a reasonable period of observation that the patient who was 41 weeks pregnant and having contractions, was in false labor. In addition, during interviews with hospital staff that included the L&D RN below, it was confirmed that the patient was not evaluated and determined to be in false labor, and was still having contractions when she left WVMC to go to PNMC.

Although the record reflected the patient was "discharged," the written instructions provided to the patient reflected he/she was directed to go to PNMC L&D.

The medical record reflected an appropriate transfer was not carried out. For example:
* Although the RN notes reflected the patient "requested" to go to PNMC, there was no documentation that reflected the patient was informed of the risks of the transfer, the hospital's EMTALA obligation, and the reasons for the request. There was no documentation that reflected a Transfer Request Form was completed and signed as required by hospital policy. In addition, during interview with the L&D RN below, the patient "requested" to go to PNMC only after the L&D RN told him/her that WVMC didn't have an available OR and that he/she may need to be transferred to a hospital where an OR was available.
* There was no documentation that reflected the physician signed a certification that the transfer was medically necessary because WVMC lacked the capability or capacity to stabilize the patient and the medical benefits outweighed the increased risks of transfer to the patient and unborn child.
* There was no documentation that reflected a PNMC physician accepted the patient for transfer as required by hospital policy. The RN notes reflected "Newberg called requesting a doctor to doctor discussion..." However, the note was dated 03/04/2019 at 0400 which was after the patient left WVMC to go to PNMC, and there was no documentation that reflected the PNMC physician had accepted the patient for transfer.
*Although the RN notes reflected "[PNMC] L&D...RN...stated there was a bed available," there was no documentation that reflected PNMC had accepted the patient for transfer and had all available resources necessary to care for the patient and her unborn child.
* Although the record reflected "Ok to take private vehicle to Newberg L&D," there was no documentation that reflected the physician arranged an appropriate transfer for this pregnant patient and the unborn child that included qualified personnel, transportation equipment including life support measures, or that the patient refused such arrangements. There was no documentation of a written refusal that reflected the patient was informed of the risks and benefits of the transfer and the reasons for refusal.
* There was no documentation that reflected the WVMC provided PNMC with copies of appropriate medical records available at the time of transfer including a copy of a physician certification or the patient's informed request for transfer.

b. An undated hospital document titled "What Happened" related to the incident involving Patient 16 reflected "...Patient and her [significant other] left the L&D Unit at approximately 3:15 am. The Hospital understands that the patient presented to Newberg at 3:45 a.m. on 3/4/19..."

c. During an interview with the L&D RN on 03/14/2019 at 1600 the following information was provided:
* The L&D RN confirmed he/she was assigned to care for Patient 16 on 03/04/2019.
* The L&D RN stated Patient 16 was 41 weeks pregnant and arrived to the L&D unit with her significant other around 0230. The patient stated she woke up having contractions while at home and wanted to be checked to see if she was in labor.
* The L&D RN stated he/she told the patient "...we don't have an OR now so depending on where you're at with a cervical check we'll determine if you're in labor or not, and if we need you to go to another hospital...if we need you to go to another hospital we'll transfer you by ambulance."
* The L&D RN stated the patient said she didn't want to go anywhere by ambulance.
* The L&D RN stated he/she got the patient on the fetal monitor and checked her cervix. The patient was 4 cm dilated, had no bloody show, and was -3 station. The L&D RN stated the patient rated her contraction pain an 8 on a pain rating scale of 1-10.
* The L&D RN stated he/she called Physician A, reported the patient's condition to the physician, and told the physician that the patient wanted to take a private vehicle to PNMC.
* The L&D RN stated Physician A stated "Okay, I'm fine with her discharging and going to PNMC if that's what she wants to do."
* The L&D RN stated he/she called the CN at PNMC. The L&D RN stated he/she told the CN "we have a patient here who wants to come there to see if she's in active labor." The L&D RN stated he/she asked the CN at PNMC if they had available beds, and the CN stated they did.
* The L&D RN stated the patient was in the L&D unit for 40 minutes. The L&D RN stated that for a pregnant patient who was 4cm dilated, he/she would normally keep the patient in the L&D unit for an hour after the first check for labor in order to "recheck" her again to see if labor had progressed. However, the L&D RN stated for Patient 16, he/she checked her for labor one time only and did not recheck her again. The L&D RN stated after that the patient left the L&D unit with her significant other and walked out to their car and left the hospital.
* The L&D RN stated the patient was not examined and determined to be in false labor prior to when she left the hospital. He/she stated "I felt she was in the early phases of labor."
* The L&D RN was asked if the patient was having contraction when she left the hospital. The L&D RN stated "I believe she was."
* The L&D RN stated that when the patient left the hospital he/she believed the patient was going to PNMC.
* The L&D RN stated the normal process for transferring a patient to another hospital was that the physician would come in and examine the patient, the physician would call the accepting physician at the receiving hospital, and "we would fill out an EMTALA transfer form and call an ambulance to transfer the patient." The L&D RN stated no transfer form with physician certification was done. He/she stated "I saw it as a discharge, not a transfer."

