HospitalInspections.org

Based on interview, review of medical record or internal investigation documentation for 14 of 27 individuals who presented to PHCG for emergency services (Patients 2, 3, 4, 5, 6, 9, 12, 13, 14, 15, 16, 20, 22 and 23 ), review of medical record documentation for 20 patients who presented to other PeaceHealth hospitals (SHRB, SHUD and SWMC) for emergency services (Patients 28 through 47), review of the central log and review of hospital policies and procedures it was determined that the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure it met its EMTALA obligations in the following areas:
* To maintain a central log that was complete and accurately reflected the individuals who presented to PHCG for emergency services.
* To provide MSEs for all individuals who presented to the hospital for emergency services.
* To ensure that hospital staff did nothing to dissuade patients from staying at the hospital for the provision of a MSE and that staff obtained, or attempted to obtain, written and informed refusal of MSEs and treatment for individuals who left the hospital prior to an MSE.
* To provide stabilizing treatment within the hospital's capability and capacity for a patient with a psychiatric EMC.
* To provide appropriate transfers to other hospitals for further examination and stabilizing treatment not within PHCG's capability or capacity.

Findings included:

1. Refer to the findings identified under Tag C2405, CFR 489.20(r)(3), that reflects the hospital's failure to maintain a complete and accurate central log of those individuals who presented to PHCG.

2. Refer to the findings identified under Tag C2406, CFR 489.24(a)&(c), that reflects the hospital's failure to ensure all individuals who presented for emergency services received a MSE and the failure to obtain, or attempt to obtain, informed refusal of MSEs for those patients who left prior to an MSE.

3. Refer to the findings identified under Tag C2407, CFR 489.24(d), that reflects the hospital's failure to ensure all individuals with a psychiatric EMC received stabilizing treatment that protected the patient until an appropriate transfer could be affected.

4. Refer to the findings identified under Tag C2409, CFR 489.24(e), that reflects the hospital's failure to ensure the physician certification of transfer benefits and risks contained patient-specific and individualized risks of transfer and that appropriate transportation with qualified personnel was used.

Based on interview, review of medical record or internal investigation documentation and central log documentation for at least 19 of 27 individuals who presented to PHCG for emergency services (Patients 2, 3, 4, 6, 8, 9, 10, 12, 14, 15, 16, 17, 18, 21, 22, 24, 25, 26 and 27 ), review of medical record documentation for 20 patients who presented to other PeaceHealth hospitals (SHRB, SHUD and SWMC) for emergency services (Patients 28 through 47) and review of policies and procedures, it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure maintenance and timely retrieval of a central log that contained complete and accurate information about each individual who came to PHCG seeking emergency services. The central log was inaccurate and contained discrepancies related to PHCG patient encounters. Further it contained entries for individuals who presented to other PeaceHealth hospitals, identified only after patient medical records were selected from the log for this survey and provided to the surveyor. Based on the numerous iterations of the log that were submitted, there is a lack of confidence that the final version received was complete and accurate.

Findings included:

1. The P&P titled "[EMTALA] Compliance Procedure," dated as reviewed 10/25/2019, included the following:
* "Each facility maintains a central log of individuals who come to the ED or L&D seeking assistance, and indicate whether these individuals:
- Refused treatment;
- Were denied treatment;
- Were stabilized, admitted, transferred, or discharged; or
- Left the ED or L&D prior to being seen."

2.a. Multiple versions of the ED central log were provided that contained different content related to patients who presented to PHCG for emergency services. This created significant challenges in the selection of a patient sample of PHCG ED encounters as some PHCG patients were reflected on some log versions but not other log versions and it was discovered that patients from at least three other PeaceHealth hospitals in Oregon and Washington States were also reflected on the logs provided. For example:

* Regarding the April 2020 log:
- One printed version reflected approximately 304 patient encounters for the month.
- A second version reflected approximately 579 patient encounters for the same month.

* Regarding the May 2020 log:
- One printed version reflected approximately 343 patient encounters for the month.
- A second version reflected approximately 731 patient encounters for the same month.

* Regarding the June 2020 log:
- One printed version reflected approximately 390 patient encounters for the month.
- A second version reflected approximately 763 patient encounters for the same month.

* Regarding the July 2020 log:
- One printed version reflected approximately 447 patient encounters for the month.
- A second version reflected approximately 923 patient encounters for the same month.

* Regarding the August 2020 log:
- One printed version reflected approximately 41 patient encounters for the month.
- A second printed version reflected approximately 455 patient encounters for the same month.
- A third version reflected approximately 902 patient encounters for the same month, August 2020.

* Regarding the September 2020 log:
- One printed version reflected approximately 65 patient encounters for the month.
- A second printed version reflected approximately 306 patient encounters for the same month.
- A third version reflected approximately 617 patient encounters for the same month, September 2020.

2.b. PHCG patients were not consistently identified on all versions of the ED log provided. For example:

* Regarding May 2020 log entries:
- Patient 6 was not identified on the first log version.

