HospitalInspections.org

Based on interview and email communications, review of central log and medical record documentation for 10 of 22 encounters of individuals who presented to the hospital for emergency services (Patients 2, 6, 7, 10, 11, 13, 16, 20, 21, and 22), review of P&Ps, review of scope of services documents, review of imaging operations documentation, and review of SA licensing documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured it met its EMTALA obligations in the following areas:
* To develop P&Ps and scope of service documents that clearly delineate the hospital's capabilities and capacity to provide MSEs, further examination, stabilizing treatment, and admission.
* To provide MSEs within its capabilities and capacity.
* To affect appropriate transfers to other hospitals for further exam and stabilizing treatment that is not within the hospital's capabilities and capacity, that includes physician certification of patient specific risks of transfer, and use of appropriate medical transportation with qualified personnel.
* To obtain or attempt to obtain written and informed refusal of MSEs, further examination and stabilizing treatment, or transfer, and to ensure the medical record contains required documentation.

Findings include:

1.a. The P&P titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance For Legacy Health Emergency, Labor And Delivery, Psychiatric Emergency Services And Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements for Non-Compliance" with "Last Revision Date: 02/23" was reviewed. It included the following information related to the provision of MSEs:
* "'Medical Screening Examination' or 'MSE' is a process to determine, with reasonable clinical confidence, whether or not an EMC exists or whether a patient is in labor. The MSE may range from a simple process (such as a brief history and focused physical examination) to a complex process (requiring imaging, laboratory tests and other diagnostic tests or procedures)."
* "'Capabilities of a medical facility'" means that there is physical space, equipment, supplies, and specialized services that the hospital provides."
* "If an individual comes to one of Legacy's Dedicated Emergency Departments, Legacy will provide an appropriate Medical Screening Examination within the capability of the department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists ..."
* "All individuals presenting to a DED requesting an examination or treatment, or for whom a prudent layperson observer would conclude from the individual's appearance or behavior a need for examination or treatment of a medical condition, will receive an MSE within the capability of the applicable DED to determine whether an EMC exists or whether a patient is in labor."
* "The MSE will be performed by a Qualified Medical Person ... The MSE may also include the consulting services of on-call LIPs if, in the judgment of the practitioner performing the MSE, such consulting services are necessary to determine whether the individual has an EMC and/or to provide further examination and necessary stabilizing treatment ... The MSE must be the same appropriate screening examination, including ancillary services routinely available to the DED, provided by the DED to any individual coming to the DED or Obstetrical Unit with similar signs and symptoms."
* "If the patient has an EMC or is in labor ...Legacy shall provide, within the capabilities of the staff and facilities available, further examination and treatment required to stabilize the patient's medical condition ... Legacy shall continue to monitor a patient who has or may have an EMC in accordance with the patient's needs until the patient is stabilized, transferred or discharged."

1.b. In response to requests for a document that described LMHMC's scope of services that reflected the hospital's full capabilities and capacity the following were provided:
* "System Scope of Service Plan" with "Last Revision Date: July 2022."
* "Legacy Mount Hood Medical Center Emergency Department Scope of Service" with "Last Review Date: July 2020."
* "Legacy Mount Hood Medical Center Emergency Department Scope of Service" with "Last Review Date: March 2023."

None of the EMTALA P&P, the Legacy System Scope of Service Plan, the ED Scope of Service documents, or other P&P or formal document, described LMHMC's scope of hospital services that delineated its hospital-specific capabilities and capacity to provide MSEs, further examination, stabilizing treatment and admission.

1.c. The "System Scope of Service Plan" with "Last Revision Date: July 2022" was reviewed. It reflected that "The objective of this plan is to describe how Legacy Health (LH) delivers safe, high quality, integrated, interdisciplinary health care across the continuum of services provided to the community." It did not describe or delineate the unique scope of services or capabilities and capacity of LMHMC or any of the other Legacy System hospitals.

1.d. The "Legacy Mount Hood Medical Center Emergency Department Scope of Service" with "Last Review Date: July 2020" was reviewed. It included the following:
* "Description of Services: ...
d. Age groups served: serves all ages.
e. Patient classification: Mount Hood Medical Center Emergency Department provides ambulatory care.
f. Primary patient population/diagnoses:
1) All types of physiologic and psychological complaints may be seen in the Mount Hood Medical Center Emergency Department.
2) The types and conditions seen in the emergency department will vary because of geographical and population differences, but may consist of (but not limited to): chest pain, stroke, abdominal pain, kidney stones, shortness of breath, seizures, diabetes, substance abuse, lacerations, orthopedic injuries, vaginal bleeding, severe or prolonged headaches, asthma, eye injuries, physical assaults, sexual assaults, motor vehicle crash, infectious diseases, on the job injuries and follow-up, and behavioral health clients.
3) Each patient may receive an assessment in accordance with their individual presentation, chief complaint, medical condition, and past medical history. Use of ancillary services and testing are done as the condition warrants. In order to provide continuity of care, all patients requiring medical follow up for their presenting chief complaint who do not have a primary care physician, are referred to a primary care or a specialty physician consult, who is available by way of a rotating call system as mandated by medical staff [bylaws].
4) Medical management and interventions provided are consistent with approved emergency services standards of care."

There was no description of what clinical, specialty, and ancillary services comprised LMHMC's capabilities and capacity.

* The ED Scope of Service document included the following:
"Access to Services: ...
b. Criteria for admission to an inpatient unit or transfer to an appropriate facility are, but not limited to:
1) Unstable or potentially unstable cardiovascular status
2) Unstable or potentially unstable airway/respiratory status
3) Unstable or potentially unstable neurological status
4) Unstable or potentially unstable hemodynamic status
5) Unstable or potentially unstable metabolic status
6) Unstable or potentially unstable surgical status
7) Unstable or potentially unstable pediatric patients with trauma diagnosis
8) Unstable or potentially unstable burn status
c. Obstetric patients transfer to an appropriate facility are, but not limited to:
1) Unstable or potentially unstable, pregnant or postpartum
2) Immediate postpartum
3) Any pregnant patient requiring inpatient admission and obstetric services."

There was no description of LMHMC's inpatient capabilities and capacity.

1.e. The "Legacy Mount Hood Medical Center Emergency Department Scope of Service" with "Last Review Date: March 2023" was reviewed.
* Under the "Access to Services" section, item c. 3) had been changed to: "Any pregnant patient requiring inpatient admission and/or obstetric services."

1.f. In response to an additional request for the hospital's description of its scope and extent of clinical and ancillary services, the "Scope of Service Procedural Areas, LHS Imaging Services" plan with "Last Revision Date: May 2022" was provided.
* In an email from the hospital dated 04/13/2023 at 1001 that contained the plan an ACCC wrote the following:
"Imaging: Hours of Operation:
Monday - Friday on site 7am-4pm and take call til. 6pm.
Every other Sat/Sun on site 8-4:30, opposite weekend covered on call.
Ultrasound in the hospital is staffed 0630-0100 Monday-Friday. Call 0100-0630am.
Sat/Sun is staffed 24 hours."
* The "LHS Imaging Services" plan contained the scope of imaging for each Legacy System hospital. For LMHMC it reflected the following:
- "Imaging Services at Mount Hood Medical Center is comprised of General Radiology, CT, MRI, Ultrasound, Nuclear Medicine, and Mammography"
- "24/7 except Mammography which is offered Mon-Fri and MRI M-F 630am-6:30pm MRI Sat 8-4:30 pm"

The onsite and on call hours for the imaging department and for the ultrasound modality that were provided in the email were not reflected in the formal Legacy System Imaging Services plan. Nor was there information about the required response time for on call staff. It was unclear how ED staff would know what the hospital's onsite versus on call capabilities were to ensure there were no unnecessary delays created in the provision of MSEs.

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2.a. Refer to the findings identified under Tag A2406, CFR 489.24(a)&(c), that reflects the hospital's failure to ensure all individuals who presented for emergency services received MSEs within the hospital's capability and capacity.

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3.a. Refer to the findings identified under Tag A2409, CFR 489.24(e) that reflects the hospital's failure to affect appropriate EMTALA transfers to other hospitals with the necessary capability and capacity for patients for whom an EMC had not been ruled out, removed or resolved.

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4.a. The P&P titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance for Legacy Health Emergency, Labor and Delivery, Psychiatric Emergency Services and Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements for Non-Compliance," dated last revised "02/23," was reviewed. Under "Refusal of MSE, Treatment or Transfer" it reflected:
* "a. A patient has the right to refuse the MSE, further examination, treatment or transfer to another facility."
* "b. The DED shall make good faith efforts to encourage the patient to remain for the MSE. If the patient refuses the MSE, the reasons for refusing the MSE (if known) and the time of departure shall be recorded in the patient's health record."
* "c. If the patient leaves before receiving a MSE without the knowledge of the DED, the time and circumstances (to the extent known) of the patient's departure shall be recorded in the patient's health record."
* "d. If the patient has received an MSE and refuses further examination or treatment, or transfer, the patient shall be informed of the risks and benefits of the examination or treatment, or transfer. If the patient refuses to consent to the examination, treatment, or transfer, then the health record shall reflect:
i. A description of the examination, treatment or transfer that was refused;
ii. The reasons for the refusal;
iii. The risks and benefits were explained to the patient;
iv. The steps taken to document the patient's refusal and
v. The time of departure."