d. During interview with the BCM on 03/13/2019 at 1600 the following information was provided:
* The BCM confirmed PNMC did not accept Patient 16 for transfer.
* The BCM stated no patient should be transferred to another hospital without a physician certification and transfer form completed. The BCM confirmed Patient 16's medical record contained no physician certification including risks and benefits of transfer and no transfer form.
* The BCM confirmed there was no documentation that reflected Patient 16's medical records or a copy of a transfer form with physician certification including risks and benefits of transfer were sent to PNMC.

e. During an interview on 03/13/2019 at 1530, the CQO confirmed that neither Physician A nor any other physician examined Patient 16.

f. During an interview on 03/14/2019 at 0840, the CQO stated he/she had no documentation that reflected that Physician A received EMTALA training prior to the incident involving Patient 16.

3.a. The medical record of 15-year old Patient 15 was reviewed and reflected:
* The patient presented to the ED on 03/02/2019 at 0932 with a chief complaint of "Blood Glucose Alteration in."
* Physician notes electronically signed by the physician and dated 03/03/2019 at 1734 reflected "...Pt presents with complaints of vomiting since approx 0500. Pt is type 1 diabetic and [his/her] blood sugars read 'high' at home...Narrative History of Present Illness: [patient]...presents to the emergency department with vomiting for 12 hours...At the moment [he/she] presents acutely short of breath, nauseated and mildly confused, with a rapid respiratory rate and a smell of ketones suggesting ketoacidiosis..." The "Physical Exam Narrative" reflected "General: Severely dehydrated tachypneic with Kussmaul respirations, smells of ketones, appears critically ill...Neuro: Awake but seems drowsy, irritable, yells that (sic) asked that [he/she] just wants to go to sleep..." The "Narrative Medical Decision Making" reflected "...severe diabetic ketoacidosis with a glucose above 660...The patient is given a single 20 cc/kg bolus but still seems severely dehydrated so [he/she] was given an additional 10cc/kg bolus of normal saline. Our own on-call pediatrician [Physician B] was paged twice but did not respond. After discussion with the intensivist at OHSU Doernbecher pediatric intensive care unit, the patient is started on regular insulin 0.05 units/kg/h...also started on normal saline at 1.5 times maintenance...As we slowly replete [his/her] IV fluid and correct [his/her] glucose and monitor for the onset of any electrolyte abnormalities, the kids team from OHSU was sent over to collect the patient and take [him/her] to the pediatric intensive care unit over at OHSU..." The "Discharge Dispo ED" reflected "Disposition: Acute Care Hospital...Condition: Critical."