* Regarding June 2020 log entries:
- Patients 8, 9, 10 and 12 were not identified on the first log version.

* Regarding July 2020 log entries:
- Patients 14 and 16 were not identified on the first log version.

* Regarding August 2020 log entries:
- Patients 21 and 22 were not identified on the first log version.
- Patients 17, 18 and 22 were not identified on the second log version.

* Regarding September 2020 log entries:
- Patients 25 and 26 were not identified on the first log version.
- Patients 24, 25, 26, and 27 were not identified on the second log version.

2.c. The following medical records that reflected ED encounters for patients at other PeaceHealth hospitals between 05/13/2020 and 09/19/2020 were provided to the surveyor after survey samples had been selected from the logs referenced under Finding 2.a. above in this Tag:

* SHRB ED medical records for Patients 29, 31, 32, 33, 35, 36, 37, 38, 39, 43, 44, 46 and 47.

* SHUD ED medical records for Patients 28, 30, 34, 40, 42 and 45.

* SWMC medical record for Patient 41.

3. Refer to the findings identified under Tag C2406, CFR 489.24(a)&(c), that reflected the following omissions and inaccuracies in the central log related to the encounters of patients who presented to PHCG for emergency services:

* Regarding Patient 2's 04/11/2021 encounter - The log disposition was recorded as LWBS, however, the medical record reflected that was not accurate as PHCG staff refused to triage or provide an MSE for the patient and had security escort the patient out of the ED.

* Regarding Patient 4's 05/02/2020 encounter - There was no entry in any version of the log to reflect that Patient 4 presented to the hospital for emergency services and no medical record for the encounter that PHCG staff confirmed did occur.

* Regarding Patient 15's 07/11/2021 encounter - The log disposition was recorded as "Home or Self Care," however, the medical record reflected that the patient refused further examination and left prior to completion of the MSE against medical advice.

4. Refer to the findings identified under Tag C2409, CFR 489.24(e) that reflected the following inaccuracies in the central log related to the encounters of patients who presented to PHCG for emergency services:

* Regarding Patient 3's 04/18/2020 encounter - The log disposition was unclear as it was recorded as "Diverted Elsewhere." The medical record reflected that the patient was transferred by EMS to another acute care hospital.

* Regarding Patient 6's 05/27/2020 encounter - The log disposition was "Home or Self-Care." However, the medical record reflected that the patient was transferred, with an intact IV line, to another acute care hospital.

* Regarding Patient 9's 06/05/2020 encounter - The log disposition was recorded as "CAH." However, the medical record reflected that patient was transferred, with an intact IV line, to another acute care hospital.

Based on interview, review of medical record or internal investigation documentation documentation for 10 of 27 individuals who presented to PHCG for emergency services (Patients 2, 4, 5, 12, 14, 15, 16, 20, 22 and 23) and review of policies and procedures it was determined that the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure that every individual who presented to the hospital for emergency services received a MSE within the hospital's capability and capacity, and that hospital staff did nothing to dissuade patients from staying at the hospital for the provision of a MSE:
* Patients 2 and 4, individuals who presented to the hospital for emergency services, did not receive MSEs and were directed by hospital staff to leave the hospital or go to another hospital in a neighboring town.
* Patient 14, an individual who presented for emergency services, did not receive an MSE that included laboratory or diagnostic tests within the hospital's capability.
* Other individuals who presented to the hospital for emergency services left the hospital before receiving a MSE, or before the MSE had been completed, some for reasons that were unclear or unexplained, and there was no evidence that staff obtained, or attempted to obtain, their informed and appropriate written refusal in accordance with the EMTALA P&Ps.
* Individuals who provided written refusal to complete an MSE or treatment were directed to sign a form with waiver of liability language that was prohibited by the hospital's P&Ps.

Findings include:

1. The P&P titled "[EMTALA] Compliance Procedure," dated as reviewed 10/25/2019, included the following:
* "The Medical Center provides an appropriate MSE by physicians or [QMPs] as defined by the Governing Board, within the capability and capacity of the Medical Center, regardless of the person's insurance status or ability to pay when:
- An individual comes to a dedicated ED or L&D and requests examination or treatment. The request for services may be made by the Patient or by another person on the Patient's behalf.
- Regardless of whether it is requested, if, by a person's appearance or behavior, a reasonably prudent layperson would conclude that an [EMC] exists, a MSE is provided ...
- Patients found on Medical Center grounds, including sidewalks, driveways, and parking lots or otherwise within 250 yards of the Medical Center, requesting emergency care or in obvious need of emergency care, are assisted by a Workforce member to whom they present, within the skills of the Workforce member, and taken or directed to the ED."
* "The Medical Center provides necessary stabilizing treatment for [EMCs] and laboring individuals within its capability and capacity."
* "If the Medical center is not capable of providing stabilizing treatment, it provides an appropriate transfer, regardless of the Patient's ability to pay."
* "Patients have the right to refuse any offered MSE and stabilizing treatment. Medical Center Workforce members:
- Explain the risks and benefits of screening and treatment;
- Make reasonable attempts to obtain the Patient's signed written refusal of examination and treatment, but the Patient's signature is not required;
- Do not suggest to Patients that they cannot leave the ED waiting room or treatment areas or go elsewhere for care; and
- Do not require the Patient to sign a waiver of liability prior to leaving without being seen."
* "Registration of the Patient may be started after the initial nurse triage as long as it does not delay the MSE."
* "Insurance authorization is not sought until after the MSE and necessary stabilizing treatment has begun, and then only if the process does not delay treatment or unduly discourage the Patient from remaining for further treatment."