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5.a. The central log for Patient 7 reflected that they presented to the ED on 03/20/2023 at 0423 with a chief complaint of "Difficulty Breathing." The ED disposition on the log was "*Left Against Medical Advice (Elopement, LWBS)*."

5.b. The medical record for Patient 7's 03/20/2023 ED encounter was reviewed and included:
* At 0423 "Patient arrived in ED."
* At 0424 "Triage Start."
* At 0424 "Arrival Complaint" reflected "Difficulty Breathing."
* At 0426 RN triage notes reflected "Pt presents with c/o SOB and CP when [they breath] in that started a few hours ago. Pt reports having a boil to [their] thigh that recently popped and [they are] concerned the infectiomn [sic] spread. Pt is speaking in full sentences, NAD or SOB observed in triage, SpO2 is 99% on RA; denies cough. GCS 15."
* At 0427 "Patient Acuity 3-Urgent."
* At 0427 a pain assessment, C-SSRS and vital signs were recorded and the BP was 160/101.
* At 0427 "Triage Completed."
* At 0428 "Patient roomed in ED."
* At 0442 "... EKG completed and given to LIP."
* At 0521 an RN note reflected "Pt states [they are] leaving and [plan] to schedule an appt with [their] PCP this morning. Pt left with all belongings."
* At 0522 "Patient discharged" and "Departure Condition ... Discharge teaching done by: Pt left w/No Teaching"
* At 0522 "ED Disposition set to LWBS after Triage."

5.c. There was no other triage or MSE documentation in the record. There was no documentation that reflected the hospital encouraged or made efforts to encourage the patient to remain at the hospital for an MSE as required by the hospital's EMTALA P&P.

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6.a. The central log for Patient 11 reflected that they presented to the ED on 03/23/2023 at 1943 with a chief complaint of "sz." The ED disposition on the log was "*Left Against Medical Advice (Elopement, LWBS)*."

6.b. The medical record for Patient 11's 03/23/2023 ED encounter was reviewed and included:
* At 1943 "Patient arrived in ED."
* At 1944 "Arrival Complaint" reflected "sz."
* At 0946 RN triage notes reflected "Pt to ED. Bystander called 911 for pt being 'unresponsive' pt reported to EMS that [they were] 'sitting in the chair and just fell over to the ground'. Pt reports that [they have] been weak for a few weeks. EMS reports that pt may or may not have been unresponsive. Pt reported that 'this happened a few weeks ago as well'. Pt awake and alert during triage." EMS vital signs were recorded, a CBG was recorded, and "Pt sitting in wheelchair in triage lobby."
* At 1948 vital signs were recorded.
* At 1950 "Patient Acuity 3-Urgent"
* At 1950 a pain assessment was recorded.
* At 1950 "Triage Completed."
* At 2007 "Chief Complaints Updated" reflected "Loss of Consciousness."
* At 2053 an RN note reflected "Pt walked out of ED. Pt asked while heading out the door if [they were] going to smoke or leaving. Pt stated 'thanks guys but I think I'm gonna leave.' Pt advised to return for any reason if [they changed their] mind."
* At 2054 physician "Orders Placed" included oxygen therapy, cardiac monitoring, continuous pulse oximetry, insert peripheral IV, blood glucose, urine dip, orthostatic blood pressure, notify physician, weigh patient, labs, and ECG.
* At 2054 an RN ordered labs, cardiac monitoring, peripheral and saline lock IV, and ECG.
* At 2054 "Departure Condition: Stable ... Discharge teaching done by: Pt left w/No Teaching."
* At 2055 "Patient discharged." and "ED Disposition set to LWBS after Triage."

6.c. There was no other triage or MSE documentation in the record. There was no documentation that reflected the hospital encouraged or made efforts to encourage the patient to remain at the hospital for an MSE as required by the hospital's EMTALA P&P.

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7.a. The central log for Patient 13 reflected that they presented to the ED on 03/24/2023 at 1529 with a chief complaint of nausea, vomiting and headache. The ED disposition on the log was "*Left Against Medical Advice (Elopement, LWBS)*."

7.b. The medical record for Patient 13's 03/24/2023 ED encounter was reviewed and included:
* At 1529 "Patient arrived in ED."
* At 1531 "Arrival Complaint" reflected "Nausea, Vomiting, Headache."
* At 1545 "Triage Started."
* At 1545 RN triage notes reflected "Pt being seen today with c/o sudden onset of n/v. Pt felt like [they were] having a panic attack, pt with history of anxiety, not on medication. Pt in Nursing school."
* At 1547 vital signs were recorded and the HR was 104.
* At 1548 a pain assessment was recorded.
* At 1548 "Triage Completed."
* At 1645 a POCT urine dipstick lab was resulted.
* At 1655 a " U HCG Qualitative POCT" lab was resulted.
* At 1729 an RN note reflected "Pt reports [they are] feeling better. Up to triage station for reevaluation of vitals. All vitals WNL. Pt would like to leave. Pt advised to return for any reason."
* At 1730 "Patient discharged." and "Departure Condition ... Discharge teaching done by: RN" and "Belongings returned to patient at discharge: Yes."

7.c. There was no other triage or MSE documentation in the record. There was no documentation that reflected the hospital encouraged or made efforts to encourage the patient to remain at the hospital for an MSE as required by the hospital's EMTALA P&P.

7.d. During interview and review of the medical record for Patient 13 with the EDNM on 04/04/2023 at 1625, the EDNM confirmed there was no documentation that reflected an MSE had been conducted.

7.e. During interview with an ACCC on 04/05/2023 at 1330 they confirmed the hospital was not in compliance with their EMTALA P&P related to encouraging patients to stay for an MSE.

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8.a. The central log for Patient 22 reflected that they presented to the ED on 03/31/2023 at 0848 with a chief complaint of "20WKS PREGNANT/ABD PAIN." The ED disposition on the log was "*Left Against Medical Advice (Elopement, LWBS)*."

8.b. The medical record for Patient 22's 03/31/2023 ED encounter was reviewed and included:
* At 0848 "Patient arrived in ED."
* At 0848 "Arrival Complaint" reflected "20WKS PREGNANT/ABD PAIN."
* At 0852 "Triage Started."
* At 0852 an RN triage addendum note reflected "Pt here for RLQ pain that started about 0500 ... had a similar occurrence a couple weeks ago and was seen and sent home but [feels] this is worse and [reports they] felt a pop in the RLQ on the way to the hospital ... denies contractions. Denies vaginal fluid or bleeding. Reports normal movement of fetus ..."
* At 0856 "Patient Acuity: 2-Emergency"
* At 0856 an RN recorded a C-SSRS and "Pain Intensity: 7."
* At 0858 vital signs were recorded.
* At 0908 an RN recorded "Patient is 28wks, patient reports right sided abdominal pain that radiates into back ... Had a similar episode at 20 weeks and was told [they] had fibroid tumor. FHR at 161."
* At 0912 ED Provider Notes documented by Physician O reflected:
- "09:41 I consulted ... OBGYN, who recommended US and transfer."
- "11:47 I consulted [physician name], Kaiser, who requested pelvic exam."
- "11:53 Patient refused pelvic exam. [They] decided to dress [themselves] and elope."
- "Patient who is 28 weeks pregnant who presents with constant and gradually worsening RLQ pain, worse with movement, that started yesterday. On exam, [they are] well-appearing, [have] a gravid uterus and [have] mild RLQ tenderness. Afebrile and not tachycardic. US imaging showed single IUP at 28 weeks and 4 days. [physician name], Kaiser requested a pelvic exam, though patient declined, dressed [themselves] and decided to elope."
* At 1153 Physician O documented "ED Disposition set to Eloped (Left before treatment completed)."
* At 1158 an RN recorded "Departure Condition: Stable ... Patient Teaching: (pt eloped) ... Discharge teaching done by: Pt left w/No Teaching ... Departure Mode: With significant other."
* At 1201 "Patient discharged."

8.c. The record reflected the patient received a MSE but refused further examination and treatment. However, there was no documentation in the medical record that reflected the reasons the patient refused; the risks and benefits of refusal were explained to the patient; and the steps taken to document the patient's refusal as required by the hospital's EMTALA P&P.