* The "Transfer Form" dated by the physician on 03/02/2019 at 1144 was reviewed. The "Reason for transfer" reflected "DKA/Needs ICU placement." The "Services not available at WVMC (specify)" was followed by "Our own pediatrician on-call [Physician B], not returning multiple pages." The form reflected the patient was transferred to OHSU by ""Ground transport-ALS/BLS" and "Other...KIDS TEAM." The "Medical Orders enroute" reflected "NS infusion Insulin infusion." The "Physician Section - Risks statement" reflected the following preprinted generic language "reasonable foreseeable medical risks and benefits of transfer include traffic delays, accidents during transport, inclement weather, rough terrain or turbulence, limitation of equipment and personnel in the vehicle, permanent disability, death and other." This was followed by a blank line.

There was no documentation that reflected pediatric on-call physician, Physician B responded to the ED physician's attempts to contact him/her, or that Physician B provided consult or came into the hospital and provided further evaluation and or treatment as necessary to stabilize the patient's EMC.

There was no documentation on the transfer form or elsewhere in the medical record of patient specific, individualized risks of transfer for this 15-year old patient with DKA who was short of breath and critically ill.

b. During an interview with the EDD at the time of the medical record review, he/she confirmed there was no documentation of patient specific individualized risks of transfer for the patient.

Online driving directions reflect the driving distance from WVMC to OHSU is approximately 37 miles and 61 minutes driving time.

c. During an interview with the CQO on 03/14/2019 at 1800 during the medical record review he/she provided the following information:
* The CQO confirmed the hospital had pediatric capability and Physician B was on-call for pediatrics on 03/02/2019.
* The CQO confirmed the medical record reflected the ED physician attempted to contact Physician B multiple times on 03/02/2019, Physician B did not respond to the ED physician's attempts to contact him/her, Physician B did not provide consult and/or come in to the ED, and the patient was subsequently transferred to OHSU for further evaluation and stabilizing treatment of his/her critical diabetic condition.
* The CQO stated that every on-call physician has a pager number and a "back up" phone number when they are on call. He/she confirmed there was no documentation that reflected the ED physician called Physician B's "back up" phone number after Physician B did not respond to "multiple pages."
* The CQO stated he/she did not know anything about Physician B's failure to respond to the ED physician's attempts to contact him/her. The CQO stated "We don't know anything about this."

4.a. The medical record of Patient 1 was reviewed and reflected:
* The patient presented to the L&D unit on 09/20/2018 at 0351 with a chief complaint of contractions.
* A MSE was conducted that included the following:
- The RN triage notes dated 09/20/2018 at 0414 reflected "Pain (0-10 scale)...9/10...Pain Location...Abdominal..."Membranes...Intact...Vaginal Exam...3-4cm/50/-3..."
- The physician notes dated 09/20/2018 at "5:30" reflected "30 [weeks] 6 [days]...presents [with] contractions...prenatal care has been complicated by...Hx of...cesarean 2/2 placental abruption - methamphetamine use...Preterm delivery...Asthma...she reports regular [contractions]...Preterm labor - Will start Magnesium sulfate...UDS and CBC pending...Dispo transfer to OHSU now."

* The "Transfer Form" dated and timed by the physician on 09/20/2018 at "5:37" was reviewed. The "Reason for transfer" reflected "Preterm...Services not available at WVMC (specify)...NICU." The form reflected the patient was transferred to OHSU by "Ground transport-ALS/BLS" with "Transport Personnel...ALS Paramedic." The "Medical Orders enroute" reflected "Continue Magnesium infusion, continue Penicillin."

The "Physician Section - Risks statement" reflected the following preprinted generic language "reasonable foreseeable medical risks and benefits of transfer include traffic delays, accidents during transport, inclement weather, rough terrain or turbulence, limitation of equipment and personnel in the vehicle, permanent disability, death and other." This was followed by a blank line. There was no documentation of patient specific, individualized risks of transfer on the transfer form or elsewhere in the medical record for this pregnant patient in preterm labor or the unborn child who required a NICU.

b. During an interview with the BCM at the time of the medical record review, he/she confirmed there was no documentation of patient specific individualized risks of transfer for the pregnant patient or the unborn child.