2.a. Review of the ED central log reflected that Patient 2 presented to the hospital by "Other" on 04/11/2020 at 1043 and was discharged on 04/11/2020 at 1123. The patient's chief complaint was recorded as "Mental Health Crisis" and his/her disposition was recorded as "LWBS Before Triage."

2.b. Review of the medical record for Patient 2's 04/11/2020 encounter reflected it included the following entries:
* At 1043 a PAS recorded "Patient arrived in ED."
* At 1043 "Arrival Complaint" was recorded as "Mental Health Crisis."
* At 1044 "EDIE Resulted" was recorded.
* At 1114 the next entry recorded was by an RN who wrote "Provided pt with [his/her] paperwork and Zyprexa Rx from last night, which [he/she] left here after leaving abruptly. Pt requesting a ride to [SHRB]. Explained that we could not provide [him/her] with that. [Patient] denies any need to be seen at this time. Went over discharge instructions from last night. Instructed pt to fill the Rx at any pharmacy, provided pt with directions to Wal-mart which is the closest pharmacy. Assisted pt with making two phone calls, but pt could not find a ride. States that [he/she] lives within walking distance from hospital. Security on stand by. Pt asked if the police could be called because [he/she] wanted to be arrested. Inquired about why and pt states, 'for using Meth.' Pt also reports that [he/she] has some meth in [his/her] possession although this was never seen. Encouraged pt to dispose of the meth, fill [his/her] Rx for Zyprexa, and go home to rest. Explained that if [he/she] needed to speak with the police, [he/she] was free to call them [him/herself]. Pt verbalizes understanding. Asked to use the bathroom. After being show where the bathroom was, pt refused to enter. Security escorted pt to the front door of the hospital."
* At 1123 the next entry recorded was by the RN who wrote "Patient dismissed ... ED Disposition set to LWBS before Triage."

2.c. The medical record did not clearly reflect that Patient 2's encounter had proceeded appropriately. For example:
* Although the patient's chief complaint was "mental health crisis" and he/she verbalized and demonstrated erratic and potentially concerning behaviors during the encounter including seeking to go to another hospital and requesting that police be contacted so he/she would be arrested, the encounter was managed as a security matter and the patient was not triaged nor received an MSE.
* It was not clear how the patient presented or with who as the presentation mode was described as "Other."
* It was not clear how the chief complaint of "Mental Health Crisis" had been determined, who had stated that was the chief complaint and what that meant.
* It was not clear what happened between 1044 and 1114.
* It was unclear why the patient disposition was recorded as LWBS when in fact hospital staff refused the patient triage and told [him/her] to go home, [he/she] was not offered or provided an MSE and was escorted from the hospital by security.
* There was no documentation to reflect that hospital staff had attempted to explain the risks of leaving prior to an MSE to Patient 2 and had attempted to obtain his/her signed written refusal as required by the EMTALA P&P referenced in Finding 1 above in this Tag.

2.d. Further, contrary to the 1114 RN note from the encounter described under Finding 2.b. above, there was no indication in the patient's previous encounter record that he/she had left without discharge paperwork or had left "abruptly."
* Review of the medical record for the patient's previous encounter reflected he/she had been brought to the ED by police on 04/11/2020 at 0415 with "Anxiety" and was discharged on 04/11/2020 at 0519. At 0517 the RN had recorded "Discharge instructions and rx (1) read and given to the patient by the Doctor. Patient expressed understanding. No further questions/concerns. Patient ambulated out of the ED for discharge. Gait steady ..."

2.e. Patient 2's encounter was reviewed with staff that included the CEO, Medical Director, EDNM and RMs on 10/26/2020 beginning at 1300. During interviews at the time of the record review the EDNM acknowledged that the events during the encounter were not clear. The RM stated that "security reports" might provide additional information about the encounter and later during the interview reported that security staff had confirmed that there were no security reports written on that date. In a followup email from the RM on 10/27/2020 at 1208 he/she wrote that no additional information about Patient 2's 04/11/2020 encounter was found.