8.d. An email from Physician O was dated 04/06/2023 at 1640 and was forwarded to the survey team on 04/06/2023 at 1651. In the email Physician O wrote "I have reviewed the case ... This patient was 28 weeks pregnant and presented with right lower quadrant pain. [Patient] was known to have a large fibroid on that side of [their] uterus which was discovered on a similar visit, 2/20/2023. I consulted ... with OB/GYN at [LEMC Randall] who request a transfer for further evaluation. After explaining this to the patient [they] reported that [they] had Kaiser Insurance and wanted to go there. I called the Kaiser transfer center and spoke with [physician name] who requested a pelvic exam to ensure [the patient's] cervix wasn't dilated. The patient refused the pelvic exam, [they] dressed [themselves] and left before I could return with the AMA form for [them] to sign. It would be my normal practice to explain the potential risks to the patient, but by the charting, it seems [they] left before this happened which is technically called Eloping."

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9.a. The "Verification of Release of Legacy Health System From Liability" form with a version date of "(01-2018)" was provided by an ACCC on 04/05/2023 who indicated it was the AMA form and was to be attached to the EMTALA P&P referenced under Findings 1.a. and 4.a. above in this Tag. The form consisted of the following language and lines for signatures and dates/times:
"I, [Line for "Print name"]
Release Legacy Health System*, their employees/agents, and the physicians from all liability in regard to the following:
[Line for "Procedure/Treatment/Care"]
I acknowledge that I have been provided with an explanation about the benefits and risks for the above. I have had the opportunity to have all my questions answered and I understand the consequences involved.
[Line for "Patient or Qualified Consenter Signature" and "Date/Time"]
[Line for "Witness (Staff)" and "Date/Time"]
When patient is a minor or not able to give consent:
[Line for "Qualified Consenter Signature" and "Date/Time"]
[Line for "Relationship to Patient"]
*For purposes of this document Legacy Health include the following: Legacy Emanuel Medical Center, Legacy Good Samaritan Medical Center, Legacy Meridian Park Medical Center, Legacy Mount Hood Medical Center, Legacy Salmon Creek Medical Center, Legacy Silverton Medical Center, Randall Children's Hospital at Legacy Emanuel, Legacy Medical Group, and Legacy Hospice."

There was no reference to this form in the EMTALA P&P and the language on the form did not align with Section 6 of the EMTALA P&P as described under Finding 4.a. above. It was not clear why an individual would be asked to "Release [the hospital] from all liability," there was no language that indicated an individual was refusing anything, and there was reference to "consenter" and giving "consent." The form depicted an individual's consent for something versus refusal of something. The purpose of the form was unclear and particularly in the context of EMTALA.































29708

Based on interview and email communications, review of central log and medical record documentation for 3 of 7 encounters of pregnant individuals who presented to the hospital for emergency services after it had discontinued maternity services and closed its FBC unit (Patients 10, 16, and 21), review of P&Ps, review of scope of services documents, review of imaging operations documentation, and review of SA licensing documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured that every individual who presented to the hospital for emergency services received a MSE within the hospital's capabilities and capacity:
* MSEs for pregnant individuals did not include objective evaluation of the pregnant individual and the unborn child/children. The MSEs were not consistent with CMS SOM Appendix V that reflected "For pregnant women, the medical records should show evidence that the screening examination included ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of the membranes, i.e., ruptured, leaking, intact."

Finding include:

1.a. The P&P titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance For Legacy Health Emergency, Labor And Delivery, Psychiatric Emergency Services And Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements for Non-Compliance" with "Last Revision Date: 02/23" was reviewed. It included the following information related to the provision of MSEs:
* "'Medical Screening Examination' or 'MSE' is a process to determine, with reasonable clinical confidence, whether or not an EMC exists or whether a patient is in labor. The MSE may range from a simple process (such as a brief history and focused physical examination) to a complex process (requiring imaging, laboratory tests and other diagnostic tests or procedures)."
* "'Capabilities of a medical facility'" means that there is physical space, equipment, supplies, and specialized services that the hospital provides."
* "If an individual comes to one of Legacy's Dedicated Emergency Departments, Legacy will provide an appropriate Medical Screening Examination within the capability of the department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists ..."
* "All individuals presenting to a DED requesting an examination or treatment, or for whom a prudent layperson observer would conclude from the individual's appearance or behavior a need for examination or treatment of a medical condition, will receive an MSE within the capability of the applicable DED to determine whether an EMC exists or whether a patient is in labor."
* "The MSE will be performed by a Qualified Medical Person ... The MSE may also include the consulting services of on-call LIPs if, in the judgment of the practitioner performing the MSE, such consulting services are necessary to determine whether the individual has an EMC and/or to provide further examination and necessary stabilizing treatment ... The MSE must be the same appropriate screening examination, including ancillary services routinely available to the DED, provided by the DED to any individual coming to the DED or Obstetrical Unit with similar signs and symptoms."
* "If the patient has an EMC or is in labor ...Legacy shall provide, within the capabilities of the staff and facilities available, further examination and treatment required to stabilize the patient's medical condition ... Legacy shall continue to monitor a patient who has or may have an EMC in accordance with the patient's needs until the patient is stabilized, transferred or discharged."

1.b. Review of SA licensing documents reflected that LMHMC had closed its FBC Unit and discontinued maternity services effective 03/19/2023 where LDRP and nursery services had historically been provided and where pregnant patients presenting to LMHMC for emergency services had historically received MSEs by qualified obstetric physicians and other LIPS.

1.c. In an email from an ACCC dated 04/13/2023 at 1001 the following description of the hospital's ultrasound capabilities was provided:
"Imaging: Hours of Operation:
Monday - Friday on site 7am-4pm and take call til. 6pm.
Every other Sat/Sun on site 8-4:30, opposite weekend covered on call.
Ultrasound in the hospital is staffed 0630-0100 Monday-Friday. Call 0100-0630am.
Sat/Sun is staffed 24 hours."

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2.a. Review of the central log for Patient 10 reflected they arrived to the ED on 03/22/2023 at 0523 with a chief complaint of "Abdominal Pain; 36wks pregnant." The log reflected the patient's "[Discharge Disposition]" was "[Transfer to another hospital]," and "[Discharge]" date and time were recorded as 03/22/2023 at 0634, one-hour and 11 minutes after arrival.

2.b. The medical record for Patient 10's 03/22/2023 encounter was reviewed and included the following triage and MSE documentation:
* At 0523 an RN recorded "Arrival Complaint" as "Abdominal Pain; 36weeks pregnant."
* At 0531 an RN recorded "EDC 4-16-2023, scheduled c -section today at Legacy Salmon Creek. Denies vag bleeding or fluid discharge. Nauseated. Abd pain started one hour pta."
* At 0535 an RN recorded "Vital Signs" that included HR of 98, BP 126/81, and RR of 22.
* At 0535 a call was made to request an OB "Consult."
* At 0536 an RN recorded "Triage Plan Patient Acuity: 2-Emergency ... Triage Complete."
* At 0536 an RN recorded "Pain Intensity: 8."
* At 0537 Physician S was assigned to Patient 10's encounter and "Patient Care Initiated."
* At 0538 Physician S ordered the following: "Cardiac Monitoring; Pulse Oximetry ... [Tylenol tablets]; [Zofran injection] ... CBC ... CMP; Lipase Level; UA ... Saline Lock IV."
* At 0544 an RN recorded "Call placed to Life Flight for standby."
* At 0545 a "Consults" note reflected the OB "Consult by phone complete - Transport initiated during call - Lifelight [sic] Air activated by CRN."
* At 0547 an RN recorded that a dose of Tylenol was administered by mouth and a dose of Zofran was administered IV.
* At 0547 an RN recorded "Pain Intensity: 4" under the assessment heading "Vitals Resp Rate and Pattern required with pain assessment and interventions." There was no RR or "Resp Rate and Pattern" documented.
* At 0549 an RN recorded "Call placed to Life Flight to activate crew. ETA 0615."
* At 0612 an RN recorded "Vitals Assessment $ [sic] Re-assess Vitals?: Yes."
* At 0612 an RN recorded vital signs that included BP of 136/88 and HR of 92, but no RR.
* At 0632 an RN recorded "Life Flight crew leaving department."
* At 0632 an RN recorded "Patient discharged."