5.a. The medical record of Patient 17 was reviewed and reflected:
* The patient presented to the ED on 03/04/2019 at 0924 by ambulance with a chief complaint of "MVC" and "Stated Complaint" of "TRAUMA." The "Priority" reflected "2 - Emergent." A MSE was conducted that included physical exam, CT chest, CT cervical spine, CT abdomen, CT head, CXR, CBC, CMP, Plt Count, PT, Total Bilirubin and Troponin labs.
* Physician notes signed by the physician and dated 03/04/2019 at 1034 reflected "Patient...comes in via medics for evaluation of altered mental status and injury sustained in a motor vehicle crash...patient was the driver of a vehicle which hit a fire hydrant at a high rate of speed..."
* Physician notes signed by the physician and dated 03/04/2019 at 1712 reflected "Clinical Impression...Closed right hip fracture, Cervical spine fracture, MVC...Pneumothorax on right, Multiple rib fractures, Splenic lesion, Laceration of head...Condition...Critical...Disposition...Acute Care Hospital 02."

* The "Transfer Form" dated by the physician on 03/04/2019 with an illegible time was reviewed. The "Reason for transfer" reflected "Trauma...AMS, PTX, Femur fx ? petachial [illegible] ? aortic injury...Services not available at WVMC...Trauma [illegible], neuro [illegible]." The form reflected the patient was transferred to OHSU ED by "Air ambulance" The "Physician's statement of Condition of patient" reflected "Stable."

The "Physician Section - Risks statement" reflected the same preprinted generic language as reflected in the findings above. This was followed by a blank line. There was no documentation of patient specific, individualized risks of transfer for this patient who was in critical condition with multiple fractures and internal injuries, and required transfer by air ambulance for emergency trauma services. In addition, it was unclear how this patient's condition with extensive traumatic injuries was determined to be "Stable."

b. During an interview with the EDD at the time of the medical record review, he/she confirmed there was no documentation of patient specific individualized risks of transfer for the patient.

6.a. The medical record of Patient 5 was reviewed and reflected:
* The 1-day old infant presented to the ED on 10/19/2018 at 1734 with a chief complaint of "Pediatric Illness" and "Stated Complaint" of "Sent by DHS." The "Priority" reflected "3 - Urgent." A MSE was conducted that included a physical exam, labwork including glucose level and drug screen, vital signs, and weight.
* Physician notes signed by the physician and dated 10/19/2018 at 2000 reflected "Baby...brought to ED by DHS [after] recently taken into DHS care secondary to concern regarding parental substance abuse [and] inability to adequately care for infant...Baby born...[after] unattended home delivery [approximately] 1630 yesterday, 10/18/2018. Mom denies tobacco [and] alcohol or street drugs but family members...state she regularly takes pain meds [and] may take cocaine [and] heroine (sic)...No details on this pregnancy or delivery available...Impression...Term [male/female] infant born [after] no prenatal care, unattended delivery - unknown duration of ROM...baby appears term - at risk for NOWS...Plan...Transfer to Salem Hospital...as unable to appropriately manage NOWS [and] possible sepsis...Needs NICU...then NOWS monitoring."

* The "Transfer Form" dated and timed by the physician on 10/19/2018 at 1935 was reviewed. The "Reason for transfer" reflected "Concerns for NOWS, concerns re (sic) risk for [illegible]...Services not available at WVMC...no capability to care for NICU baby." The form reflected the patient was transferred to Salem Hospital by "Ground Transportation ALS/BLS PANDA...Code status of ground transport...Urgent."

The "Physician Section - Risks statement" section reflected the same preprinted generic language as reflected in the findings above. This was followed by "medical deterioration in transport." There was no documentation of patient specific, individualized risks of transfer for this 1-day old infant who required a NICU for possible NOWS and sepsis.

b. During an interview on 03/14/2019 at 1535, the BCM confirmed the hospital had no NICU and therefore lacked NICU capability.

c. During an interview with the EDD at the time of the medical record review, he/she confirmed there was no documentation of patient specific individualized risks of transfer for the patient.