3.a. A document that contained a PHCG self-report to the SA of a potential EMTALA violation involving Patient 4 was reviewed. It included the following information:
* On 05/02/2020 at 1102 Patient 4 presented to PHCG ED with two children between the approximate ages of 5 and 10.
* Registration staff informed Patient 4 that due to COVID-19 restrictions the children could not accompany the patient into the ED as they were considered visitors.
* The staff person suggested that the children could "wait in the car" or "wait in the lobby."
* Patient 4 stated he/she did not want to leave the children unattended and had no one to call to pick them up.
* The patient proceeded to the "Walk-In Clinic" on the hospital's campus.
* At the clinic Patient 4 was informed that due to his/her symptoms, he/she needed to be seen in the ED.
* Patient 4 verbalized on the way out of the clinic that he/she intended to go to SHRB in another town.

3.b. Summary documentation reviewed about Patient 4's encounter at the hospital on 05/02/2020 included the following information:
* Patient 4 arrived to the ED with two children and asked to be seen because "[his/her] neck had started hurting the day before, [he/she] had numb feet and hands yesterday and a tightness in [his/her] chest."
* Because of the COVID-19 visitor restrictions in place at that time, registration staff conferred with an RN in the ED about having children present.
* The RN directed staff to ask the patient about having someone pick up the children and staff also suggested that the children wait in the lobby or in the patient's vehicle.
* After the patient indicated that those weren't acceptable options, staff suggested Patient 4 go to the "Walk-In" clinic on campus.
* Patient 4 went to the "Walk-In" clinic where they also did not see him/her and instead advised him/her to be seen in the ED because of [his/her] symptoms.
* Patient 4 told staff that he/she was going to go to the ED at SHRB and left the PHCG campus.
* The patient left PHCG without having received a MSE because he/she was told he/she could not be seen in the ED with his/her two small children present and because he/she was then told at the clinic that he/she needed to be seen in the ED.
* An occurrence report was filed on 05/02/2020 and hospital leadership staff began an investigation that included contact with Patient 4 about the encounter at PHCG, his/her condition and whether he/she had received medical care.

3.c. Review of the central log revealed that it did not contain any entry to reflect that Patient 4 had presented to the hospital for emergency services on 05/02/2020.

3.d. Review of medical records revealed that no medical record had been generated for Patient 4's 05/02/2020 encounter at the hospital.

3.e. There was no documentation to reflect that, when Patient 4 proceeded to leave the ED, hospital staff had attempted to explain the risks of leaving prior to an MSE and had attempted to obtain his/her signed written refusal as required by the EMTALA P&P referenced in Finding 1 above in this Tag.

3.f. According to an on-line distance tool, SHRB in Springfield, Oregon is approximately 22 miles and 25 minutes drive-time from PHCG in Cottage Grove, Oregon.

3.g. Review of PHCG internal investigation documentation reflected the hospital had developed a corrective action plan in response to its investigation of Patient 4's encounter. Corrective actions included an email sent by the EDNM to PHCG staff that was dated 05/04/2020 at 1633 and included the following direction to staff: "... we have visitor restrictions in place due to Covid-19. Please keep in mind that PeaceHealth's visitor restrictions do not excuse us from offering [MSEs] and fulfilling our EMTALA responsibilities ... If a patient presents to be seen in the ED and is accompanied by children, we can't suggest to the parent that they won't be seen if they have children with them. Additionally, we can't suggest that they be seen in the clinic or anywhere else. We also should not be suggesting that the parent find child care or leave their children in their vehicle. Any suggestion that dissuades a patient from being seen in the ED can be construed as an EMTALA violation. We must offer a [MSE] to every patient that presents to the ED. In the case of a patient arriving with children, family caregiver, etc., we must make allowances to accomplish the [MSE]."

3.h. Patient 4's 05/02/2020 encounter was reviewed with staff that included the CEO, Medical Director, EDNM and RMs on 10/26/2020 beginning at 1300. During interviews at the time of the record review staff present confirmed the findings described above for Patient 4. They further stated that the hospital had an EMTALA obligation and "at no point did staff say they wouldn't see [Patient 4]." No additional information was provided to contradict the findings above that reflected that hospital staff had dissuaded the patient from staying for an MSE.

4.a. Review of the ED central log reflected that Patient 14 presented to the hospital on 07/06/2020 at 0324 and was discharged on 07/06/2020 at 0358. The patient's chief complaint was recorded as "Hallucinations" and his/her disposition was recorded as "Home or Self Care."