2.c. The medical record for patient 10 contained an "ED Provider Note" electronically signed by Physician S at 0717. That note included the following MSE information for Patient 10:
* Patient 10 "presents w/ abd pain, n/v, 36w3d twins."
* "Gestational age: 36 weeks and 3 days based on last miscarriage ..."
* "Fetal movement: +movement reported by patient."
* "... pt believes is scheduled for c-section tomorrow 3/23."
* "One baby with polyhydramnios. Believes some placental insufficiency."
* "Abdominal pain / cramping since approx 0500. +n/v x 1 episode."
* "Consideration of Labor
Abdominal pain: cramping
Contractions (frequency/severity): pt states does not feel like contractions
Leaking or gush of fluid (color): none
Vaginal bleeding: none
+mild backache which patient related to pregnancy
Denies pelvic pressure, urge to defecate or urge to push."
* I reviewed patient's prior external records (not from this ED ... obstetrics team 3/8/2023 provides corroborative history. Including discussion of twin A with FGR and polyhydramnios. Recent E. coli UTI which was treated."
* "MDM Summary ... 1. Acute abd pain. 2. Nausea and vomiting ... Patient does not believe [they are] laboring and I do not suspect [they are] either. No suggestion of rupture of membranes. Also less likely ddx including but not limited to hepatobiliary dz, SBO, diverticulitis, appendicitis, AAA, pyelonephritis, renal stone, etc. Also consider unlikely fibroids, endometriosis and extremely unlike torsion, uterine/ovarian infectious process / toa, trauma, HELLP, chorioamnionitis, placenta acreta / abruption, etc. etc. [sic] based on clinical presentation and history. Normal blood pressure, do not suspect preeclampsia. Given that the patient's differential includes the possibility of the aforementioned potentially life-threatening conditions, appropriate screening diagnostics will be sent: Labwork to evaluate for evidence of anemia, electrolyte abnl including hypokalemia, hyperkalemia, hypematremia [sic], hyponatremia, hyperglycemia, etc."
* "Initial Plan / Interventions: Supportive treatment. PO tylenol PO zofran. Will monitor patient and reassess."
* "Clinical Course: 0546: Consult: I discussed the management of patient with the following consultants or providers to determine disposition: ... obgyn from [LEMC]. Agrees patient needs to be transferred. We are going to connect to [another physician] at [LSCMC] as patient gets primary OB/GYN care there, due to deliver there tomorrow. Lifelight [sic] being activated to start preparing for potential take-off. 0551: [Patient 10 accepted for transfer by LSCMC physician]. 0632: Patient leaving department, feels improved. Tylenol and Zofran seem to improve patient's symptoms. Vital signs stable."
* "I independently reviewed the relevant lab and imaging studies to help with my assessment and plan for this patient including the following: Labs: Independent interpretation details documented in ED course and/or synopsis. Rhythm strip independently interpreted by me: Normal sinus rhythm, normal QT."
* "Diagnosis and Disposition: 1. Acute abdominal pain 2. Nausea and vomiting, unspecified vomiting type 3. Third trimester pregnancy Condition: Improved Disposition: LifeFlight transfer to [LSCMC]."

2.d. There was no documentation in Patient 10's medical record to reflect that the MSE for the patient 36 weeks pregnant with twins included an objective evaluation labor. For instance, there was no evidence of assessment of the "cramping" the patient complained of, no monitoring of uterine activity, and no assessment of cervical dilation within the capabilities of LMHMC. Further, there was no documentation to reflect the MSE included any evaluation or consideration of the fetal health of the twins the patient was carrying. For instance, there was no evidence of FHR monitoring or ultrasound assessment within the capabilities of LMHMC, for both twins, at least one of which had risk factors.

2.e. Patient 10's medical record did not include documentation to reflect what discussion occurred between Physician S and the OB consulting physician that led to the patient's transfer. Particularly as Physician S had written in the "ED Provider Note" that they did not believe Patient 10 was "laboring" but then wrote "possible labor" as the EMC on the transfer form.

2.f. Documentation on an "EMTALA Patient Transfer Form" signed by Physician S on 03/22/2023 at 0551 reflected "Emergency Medical Condition (EMC) or Summary of Diagnosis: possible labor," and "Reason for Transfer ... Lack of capacity and/or capability" as "OBGYN." It was not clear what aspects of an MSE LMHMC did not have capabilities or capacity for.

2.g. During interview with the EDNM at the time of the record review on 04/05/2023 at ~1100 they confirmed there was no documentation of FHR or other monitoring of fetal health of the twins.

2.h. During telephone interview with Physician S on 04/05/2023 at 1315 they stated they "vaguely remember" Patient 10 and "don't remember details" about the patient's encounter, so could only say what their usual practice was. Physician S stated that "I'm sure I said I'm not an OB as I always do. That's pretty standard for me." They stated they were "sure" that they "placed ultrasound" and "looked at FHR" and "can't imagine not doing that." They also stated, "I don't actually remember" and it would be their practice to bring an US to the room and look for fetal movements and HR. They stated, "I do that for every pregnant [patient]." Physician S stated "I'm not sure what other monitoring I did." They stated that they would have used "TeleOB." Physician S also stated it "would be my practice" to assess fetal movement and FHR for any pregnant patient in the ED and they would have told Patient 10 that LMHMC didn't have fetal monitoring.

2.i. Refer also to the findings for Patient 10 under Tag A2409 related to the hospital's failure to affect a transfer that met all of the appropriate transfer requirements.

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3.a. Review of the central log for Patient 16 reflected they arrived to the ED on 03/26/2023 at 1938 with a chief complaint of "Pregnant." The log reflected the patient's "[Discharge Disposition]" was "[Transfer to another hospital]," and "[Discharge]" date and time were recorded as 03/26/2023 at 2030, 52 minutes after arrival.

3.b. The medical record for Patient 16's 03/26/2023 encounter was reviewed and included the following triage and MSE documentation:
* At 1939 the "Arrival Complaint" was recorded as "Pregnant."
* At 1940 an RN recorded "[Physician V] at bedside to do pt assessment."
* At 1940 an RN recorded "Chief Complaint Updated" to "Pregnancy, Vaginal Discharge."
* At 1940 an RN recorded "Pt presents G2P1 30weeks plus 1 day with concern water broke over 24 hours ago because [they] cannot 'stop leaking' denies bloody show. Last pregnancy was full term, c-section ... having some decreased fetal movement ... does not feel need to bare [sic] down at this time; denies abd or back pain."
* At 1941 an RN recorded "Vital Signs" that included HR of 119, BP of 147/71, and RR of 20.
* At 1942 an RN recorded "Triage Plan Patient Acuity: 1-Resuscitation ... Triage Complete."
* At 1945 an RN recorded "Fetal Heart Rate" by "Doppler" of "135-150."
* At 1953 a call was made to request an OB "Consult."
* At 1955 the OB "Consult" responded.
* At 1957 and 1958 Physician V ordered the following: "CBC ... Basic Metabolic Panel; Hepatic Function Panel ... Saline Lock IV ... POCT Urine Dipstick ... Urine Total Protein/Creatinine Ratio."
* At 1958 an RN recorded "Pt denies having contraction, denies pain. Pt states [they] thinks [their] water broke and states the 'fluid' was clear. Denies any odor associated with 'fluid.'"
* At 2009 Physician V recorded "ED Disposition set to Transferred to Another Facility."
* At 2018 an RN recorded "Per [Physician V's] instructions, IV is left in place. IV in right forearm is intact, flushing and drawing well. IV is secured, iv [sic] locked, and wrapped with tagaderm [sic] for transport. [RN at LEMC] is aware of IV remaining in place. Pt and significant other given clear directions by [Physician V] to drive via POV directly to [LEMC] where they will be expecting pt at FBC. Pt and s/o understood and agreed to instructions."
* At 2030 an RN recorded "Patient discharged."

3.c. The medical record for Patient 16 contained an "ED Provider Note" electronically signed by Physician V the following morning on 03/27/2023 at 0145. That note included the following MSE information for Patient 16:
* Patient 16 "G2P1 ... approximately 30 weeks pregnant who presents to ED with concern for water break and decreased fetal movement that started yesterday ... started leaking clear liquid yesterday and it is non-bloody ... will come out more when [they are] either coughing or sneezing. Also complains of ongoing cough and post-tussive emesis for a few days. [Their] last pregnancy was full term and [they] had a c-section. History of high blood pressure but is not medicated for it. Denies abdominal pain/cramping. bloody discharge, fevers, headaches, or any other medical complaints."
* "BP (!) 162/80 - Pulse 119 ... Gravid and non-tender abdomen."
* "MDM Summary ... Concern for premature rupture of membranes and decreased fetal movement. Differential diagnosis includes but is not limited to pregnancy, ruptured membrane, UTI, amongst others. [Patient 16] does have blood pressure that is initially elevated in the severe range. [They do] not have other symptoms of preeclampsia ... not currently taking blood pressure medications. Plan for labs and consult with OBGYN."
* "Diagnostic tests considered but not performed: CT or US imaging of abdomen. Will consult with OBGYN first and re-assess."
* "I reviewed the relevant lab and imaging studies to help with my assessment and plan for this patient. I independently interpreted the following: No results found for this visit on 03/26/23."
* "1955 I consulted [on-call OB] who requested labs and urine and that if patient's second BP is not in the severe range, then patient can transfer to [LEMC] in private vehicle. I also consulted [OB hospitalist at LEMC], who accepted patient for transfer."
* "2000 Fetal heart rate of 135-150 BPM over 60 seconds. Repeat BP of 134/70."
* "2006 Patient re-evaluated and is stable. [They feel] comfortable going to [LEMC] in private vehicle."
* "Considered admission or transfer given patient is 30 weeks pregnant and may have a ruptured membrane."
* "Patient presents with concern for water break and decreased fetal movement today. On exam, [patient] is well-appearing, comfortable and has a gravid and non-tender abdomen. There is a fetal heart rate of 135-150 BPM over 60 seconds ... OB hospitalist at [LEMC], accepted patient for transfer for further evaluation. [Patient's] blood pressure normalized here in the ED without any medical intervention and [they are] stable for transfer to [LEMC] via private vehicle."
* "Discussed with patient the diagnostic findings, aftercare, follow-up, and return precautions. Patient was given the opportunity to ask questions."
* "Diagnosis and Disposition: 1. Pregnancy complications, antepartum, third trimester 2. Elevated blood pressure reading."