Online driving directions reflect the driving distance from WVMC to Salem Hospital is approximately 25 miles and 35 minutes driving time.

7.a. The medical record of Patient 9 was reviewed and reflected:
* The patient presented to the L&D unit on 12/07/2018 at 0957 with a chief complaint of "High blood pressure and decreased fetal activity. A MSE was conducted and included:
* The RN notes reflected "[1000]...came to birthing center per direction of her careprovider (sic)...pt had checked her bp at home and gotten value of 172/116, combined with decreased fetal movement....[1003] MHR: 139...[1004] MSp02: 99 %...MHR: 114...[1012] BP: 185/104...[1030] Pain: 0...Edema: left: 1, right: 1...Contraction intensity: No Contractions...Acceleration: Present...Decelerations: Absent..."
* The physician notes electronically signed by the physician and dated 12/08/2018 at 1016 reflected "...[patient] is currently at 29 weeks estimated gestation...Physical Examination...On admission, her blood pressure was 185/104. She had a few other elevated pressures...Abdomen: Gravid. Nontender...Assessment...Chronic hypertension with acute exacerbation in pregnancy...Type 2 diabetes mellitus with large doses of insulin and marginal glycemic control...I controlled the patient's blood pressure and started her on magnesium sulfate, so that she could be transferred...She was then transferred by ambulance to St. Vincent's Medical Center. She received a 4 gram bolus of magnesium sulfate and was put on maintenance drip of 2 grams per hour prior to the transfer and it was continued during her transfer."

* The "Transfer Form" was signed by the physician on 12/07/2018 at 1325. The form reflected the "Reason for transfer" was "Chronic HTN [with] Acute Exacerbation - Type 2 DM. 29 wks [gestation]...Services not available at WVMC...Perinatologist, NICU." The form reflected the patient was transferred to PSVMC by "Ground transport-ALS/BLS" and "Transport Personnel...ALS Paramedic...Code status of ground transport...Urgent." The "Medical Orders enroute" reflected "Magnesium Sulfate 2g/hr continuous infusion."

The "Physician Section - Risks statement" reflected the same preprinted generic language as reflected in the findings above. This was followed by "Delivery En Route." The record lacked patient specific, individualized risks of transfer on the transfer form or elsewhere in the medical record for this patient who was 29 weeks pregnant with an acute exacerbation of elevated blood pressures and decreased fetal movement, or the unborn child who required a NICU.

b. During an interview with the BCM at the time of the medical record review, he/she confirmed there was no documentation of patient specific individualized risks of transfer for the pregnant patient. The BCM stated "He/she could've had a seizure during transport."

8.a. The medical record of Patient 2 was reviewed and reflected:
The patient presented to the L&D unit on 10/03/2018 at 1102 with a chief complaint of headache, decreased fetal movement and preeclampsia. A MSE was conducted and included:
* The physician notes signed by the physician and dated 10/03/2018 at 1100 reflected "...worsening swelling, elevated BP, [and] now HA [and] non-reassuring FHT...worsening status [with] preeclapsia (sic) at 32 [weeks]...Transfer care to L&D St Vincent's."
* The RN notes reflected "[1105]...MHR: 89...[1106] BP: 142/90...[1117] Temp.: 99.0 [degrees] F...[1118] BP: 145/90...[1130] Pain: 5...Edema: left: 1, right: 1...Contraction intensity: No Contractions...Accelerations: Present...Decelerations: Absent...[1133]...[Physician] at bedside obtaining consent for pt transfer..."

* The "Transfer Form" was signed but not timed by the physician on 10/03/2018. The form reflected the "Reason for transfer" was "Preterm High Risk Prenatal Care." The form reflected the patient was transferred to PSVMC by "Ground transport-ALS/BLS" with "Transport Personnel...BLS/EMT." The "Medical