4.b. Review of the medical record for Patient 14's 07/06/2020 encounter reflected it included the following entries:
* At 0324 an entry reflected that the patient arrived to the ED by car.
* At 0332 an RN recorded VS that included HR of 122 and "BP (!) 152/119."
* At 0341 an RN recorded "Patient presents with concerns that [he/she] is having 'hallucinations that seemed to be going on since last Thursday ever since starting flexeril'. Patient states [he/she] 'will at time think [he/she] is dreaming but then realize it is not real'. Patient awake, alert, oriented, Skin pink, warm, dry. Gait steady."
* At 0345 an AVS form was generated with an electronic notation that it was "Printed at 7/6/2020 3:45 AM."
* At 0357 the RN recorded "Discharge instructions read and given to the patient and patient's SO by the ER Doctor. Patient expressed understanding. Patient ambulated out of the ED with SO for discharge."
* At 0357 an MD recorded "[He/she] recently started to take Flexeril. "[He/she] has been taking it three times a day at the 10 mg dose. [He/she] then started to have hallucinations. Tonight [he/she] says that [his/her] bed was moved to the place [he/she] works, and [his/her SO] say that [he/she] was cleaning up invisible dog and cat [waste] (they don't have animals) ... Vitals ... BP: (!) 152/119 ... Heart Rate: 122 ... slight tremor noted ... Based on my initial evaluation I think this is most likely an adverse reaction to Flexeril, but I also considered infection, intoxication, metabolic abnormality, and additional emergency causes of the Patient's presentation. Upon arrival [he/she] was already feeling better. I advised [him/her] to no longer take the medication, and that his should pass ... I found no evidence of a condition requiring further emergent medical intervention or admission ... Final impression Non-dose-related adverse effect of medication, initial encounter."
* At 1232 later that day, an AVS form was generated with an electronic notation that it was "Printed at 7/6/2020 12:32 PM."

4.c. There was no documentation of labwork or other diagnostic testing in the record. The patient's significantly elevated BP was not addressed nor retaken during the encounter, nor were the noted tremors addressed. In the absence of laboratory and diagnostic testing it was unclear how the "considerations" referenced in the MD's 0357 note had been ruled out. Further, review of the AVS form reflected no direction to stop taking Flexeril. The only mention of Flexeril was on the "Your Medication List" attached to the AVS which read "Ask your doctor about these medications: [Flexeril]."

4.d. Patient 14 's encounter was reviewed with staff that included the CEO, Medical Director, EDNM and RMs on 10/26/2020 at 1515. During interviews at the time of the record review the EDNM stated that there was no additional MSE information related to Patient 14's encounter.

5.a. Review of the ED central log reflected that Patient 5 presented to the hospital by "Ambulance" on 05/09/2020 at 1807 and was discharged on 05/09/2020 at 2002. The patient's chief complaint was recorded as "Hyperglycemia; Dizziness" and his/her disposition was recorded as "LWBS After Triage."

5.b. Review of the medical record for Patient 5's 05/09/2020 encounter reflected it included the following entries in the order that follows:
* At 1807 a PAS recorded "Patient arrived in ED."
* At 1810 an RN recorded "Triage Completed."
* At 1810 the RN recorded "Triage Started."
* At 1810 the RN recorded "Pt brought in by EMS with c/o high blood sugar. Pt states that [he/she] has been out of [his/her] insulin for about 4 days. Pt reports some lightheadedness at times and feels hot. [He/she] reports it was hot in [his/her] house also."
* At 1811 an MD recorded labwork and IV infusion orders that were the first of numerous labwork and infusion orders by the MD and a DO.
* At 1822 the first "POCT Glucose" result, identified as "Abnormal Result Collected: 5/9/2020 18:20 ... Glucose, POC: 377 mg/dL ^ (Ref Range: 70 - 99)."
* At 1901 a DO recorded "First Provider Evaluation of Patient."
* At 1906 the PAS recorded "Registration Completed."
* At 1917 an RN recorded "Pt asked for dinner tray, MD notified. Awaiting for further lab results before pt to be given food."
* At 1932 the RN recorded "Pt asks again for food. MD notified and agreed to a pack of crackers. Pt given a pack of saltine crackers, and pt stated, 'this is all, this is suppose to keep me going. I just want to leave.' RN tried to talk pt into waiting for labs to return and pt requests to leave. MD notified."
* At 1943 a "POCT Glucose" result, identified as "Abnormal Result Collected: 5/9/2020 19:41 ... Glucose, POC: 291 mg/dL ^ (Ref Range: 70 - 99)."
* At 1944 an RN recorded "Pt advised staff [he/she] wishes to leave. Pt states [he/she] is feeling a little better and is very hungry. Attempted to get pt to stay longer. Pt declined. Pt permitted CBG test prior to leaving. Pt signed AMA form. Encouraged to return as needed."
* At 1957 the RN recorded "Pt continues to request to leave. Encouraged to return to ED as needed and follow-up with [his/her] PCP. Assisted to main lobby via WC. Pt states friend to pick [him/her] up."
* At 2001 the RN recorded "ED Disposition set to LWBS after Triage."
* At 0058 on 05/10/2020, after the patient had left the hospital, labwork collected on 05/09/2020 at 1837, was "resulted" and included "Glucose 394 ^" and numerous other abnormal results.
* An untimed "Leaving Against Medical Advice" form was signed and dated by an RN and Patient 5 on 05/09/2020. The form reflected only "Releasing of Self or Minor. This is to certify that I, the undersigned, am (leaving or taking) from Cottage Grove Community Hospital and Clinics [space for a name] against medical advice of the hospital and/or the attending provider, who are absolved from all responsibility and any liability for ill effects from this action. I acknowledge that treatment was offered and/or that I have been informed of the risks of leaving."