3.d. There was no documentation in Patient 16's medical record to reflect that the MSE included objective evaluation of possible ruptured membranes, uterine activity, or cervical dilation within the capabilities of LMHMC. Further, the MSE included only one "60 second" evaluation of FHR and did not include other objective assessment of fetal health and movement. For instance, there was no evidence of an ultrasound assessment within the capabilities of LMHMC.

3.e. Patient 16's medical record did not include documentation to reflect what discussion occurred between Physician V and the OB consulting physician as to what specific aspects of examination and treatment LEMC had capability to provide for the patient that LMHMC did not, and what specifically necessitated the need for transfer.

3.f. Documentation on an "EMTALA Patient Transfer Form" signed by Physician V on 03/26/2023 at 2008 reflected "Emergency Medical Condition (EMC) or Summary of Diagnosis: Pregnant, Leaking fluids," and "Reason for Transfer ... Lack of capacity and/or capability" as "need for OB care." It was not clear what aspects of an MSE LMHMC did not have capabilities or capacity for.

3.g. An email from Physician V was dated 04/05/2023 at 1600 and was forwarded to the survey team on 04/06/2023 at 1006. In the email Physician V wrote they "Yes, I saw [Patient 16]. As I recall [their] initial BP was elevated in the severe range. After discussing with the [OB] on call, we determined that if [their] BP were to not still be in the severe range on recheck and [they were] clinically stable that [they] could be transferred by private vehicle. [Their] repeat BP was not in the severe range and [they were] very comfortable on re-eval." I did talk with [Patient 16] about my discussion with the [OB] doc and that since [they were] stable, it appeared safe to transfer by POV. I try to have an even-handed discussion with my patients about risks and benefits on both side of choices (such as transfer by POV vs. EMS or admission vs. DC) and while I do not remember exactly what risks I articulated, I likely said something to the effect that we could call an ambulance to transport [them] and that it's conceivable something could happen between here and [LEMC] where the paramedics could intervene but that after discussion with [OB] and improvement in BP it appeared safe to go by POV. I likely would also have mentioned something to the effect that transfer by POV would almost certainly be faster and there could be cost to taking an ambulance." There was no other information provided about Patient 16's encounter.

3.h. Refer also to the findings for Patient 16 under Tag A2409 related to the hospital's failure to affect a transfer that met all of the appropriate transfer requirements.

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4.a. Review of the central log for Patient 21 reflected they arrived to the ED on 03/30/2023 at 2352 with a chief complaint of "Vaginal Bleeding; 24 weeks pregnant." The log reflected the patient's "[Discharge Disposition]" was "[Transfer to another hospital]," and "[Discharge]" date and time were recorded as 03/31/2023 at 0116, one-hour and 24 minutes after arrival.

4.b. The medical record for Patient 21's 03/30/2023 encounter was reviewed and included the following triage and MSE documentation:
* At 2352 the "Arrival Complaint" was recorded as "Vaginal bleeding, 24 weeks pregnant."
* At 2354 an RN recorded "Pt is 24 wks and 4 days pregnant, G2 P1 with vaginal bleeding that started yesterday morning, started as brown, now bright red, low pelvic cramping starting this evening, intermittent."
* At 2355 an RN recorded "Vital Signs" that included HR of 100, BP of 122/68, and RR of 14.
* At 2356 an RN recorded "Triage Plan Patient Acuity: 12-Emergency ... Triage Complete."
* At 2359 Physician U was assigned to Patient 21's encounter and "Patient Care Initiated."
* On 03/31/2023 at 0007 a call was made to request an OB "Consult."
* At 0012 the OB "Consult" responded.
* At 0017 an RN recorded "Fetal Heart Rate" by "Doppler" of "140 bpm."
* At 0018 an RN recorded "All Patients Subjective Assessment - Fetal Movement: Present (pt has had previa previously) - Bleeding: Bleeding."
* At 0022 Physician U ordered the following: "Maintain IV Access ... CBC ..."
* At 0031 an RN recorded an IV was placed, flushed and dressed.
* At 0043 an RN recorded a "Pelvic Exam ... Performed by [Physician U] .. Vaginal Exam Type: Speculum ..."
* At 0050 Physician U recorded "ED Disposition set to Transferred to Another Facility."
* At 0050 Physician U recorded "Discharge Instructions" as "Please go directly to the Family Birth Center at [LEMC].'
* At 0113 an RN recorded that there was "Small delay in patient leaving. Pt called mid-wife with an update and just wanted to let the mid-wife know what we did here and found in the pelvic exam. Pt's mid-wife stayed on track with treatment and pt is now willing to continue to head over to [LEMC]."
* At 0115 an RN recorded "Departure Mode: With significant other ... (ride to [LEMC])."
* At 0115 an RN recorded "Patient went home."
* At 0116 an RN recorded "Patient discharged."

4.c. The medical record for Patient 21 contained an "ED Provider Note" electronically signed by Physician U on 03/31/2023 at 1727. That note included the following MSE information for Patient 21:
* Patient 21 "G2P1 ... who is 24 weeks and 4 days pregnant who presents to ED with vaginal bleeding ... pelvic cramping and tightness ... reports [they] called the on call Mount Hood family medicine [clinic] today and [were] advised to visit this ED for US imaging and further evaluation. Denies contractions."
* "MDM Summary ... 1. Vaginal bleeding and pelvic cramping - Differential diagnosis includes but is not limited to complications with pregnancy, second trimester bleeding, pelvic cramping, amongst others. Plan OB consult. Diagnostic tests considered by not performed: none."
* "I reviewed the relevant lab and imaging studies to help with my assessment and plan for this patient. I independently interpreted the following: No results found for this visit on 03/30/23. Labs reviewed. CBC with anemia ... otherwise unremarkable."
* "OB consult - [OB physician] - agrees with plan for transfer."
* "0035 Speculum exam showed white discharge and no bleeding from cervix. Patient refused ambulance transport and is requesting private vehicle transport. Given presentation today, feel this is appropriate."
* "Possible transfer to [LEMC] or another hospital given no FBC here at [LMHMC]."
* "Patient presents with vaginal bleeding that started yesterday and pelvic cramping today. On speculum exam, there was white discharge and no active bleeding from the cervix. Given [patient's] presentation and there is no FBC here at [LMHMC], [patient] requires transfer to [LEMC] ED for further evaluation. Patient agreeable to plan.
* "Diagnosis and Disposition: 1. Second trimester bleeding."

4.d. There was no documentation in Patient 21's medical record to reflect that the MSE included objective evaluation of uterine activity, and although a pelvic exam was done there was no evaluation of possible ruptured membranes or cervical dilation. Further, the MSE included only one episode of FHR evaluation and did not include other objective assessment of fetal health and movement. For instance, there was no evidence of an ultrasound assessment within the capabilities of LMHMC and for which the patient was advised by the clinic to go to the LMHMC ED.

4.e. Patient 21's medical record did not include documentation to reflect what discussion occurred between Physician U and the OB consulting physician as to what specific aspects of examination and treatment LEMC had capability to provide for the patient that LMHMC did not, and what specifically necessitated the need for transfer.

4.f. Documentation on an "EMTALA Patient Transfer Form" signed by Physician U on 03/31/2023 at 0046 reflected "Emergency Medical Condition (EMC) or Summary of Diagnosis: vagbleeding [sic]" and "Reason for Transfer ... Lack of capacity and/or capability" as "No FBC." It was not clear what aspects of an MSE LMHMC did not have capabilities or capacity for.

4.g. An email from the LMHMC CMO dated 04/06/2023 at 1632 was forwarded to the survey team on 04/06/2023 at 1647. In the email the CMO wrote: "I spoke with [Physician U] on 4/5/23 at approximately 1:35 p.m. regarding [Patient 21]. [Physician U] does not recall the specifics of [their] transfer conversation ... although [their] standard work is to review the patient-specific risks of transfer during the transfer discussion." There was no other information provided about Patient 21's encounter.

4.h. Refer also to the findings for Patient 21 under Tag A2409 related to the hospital's failure to affect a transfer that met all of the appropriate transfer requirements.







































29708

Based on interviews and email communications, review of central log and medical record documentation for 6 of 7 individuals, including three who were pregnant, who presented to the hospital for emergency services and were transferred to other hospitals for further examination or stabilizing treatment (Patients 2, 6, 10, 16, 20, and 21), and review of P&Ps, 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:
* Patients for whom EMCs had not been ruled out, were transferred to other hospitals for further examination and stabilizing treatment without a physician certification that included patient specific and individualized risks of transfer.
* Patients for whom EMCs had not been ruled out, were transferred to other hospitals for further examination and stabilizing treatment in POVs by family members. Appropriate medical transportation with qualified personnel was not used for transfer to ensure proper response to changes in patient condition, including management of IV cannulas left in place. Informed discussion with the patients about the additional risks of transfer by POV was not evident.

Findings include:

1. The P&P titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance for Legacy Health Emergency, Labor and Delivery, Psychiatric Emergency Services and Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements for Non-Compliance" with "Last Revision Date: 02/23," was reviewed. It stipulated:
* "Transfer of Unstable Individuals ... A decision regarding patient transfer may be made by either patient request or LIP certification."
* "Upon Individual request. An individual may be transferred if the individual or the person acting on the individual's behalf is fully informed of the risks of the transfer, the alternatives (if any) to the transfer, and of Legacy's obligations to provide further examination and treatment sufficient to stabilize the individual's EMC, and to provide for an appropriate transfer."
* "With certification. The individual may be transferred if a LIP or, should a LIP not physically be present at the time of the transfer, another Qualified Medical Person in consultation with a LIP, has certified that the medical benefits expected from transfer outweigh the risks. The date and time of the certification should be close in time to the actual transfer. A certification that is signed by a non-LIP Qualified Medical Person shall be countersigned by the responsible LIP within twenty-four (24) hours."
* "When Legacy transfers an individual with an unstabilized EMC to another facility, the transfer shall be carried out in accordance with the following procedures. The transfer shall be documented using the EMTALA Patient Transfer Form, which must be completed in full and included in the patient's medical record ..."
* "The transfer must be effected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The LIP is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer."
* "Patient Refusal of Transfer. If Legacy offers an appropriate transfer and informs the individual or the person acting on the individual's behalf of the risks and benefits to the individual of the transfer, but the individual or the person acting on the individual's behalf does not consent to the transfer, Legacy must take all reasonable steps to have the individual or person acting on the individual's behalf acknowledge such refusal in writing. If the individual refuses to acknowledge in writing, the medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual."

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2.a. The medical record of two-year-old Patient 2's 03/13/2023 encounter was reviewed and included the following:
* At 0533 an RN recorded "Arrival Complaint" as "Vomiting."
* At 0538 an RN recorded "Pt brought in by [patient's representative]. C/o vomiting x 2 this morning. [Patient's representative] is concerned that [patient] possibly swallowed a coin ..."
* The patient received an MSE and was transferred by POV with the patient representative to another hospital for further examination and stabilizing treatment of "Ingested FB."
* The record reflected Physician U discussed the transfer with the patient's representative. Those notes included:
- MD discharge instructions dated 03/13/2023 at 0724 reflected "Please go to the [LEMC Randall] ER."
- MD "ED Course" notes dated 03/13/2023 at 0735 reflected "Patient is vomiting here in the ED. Plan for transfer to [LEMC Randall]. Discussed with [patient's representative] plan for transfer. [Patient's representative] is agreeable to the plan."
* At 0747 an RN recorded "Patient discharged."

2.b. Physician transfer certification documentation on an "EMTALA Patient Transfer Form" signed by Physician U and dated 03/13/2023 at 0738 reflected:
* The risks of transfer were "Worsening Sx." The risks were not individualized and patient specific. It was not clear what "Worsening Sx" meant for Patient 2.
* The mode of transportation section reflected:
- "The patient will be transferred by qualified personnel and transportation equipment, including the use of necessary and medically appropriate life support measures ..." This was followed by "BLS," "ALS," "Secured Transport," "Air," and "Other:," each preceded by a checkbox. None of those checkboxes were marked.
- "Patient Requests Transfer by Privately Owned Vehicle (POV). The patient/representative requests transfer to receiving facility by POV and accepts the risks of transport by POV. The patient/representative was offered and declined transport by qualified personnel and transportation" preceded by a checkbox. An "X" was recorded in that checkbox.
- Spaces for patient/representative signature, date, and time. Those spaces were blank.
* The patient consent section was signed by Patient 2's representative on 03/13/2023 at 0737 and included:
- A paragraph preceded by a checkbox reflected "I acknowledge that my medical condition has been evaluated and explained to me by the physician who has recommended that I be transferred. The potential benefits and risks associated with transfer and the probable risks of not being transferred have been explained to me and I fully understand them. With this knowledge and understanding, I agree and consent to be transferred." An "X" was recorded in that checkbox.

2.c. The documentation in the medical record was not clear the hospital obtained or attempted to obtain a written informed refusal of an appropriate transfer. Although the documentation reflected Patient 2's representative "accepts the risks of transport by POV" and had been offered and declined an appropriate transfer, there was no documentation on the transfer form or elsewhere in the medical record that reflected Patient 2's representative had been informed of the additional risks of transfer by POV. It was also not clear who initiated the discussion about transporting the patient by POV.

2.d. An email from the LMHMC CMO dated 04/06/2023 at 1632 was forwarded to the survey team on 04/06/2023 at 1647. In the email the CMO wrote: "I spoke with [Physician U] on 4/5/23 at approximately 1:35 p.m. regarding [Patient 2]. [Physician U] does not recall the specifics of [their] transfer conversation ... although [their] standard work is to review the patient-specific risks of transfer during the transfer discussion." There was no other information provided about Patient 2's encounter.

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3.a. The medical record of Patient 6's 03/16/2023 encounter was reviewed and included the following:
* At 1235 an RN recorded "Arrival Complaint" as "Fall."
* The patient received an MSE and was transferred to another hospital for further examination and stabilizing treatment of an "Intracranial Bleed."
* At 1245 an RN recorded ""Pt states that [they] fell off of [their] roof ... presents with approx 1 cm lac to the back of [their] head ... had a LOC approx. 3 min ..."
* At 1251 an RN recorded vital signs and the BP was "227/112!".
* At 1540 an RN recorded vital signs and the BP was "161/111!".
* At 1609 an RN recorded vital signs and the BP was "197/94!".
* At 1637 PA-C ED "Visit Diagnoses" included:
- "Subdural hematoma ..."
- "Subarachnoid hematoma ..."
- "Intraparenchymal hemorrhage of brain ..."
- "Laceration of scalp ..."
- "Fall from roof ..."
- "Left lower lobe pulmonary nodule ..."
- "Abrasion of scalp ..."
* At 1639 an RN recorded "Patient discharged."

3.b. Physician transfer certification documentation on an "EMTALA Patient Transfer Form" signed by Physician V and dated 03/16/2023 at 1620 reflected the patient was transferred by "ALS" to LEMC and the risks of transfer were "Unanticipated Deterioration, Delays, Accidents." The risks were not individualized and patient specific. It was not clear what "Unanticipated Deterioration" meant for Patient 6. Delays and accidents are not patient specific risks as those are applicable to all transfers. There was no documentation on the transfer form or elsewhere in the medical record that reflected individualized and patient specific risks had been identified and the patient had been informed of the risks.

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4.a. Review of the central log for Patient 10 reflected they arrived to the ED on 03/22/2023 at 0523 with a chief complaint of "Abdominal Pain; 36wks pregnant." The log reflected the patient's "[Discharge Disposition]" was "[Transfer to another hospital]," and "[Discharge]" date and time were recorded as 03/22/2023 at 0634, 71 minutes after arrival.

4.b. The medical record for Patient 10's 03/22/2023 encounter was reviewed and included the following:
* At 0523 an RN recorded "Arrival Complaint" as "Abdominal Pain; 36weeks pregnant."
* At 0531 an RN recorded "EDC 4-16-2023, scheduled c -section today at Legacy Salmon Creek. Denies vag bleeding or fluid discharge. Nauseated. Abd pain started one hour pta."
* At 0545 a "Consults" note reflected the OB "Consult by phone complete - Transport initiated during call - Lifelight [sic] Air activated by CRN."
* At 0549 an RN recorded "Call placed to Life Flight to activate crew. ETA 0615."
* At 0632 an RN recorded "Life Flight crew leaving department."

4.c. The medical record for patient 10 contained an "ED Provider Note* electronically signed by Physician S at 0717. That note included the following information for Patient 10:
* "Patient 10 "presents w/ abd pain, n/v, 36w3d twins."
* "Clinical Course: 0546: Consult: I discussed the management of patient with the following consultants or providers to determine disposition: ... obgyn from [LEMC]. Agrees patient needs to be transferred. We are going to connect to [another physician] at [LSCMC] as patient gets primary OB/GYN care there, due to deliver there tomorrow. Lifelight [sic] being activated to start preparing for potential take-off. 0551: [Patient 10 accepted for transfer by LSCMC physician]. 0632: Patient leaving department, feels improved. Tylenol and Zofran seem to improve patient's symptoms. Vital signs stable."
* "Diagnosis and Disposition: 1. Acute abdominal pain 2. Nausea and vomiting, unspecified vomiting type 3. Third trimester pregnancy Condition: Improved Disposition: LifeFlight transfer to [LSCMC]."