5.c. There was no documentation of an MSE or other documentation in the medical record by the MD or DO who had recorded labwork and infusion orders and who had been notified of the patient's hunger and request to leave. There was no documentation that reflected the RN had attempted to discover the underlying reason the patient wanted to leave, especially in consideration of his/her elevated blood sugar. There was no documentation on the LAMA form or in the record to reflect what risks related to leaving before the MSE the patient had been informed of and who had provided that information. Further, the LAMA form included explicit waiver of liability language prohibited by the EMTALA P&P described under Finding 1 above in this Tag.

5.d. Patient 5's encounter was reviewed with staff that included the CEO, Medical Director, EDNM and RMs on 10/26/2020 at 1405. During interviews at the time of the record review the EDNM acknowledged that the RN did not document specific benefits and risks of the patient's leaving the ED without a MSE. The EDNM stated "It's hard to know what the conversation was" and that there was no additional information. In regards to lack of documentation of an MSE for Patient 5 the EDNM stated there would be a note in the record if there was one.

5.e. In a followup email from the RM on 10/27/2020 at 1208 he/she wrote that "The Provider accepted patient in [EHR], but patient left before seen by the provider, therefore there was no provider note. The note was cancelled (sic), not incomplete."

6.a. Review of the ED central log reflected that Patient 12 presented to the hospital on 06/16/2020 at 2116 and was discharged on 06/16/2020 at 2158. The patient's chief complaint was recorded as "Psychiatric Evaluation" and his/her disposition was recorded as "LWBS Before Triage."

6.b. Review of the medical record for Patient 12's 06/16/2020 encounter reflected it included the following entries:
* At 2116 staff recorded the patient's arrival by car and "Arrival Complaint" as "Crisis/Mental health Evaluations/Hearing Voices."
* At 2134 an RN signed a note that reflected "Registration called and reported that pt walked outside without telling registration."
* At 2147 the RN recorded "Initial suicide risk No Risk."
* At 2148 the RN recorded "Patient ESI Acuity 3."
* At 2158 staff recorded that the patient was discharged.
* At 2200 the RN signed a note that reflected "Pt taken to room 4 but [states] 'I will not go into the quiet room' (sic) Talked pt into being seen initially in room 6. Pt in room 6 and [states] I am here to be seen because I am stressed out. [States] '30-40 cars have been following me since yesterday when I left Bend' (sic) Reports hearing voices this afternoon that told [him/her] 'to get on the ground' (sic) Pt denies being suicidal or homicidal. After asking suicide risk questions pt starts stating that 'I am afraid for my car because my whole life belongings is in it' (sic) Attempted to tell pt that security will watch [his/her] car and make sure it is not messed with. Pt stated 'No I must check on my car' (sic) Pt at this time stood up and proceeded to leave out (sic) the room. Pt appeared to be able to make decisions at this time. Reported situation to charge RN with provider present. Pt escorted out of ambulance bay by security."
* An untimed entry was recorded that reflected "LWBS before Triage ... Pt left prior to triage being fully complete. Provider and charge RN made aware."

6.c. There was no other related documentation in the record. It was not clear what the patient's experience was at 2134 when he/she "walked outside without telling registration" and what that meant. Although the patient subsequently verbalized that he/she was hearing voices and being followed, the RN determined the patient was "able to make decisions." An MSE by a qualified practitioner had not been conducted and it was unclear if the RN was qualified to make that evaluation of the patient's decision making capacity. It was also unclear why security staff escorted the patient out of the ED. In addition, there was no documentation to reflect that hospital staff had attempted to explain to Patient 12 the risks of leaving prior to an MSE and had attempted to obtain his/her signed written refusal as required by the EMTALA P&P referenced in Finding 1 above in this Tag.

6.d. Patient 12's encounter was reviewed with staff that included the CEO, Medical Director, EDNM and RMs on 10/26/2020 at 1440. During interviews at the time of the record review the EDNM confirmed that there was no evidence that the ED staff had attempted to explain the risks and benefits of an MSE prior to the patient leaving and no evidence of attempts to obtain the patient's written refusal. He/she further confirmed there was no documentation of an MSE or other documentation by the physician.