4.d. Physician transfer certification documentation on an "EMTALA Patient Transfer Form" was signed by Physician S on 03/22/2023 at 0551 and reflected:
* "Emergency Medical Condition (EMC) or Summary of Diagnosis: possible labor" and that Patient 10 was "Clinically Stable: EMC is not resolved and patient requires continued medical care, but no material deterioration of the patient's condition is likely to result from transfer."
* "Reason for Transfer" was "Medically Indicated" and "Lack of capacity and/or capability. The patient/condition cannot be managed at this facility due to: OBGYN."
* "Document benefits and risks specific to the patient's condition and discuss with the patient/representative. Benefits: specialty care. poss delivery. Risks: worsening during tx."
* "Mode of Transportation" was recorded as "Air."

4.e. There was no documentation on the transfer form or elsewhere in the medical record to reflect that Physician S informed Patient 10 of the individualized and specific risks of transfer for Patient 10 and their unborn twins.

4.f. During telephone interview with Physician S on 04/05/2023 at 1315 they stated they "don't remember details" about Patient 10's encounter, so could only say what their usual practice was. Physician S stated they would have described the risks to "[Patient 10]" and "babies," they would have said that LMHMC didn't have fetal monitoring, that something might go wrong, that they might deliver on the flight.

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5.a. Review of the central log for Patient 16 reflected they arrived to the ED on 03/26/2023 at 1938 with a chief complaint of "Pregnant." The log reflected the patient's "[Discharge Disposition]" was "[Transfer to another hospital]," and "[Discharge]" date and time were recorded as 03/26/2023 at 2030, 52 minutes after arrival.

5.b. The medical record for Patient 16's 03/26/2023 encounter was reviewed and included the following:
* At 1940 an RN recorded "Pt presents G2P1 30weeks plus 1 day with concern water broke over 24 hours ago because [they] cannot 'stop leaking' denies bloody show. Last pregnancy was full term, c-section ... having some decreased fetal movement ... does not feel need to bare [sic] down at this time; denies abd or back pain."
* At 1953 a call was made to request an OB "Consult."
* At 1955 the OB "Consult" responded.
* At 2009 Physician V recorded "ED Disposition set to Transferred to Another Facility."
* At 2018 an RN recorded "Per [Physician V's] instructions, IV is left in place. IV in right forearm is intact, flushing and drawing well. IV is secured, iv [sic] locked, and wrapped with tagaderm [sic] for transport. [RN at LEMC] is aware of IV remaining in place. Pt and significant other given clear directions by [Physician V] to drive via POV directly to [LEMC] where they will be expecting pt at FBC. Pt and s/o understood and agreed to instructions."
* At 2030 an RN recorded "Patient discharged."

5.c. The medical record for Patient 16 contained an "ED Provider Note" electronically signed by Physician V the following morning on 03/27/2023 at 0145. That note included the following MSE information for Patient 16:
* Patient 16 "G2P1 ... approximately 30 weeks pregnant who presents to ED with concern for water break and decreased fetal movement that started yesterday ... started leaking clear liquid yesterday and it is non-bloody ... will come out more when [they are] either coughing or sneezing. Also complains of ongoing cough and post-tussive emesis for a few days. [Their] last pregnancy was full term and [they] had a c-section. History of high blood pressure but is not medicated for it. Denies abdominal pain/cramping. bloody discharge, fevers, headaches, or any other medical complaints."
* "BP (!) 162/80 - Pulse 119 ... Gravid and non-tender abdomen."
* "MDM Summary ... Concern for premature rupture of membranes and decreased fetal movement. Differential diagnosis includes but is not limited to pregnancy, ruptured membrane, UTI, amongst others. [Patient 16] does have blood pressure that is initially elevated in the severe range. [They do] not have other symptoms of preeclampsia ... not currently taking blood pressure medications. Plan for labs and consult with OBGYN."
* "1955 I consulted [on-call OB] who requested labs and urine and that if patient's second BP is not in the severe range, then patient can transfer to [LEMC] in private vehicle. I also consulted [OB hospitalist at LEMC], who accepted patient for transfer."
* "2006 Patient re-evaluated and is stable. [They feel] comfortable going to [LEMC] in private vehicle."
* "Patient presents with concern for water break and decreased fetal movement today. On exam, [patient] is well-appearing, comfortable and has a gravid and non-tender abdomen. There is a fetal heart rate of 135-150 BPM over 60 seconds ... OB hospitalist at [LEMC], accepted patient for transfer for further evaluation. [Patient's] blood pressure normalized here in the ED without any medical intervention and [they are] stable for transfer to [LEMC] via private vehicle."
* "Discussed with patient the diagnostic findings, aftercare, follow-up, and return precautions. Patient was given the opportunity to ask questions."
* "Diagnosis and Disposition: 1. Pregnancy complications, antepartum, third trimester 2. Elevated blood pressure reading."

5.d. Physician transfer certification documentation on an "EMTALA Patient Transfer Form" was signed by Physician V on 03/26/2023 at 2008 and reflected:
* "Emergency Medical Condition (EMC) or Summary of Diagnosis: Pregnant, Leaking fluids" and that Patient 16 was "Clinically Stable: EMC is not resolved and patient requires continued medical care, but no material deterioration of the patient's condition is likely to result from transfer."
* "Reason for Transfer" was "Medically Indicated" and "Lack of capacity and/or capability. The patient/condition cannot be managed at this facility due to: need for OB care."
* "Document benefits and risks specific to the patient's condition and discuss with the patient/representative. Benefits: OB Care. Risks: Death."
* "Mode of Transportation" was recorded as "Patient Requests Transfer by [POV]." The following statement read that "The patient/representative requests transfer to receiving facility by POV and accepts the risks of transport by POV. The patient/representative was offered and declined transport by qualified personnel and transportation equipment." The section was signed by Patient 16 on 03/26/2023 at 2012.

5.e. There was no documentation on the transfer form or elsewhere in the medical record to reflect that Physician V had informed Patient 16 of other individualized and specific risks of transfer for Patient 16 and their unborn child, except for the risk of "Death." It was not clear whether that was death of the patient or death of the child.

5.f. It was not clear in the medical record documentation whether the patient had initiated the request to take a POV in response to being informed that an EMS transfer was planned, or whether the patient had been initially informed that they had the option of transfer by POV as well as EMS. In addition, there was no documentation on the transfer form or elsewhere in the medical record to reflect that Physician V had informed Patient 16 of the additional risks of driving a POV for the transfer.

5.g. An email from Physician V was dated 04/05/2023 at 1600 and was forwarded to the survey team on 04/06/2023 at 1006. In the email Physician V wrote they "Yes, I saw [Patient 16]. As I recall [their] initial BP was elevated in the severe range. After discussing with the [OB] on call, we determined that if [their] BP were to not still be in the severe range on recheck and [they were] clinically stable that [they] could be transferred by private vehicle. [Their] repeat BP was not in the severe range and [they were] very comfortable on re-eval." I did talk with [Patient 16] about my discussion with the [OB] doc and that since [they were] stable, it appeared safe to transfer by POV. I try to have an even-handed discussion with my patients about risks and benefits on both side of choices (such as transfer by POV vs. EMS or admission vs. DC) and while I do not remember exactly what risks I articulated, I likely said something to the effect that we could call an ambulance to transport [them] and that it's conceivable something could happen between here and [LEMC] where the paramedics could intervene but that after discussion with [OB] and improvement in BP it appeared safe to go by POV. I likely would also have mentioned something to the effect that transfer by POV would almost certainly be faster and there could be cost to taking an ambulance."

It was unclear in this email who initiated the discussion about the use of a POV for transfer, made further unclear by Physician V's statements that POV transport would "be faster" and "there could be cost to taking an ambulance." Transport by POV would not necessarily be "faster" and would certainly take longer if the POV was involved in a MVA or encountered a MVA or other traffic-slowing event en route to the other hospital. Further, initiating discussion about the cost of an ambulance is an action that may dissuade patients from the use of safe and appropriate transportation for an EMC that has not been ruled out.

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6.a. The medical record of Patient 20's 03/30/2023 encounter was reviewed and included the following:
* At 2311 an RN recorded "Arrival Complaint" was "Animal Bite."
* At 2312 an RN recorded "Pt reports [they were] bit by a dog on [their] forehead ... intoxicated per [their] report ... Large jagged lac noted to forehead ..."
* The patient received an MSE and was transferred by POV with a family member to another hospital for further examination and stabilizing treatment of a "dog bite wound."
* On 03/31/2023 at 0001 an RN note reflected a "Peripheral IV" was placed to the left antecubital.
* At 0125 an RN note reflected "... Pt has ride to [LEMC from [family member]. Pt and family verbalize understanding of the plan for transfer to [LEMC] ... MD verbalized pt is ready to go."
* At 0129 an RN note reflected "Patient discharged."