7.a. Review of the ED central log reflected that Patient 15 presented to the hospital by "Ambulance" on 07/11/2020 at 2234 and was discharged on 07/12/2020 at 0757. The patient's chief complaint was recorded as "Suicidal" and his/her disposition was recorded as "Home or Self Care"

7.b. Review of the medical record for Patient 15's 07/11/2020 encounter reflected it included the following entries:
* At 2234 an entry reflected that the patient arrived to the ED.
* At 2237 an RN recorded "BP (!) 158/102."
* At 2241 the RN recorded "[Spouse] called EMS tonight due to patient having a few drinks and thoughts of suicide. Pt states [he/she] has PTSD and its always the reason [he/she] 'feels bad.' EMS stated [patient] 'wished [he/she] could go to sleep and never wake up.'"
* At 2251 the RN recorded that for "Suicide Risk" the patient had stated: "Yes" he/she had wished he/she were dead in the past month; "Yes" he/she had actual thoughts of killing self in the past month; "Yes" he/she had been thinking about how to do that in the past month; "Yes" he/she had some intention of acting on those thoughts; and in response to being asked if he/she had worked out the details of the plan and intended to carry out the plan the patient stated he/she "'can't tell me the plan.'"
* At 2341 the RN recorded that the "[QMHP]" was talking to the patient in the patient's ED room.
* At 2357 Abnormal labs resulted including "Glucose 272 ... Reference Range ... 70 - 99 mg/dL H^."
* On 07/12/2020 at 0042 the RN recorded "Pt provided with ice water, banana, cookies, trail mix and humus and pretzel snack. Pt sat on bed and ate."
* At 0749 the MD signed a note that reflected Patient 14 was " ... brought in from home by the medics who were called by [his/her spouse] because [he/she] was making suicidal statements ... describes having PTSD ... was in Iraq ... When asked if [he/she] has a distinct plan [he/she] is somewhat circumferential and changes the subject ... Patient is quite argumentative to any suggestions that we make. We have tried to get [him/her] dressed down but [he/she] puts up an argument and take (sic) some convincing just to get out of [his/her] clothing. Labs reveal a mild bump in the patient's LFTs and the fact that [he/she] has been drinking tonight which [he/she] corroborates. As the crisis worker is in for another patient [he/she] also visits with this patient and the plan is to let [him/her] sober overnight and [he/she] will receive a reevaluation in the morning ... Patient woke up and states that [he/she] is no longer suicidal, [he/she] wants call (sic) [his/her spouse] and go home. I have tried to convince [him/her] to stay because [he/she] came to us to get some help and I have offered that to [him/her] and explained that the crisis worker is coming back to see [him/her] specifically. [He/she] is unconvinced and decides that [he/she] does want to leave. [He/she] does not appear intoxicated any longer and seems to be able to make that decision. [He/she] is noted to ambulate to the bathroom with a steady gait. I have tried to appease [him/her] by offering a meal [his/her] usual medications or more Ativan but [he/she] still does not want to stay."
* At 0751 an AVS form was generated with an electronic notation that it was "Printed at 7/12/2020 7:51 AM."
* At 0755 the RN recorded "Discharge instructions given with community resources."
* At 1050 the QMHP signed [his/her] "ED Behavioral Health Evaluation Note" that reflected the patient "... has many firearms and knives ... Suicide Risk Level: low ... denied any suicidal ideation, planning, or intent to this writer. [He/she] was low risk on the C-SSRS. [He/she] reports no history of suicidal actions ... In consultation with [ED MD], it is difficult to assess if [Patient 14] is a threat of harm to [him/herself] or others. Reevaluation should occur in the morning after a night's sleep. After sleeping, [he/she] woke and in discussion with doctors and nurses [he/she] identified that [he/she] was no longer a threat of harm to [his/herself] or others. [He/she] was released into [his/her] own care. No referrals were made, however counseling was discussed with the patient last night and [he/she] was informed of resources that [he/she] could access should [he/she] need it, including returning to the [PHCG ED]."
* A "Columbia-Suicide Severity Rating Scale" form dated 07/11/2021 was noted in the record. It contained information inconsistent with the RN's 07/11/2021 Suicide Risk assessment note recorded at 2251. The form was not timed nor was there any indication as to who completed it.

7.c. The record did not clearly reflect the course of the patient's MSE and suicide risk evaluation throughout the encounter. Following the RN's initial suicide risk assessment on 07/11/2021 it was unclear when the QMHP assessed the patient's risk to be low, as the QMHP then documented that in consultation with the physician the risk was "difficult to assess" and "reevaluation should occur in the morning." That documentation was also reflected in the physician's note. However, that reevaluation did not occur as the patient insisted upon leaving the ED prior to the QMHP's arrival the next morning on 07/12/2021. In response to the patient's insistence to leave the ED prior to the QMHP reevaluation there was no evidence that the risks of leaving prior to completion of that portion of the MSE had been discussed with Patient 15. There was no evidence that an LAMA form had been completed or that staff had attempted to obtain the patient's written refusal as required by the EMTALA P&P referenced in Finding 1 above in this Tag. Further, contrary to the RN's 0755 note, the AVS lacked "community resources" and included only the name of one physician office, 911 and "national suicide hotlines."