6.b. Physician transfer certification documentation on an "EMTALA Patient Transfer Form" signed by Physician W and dated 03/31/2023 at 0104 reflected:
* The risks of transfer were "Unanticipated worsening of condition." The risks were not individualized and patient specific. It was not clear what "worsening of condition" meant for Patient 20.
* The mode of transportation section reflected:
- "The patient will be transferred by qualified personnel and transportation equipment, including the use of necessary and medically appropriate life support measures ..." This was followed by "BLS," "ALS," "Secured Transport," "Air," and "Other:," each preceded by a checkbox. None of those checkboxes were marked.
- "Patient Requests Transfer by Privately Owned Vehicle (POV). The patient/representative requests transfer to receiving facility by POV and accepts the risks of transport by POV. The patient/representative was offered and declined transport by qualified personnel and transportation." This was preceded by a checkbox. An "X" was recorded in that checkbox.
- This section was signed by the patient and dated 03/31/2023 at 0108.
* The patient consent section included:
- A paragraph preceded by a checkbox reflected "I acknowledge that my medical condition has been evaluated and explained to me by the physician who has recommended that I be transferred. The potential benefits and risks associated with transfer and the probable risks of not being transferred have been explained to me and I fully understand them. With this knowledge and understanding, I agree and consent to be transferred." An "X" was recorded in that checkbox.
- This section was was signed by the patient and dated 03/31/2023 at 0107.

6.c. The documentation in the medical record was not clear that the hospital obtained or attempted to obtain a written informed refusal of an appropriate transfer. The patient, who was intoxicated was transferred by POV with an intact IV and a large forehead laceration. There was no documentation in the medical record that reflected the IV was removed prior to transfer. Although the documentation reflected Patient 20 "accepts the risks of transport by POV" and had been offered and declined an appropriate transfer, there was no documentation on the transfer form or elsewhere in the medical record that reflected Patient 20 had been informed of the additional risks of transfer by POV, including how they should manage and protect their IV during transport. It was also not clear who initiated the discussion about transporting the patient by POV.

6.d. An email from the LMHMC CMO dated 04/06/2023 at 1632 was forwarded to the survey team on 04/06/2023 at 1650. In the email the CMO wrote: "On 4/6/23 at 11:15 a.m., I spoke to [Physician W] about LMH ED [Patient 20]. Below is a summary of [their] recollection of the patient encounter: [Physician W] stated that the patient was accompanied by [family member], who was not intoxicated (as the patient was), and was able to understand the situation and give consent along with the patient. The deep dog bite to the face clearly needed surgical repair by a specialist, rather than repair in the ER. [Physician W] considered this an obvious need for transfer in a stable patient. [Physician W] consulted multiple specialists and arranged transfer. [Physician W] conveyed that the patient would undergo more risk by remaining in the LMH ED. [Physician W] discussed with the patient and [family member] that risks of transport could include more bleeding during transport, although bleeding was controlled in ED and the patient was stable. It is [Physician W's] standard work to also include worsening of condition as a possible risk of transfer, up to death. [Physician W] always offers ambulance transport, though transport time can be longer than by private vehicle. The Oral Maxillofacial surgeon felt that a longer wait time could worsen the cosmetic outcome and raise the risk for infection. Delay might also mean that a different OMFS surgeon from the one who took report might be on service, which could be worse for patient care. The patient and family were very eager to have a surgeon repair it quickly and were comfortable with the [family member] driving the patient to the receiving hospital."

It was not clear in this email who initiated the discussion about using a POV for a patient transport considering the statement that ambulance transport time can be longer than by private vehicle and "a longer wait time could worsen the cosmetic outcome and raise the risk for infection." Although the email included the physician discussed that risks of transport could include more bleeding, it was not clear if this risk was about transport by POV or by ambulance.

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7.a. Review of the central log for Patient 21 reflected they arrived to the ED on 03/30/2023 at 2352 with a chief complaint of "Vaginal Bleeding; 24 weeks pregnant." The log reflected the patient's "[Discharge Disposition]" was "[Transfer to another hospital]," and "[Discharge]" date and time were recorded as 03/31/2023 at 0116, one-hour and 24 minutes after arrival.

7.b. The medical record for Patient 21's 03/30/2023 encounter was reviewed and included the following triage and MSE documentation:
* At 2354 an RN recorded "Pt is 24 wks and 4 days pregnant, G2 P1 with vaginal bleeding that started yesterday morning, started as brown, now bright red, low pelvic cramping starting this evening, intermittent."
* At 0031 an RN recorded an IV was placed, flushed and dressed.
* At 0050 Physician U recorded "ED Disposition set to Transferred to Another Facility."
* At 0050 Physician U recorded "Discharge Instructions" as "Please go directly to the Family Birth Center at [LEMC].'
* At 0113 an RN recorded that there was "Small delay in patient leaving. Pt called mid-wife with an update and just wanted to let the mid-wife know what we did here and found in the pelvic exam. Pt's mid-wife stayed on track with treatment and pt is now willing to continue to head over to [LEMC]."
* At 0115 an RN recorded "Departure Mode: With significant other ... (ride to [LEMC])."
* At 0115 an RN recorded "Patient went home."
* At 0116 an RN recorded "Patient discharged."

7.c. The medical record for Patient 21 contained an "ED Provider Note" electronically signed by Physician U on 03/31/2023 at 1727. That note included the following MSE information for Patient 21:
* "MDM Summary ... 1. Vaginal bleeding and pelvic cramping - Differential diagnosis includes but is not limited to complications with pregnancy, second trimester bleeding, pelvic cramping, amongst others. Plan OB consult. Diagnostic tests considered by not performed: none."
* "OB consult - [OB physician] - agrees with plan for transfer."
* "0035 Speculum exam showed white discharge and no bleeding from cervix. Patient refused ambulance transport and is requesting private vehicle transport. Given presentation today, feel this is appropriate."
* "Possible transfer to [LEMC] or another hospital given no FBC here at [LMHMC]."
* "Patient presents with vaginal bleeding that started yesterday and pelvic cramping today. On speculum exam, there was white discharge and no active bleeding from the cervix. Given [patient's] presentation and there is no FBC here at [LMHMC], [patient] requires transfer to [LEMC] ED for further evaluation. Patient agreeable to plan.
* "Diagnosis and Disposition: 1. Second trimester bleeding."

7.d. Physician transfer certification documentation on an "EMTALA Patient Transfer Form" was signed by Physician U on 03/31/2023 at 0046 and reflected:
* "Emergency Medical Condition (EMC) or Summary of Diagnosis: vagbleeding [sic]."
* "Clinically Stable: EMC is not resolved and patient requires continued medical care, but no material deterioration of the patient's condition is likely to result from transfer."
* "Reason for Transfer" was "Medically Indicated" and "Lack of capacity and/or capability. The patient/condition cannot be managed at this facility due to: No FBC."
* "Document benefits and risks specific to the patient's condition and discuss with the patient/representative. Benefits: OB Care. Risks: worsening of condition."
* "Mode of Transportation" was recorded as "Patient Requests Transfer by [POV]." The following statement read that "The patient/representative requests transfer to receiving facility by POV and accepts the risks of transport by POV. The patient/representative was offered and declined transport by qualified personnel and transportation equipment." The section was signed by Patient 21 on 03/31/2023 at 0053.

7.e. There was no documentation on the transfer form or elsewhere in the medical record to reflect that Physician U had informed Patient 21 of the individualized and specific risks of transfer for Patient 21 and their unborn child. It was not clear what "worsening of condition" meant, what "condition" could worsen, and whether that applied to the patient or their unborn child.

7.f. In regards to Patient 21's refusal of ambulance transport there was no documentation on the transfer form or elsewhere in the medical record to reflect that Physician U had informed Patient 21 of the additional risks of driving a POV for the transfer. Further, although the medical record reflected an IV access had been placed, there was no documentation in the record to reflect it had been removed prior to transfer, and if it had not been removed, what instructions were provided and provisions made to protect the site during POV transfer.

7.g. An email from the LMHMC CMO dated 04/06/2023 at 1632 was forwarded to the survey team on 04/06/2023 at 1647. In the email the CMO wrote: "I spoke with [Physician U] on 4/5/23 at approximately 1:35 p.m. regarding [Patient 21]. [Physician U] does not recall the specifics of [their] transfer conversation ... although [their] standard work is to review the patient-specific risks of transfer during the transfer discussion."

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8.a. Internet/GPS distance calculators reflected that LSCMC in Vancouver, Washington is approximately 22 land miles from LMHMC in Gresham, Oregon.

8.b. Internet/GPS distance calculators reflected that LEMC in Portland, Oregon is approximately 17 miles, and approximately 30 minutes drive-time (dependent on time of day and metropolitan freeway commuter traffic), from LMHMC in Gresham, Oregon.







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