In addition, the MSE by the physician did not include evaluation of the patient's elevated BP and blood glucose, there was no evidence of physician's orders for the "... banana, cookies, trail mix and humus and pretzel snack" given to the patient and there was no documentation that the elevated BP and blood glucose were retaken or reassessed during the ED encounter.

7.d. Patient 15's encounter was reviewed with staff that included the CEO, Medical Director, EDNM and RMs on 10/26/2020 at approximately 1530. During interviews at the time of the record review the EDNM stated there was no evidence that the risks of leaving the ED prior to completion of the MSE had been discussed with the patient and confirmed that the LAMA form had not been completed. He/she further confirmed that there was no additional MSE information related to evaluation or reassessment of Patient 15's elevated BP and blood glucose.

8.a. Review of the ED central log reflected that Patient 22 presented to the hospital on 08/29/2020 at 0913 and was discharged on 08/29/2020 at 1313. The patient's chief complaint was recorded as "Altered Mental Status" and his/her disposition was recorded as "Left Against Medical Advice."

8.b. Review of the medical record for Patient 22's 08/29/2020 encounter reflected it included the following entries:
* At 0913 an entry reflected that the patient arrived to the ED by ambulance.
* Continued entries reflect triage and MSE, including labwork and diagnostic imaging.
* At 1312 an RN recorded that patient "... ambulated out of room one ... states [he/she] is leaving. Encouraged pt to stay, explaining that we were attempting to transfer [him/her] to Roseburg VA and pt declined ... refusing to stop and speak with staff, including [QMHP] and MD. Once in lobby, pt sat on bench and explained to security that [he/she] was waiting for [relative] to give [him/her] ride to Roseburg. while waiting there, Registration clerk attempted to register patient and pt declined ... MD speaking with patient in lobby. Pt declines to return to ED for continued evaluation."
* At 1316 the MD signed a note that reflected Patient 22 "... presents to the [ED] with altered mental status. Patient was found on the side of the interstate 5, confused, unable to drive and out of gas. History is quite limited. The patient is rambling ... is confused at times. [He/she] complains of

Based on interview, review of medical record documentation for 1 of 1 individual (Patient 13) who was determined to have a psychiatric EMC at PHCG, a CAH that did not have an inpatient psychiatric unit, and review of policies and procedures it was determined that the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure that patients with psychiatric EMCs received stabilizing treatment within the hospital's capability and capacity until such time that an appropriate transfer to a hospital with the necessary capability and capacity could be affected. An individual who presented to the hospital for emergency services and who was assessed to have a psychiatric EMC and to be a danger to self and others, was allowed to wander into inpatient rooms and was subsequently allowed to elope from the ED, the hospital building and the campus.

Findings include:

1.a. The P&P titled "[EMTALA] Compliance Procedure," dated as reviewed 10/25/2019, included the following:
* "The Medical Center provides an appropriate MSE by physicians or [QMPs] as defined by the Governing Board, within the capability and capacity of the Medical Center, regardless of the person's insurance status or ability to pay when:
- An individual comes to a dedicated ED or L&D and requests examination or treatment."
* "The Medical Center provides necessary stabilizing treatment for [EMCs] and laboring individuals within its capability and capacity."
* "If the Medical center is not capable of providing stabilizing treatment, it provides an appropriate transfer, regardless of the Patient's ability to pay."

1.b. The document titled "Cottage Grove Medical Center" reflected that the facility was a 14-bed CAH and that its services included "a Medical Inpatient Unit, Emergency Department, Radiology, Pharmacy Services, Physical Therapy, Provider-Based Clinics, and Laboratory Services." Review of that document and other scope of service documentation provided reflected that the CAH did not provide inpatient psychiatric services and other specialty services.

2.a. Review of the ED central log reflected that Patient 13 presented to the hospital by "Ambulance" on 06/25/2020 at 1735 and was discharged on 06/26/2020 at 0200. The patient's chief complaint was recorded as "Mental Health Crisis" and his/her disposition was recorded as "Eloped."

2.b. Review of the medical record for Patient 13's 06/25/2020 encounter reflected it included the following entries:
* At 1735 a PAS recorded "Patient arrived in ED."
* At 1735 an MD recorded "First Provider Evaluation of Patient."
* At 1750 an RN recorded "Patient presents with EMS. Patient yelling at EMS. Patient yelling at this RN 'you [expletive] don't know what you are doing you are a [derogatory term] and I am not going to listen to you'. Patient yelling. This RN asked if the patient hurt anywhere and the patient yells 'no'. This RN asked if the patient had any thoughts of hurting [him/herself] and the patient states 'No now leave!'. Patient awake and alert. Skin warm and dry."
* At 1746 the RN recorded "Triage Completed."
* At 1746 the RN recorded "Patient ESI Acuity: 2."
* At 1746 the RN recorded "Triage Started."
* At 1808 the RN recorded "Pt changed into paper scrubs, but put [his/her] coat on over the scrubs. Pt turned music on [his/her] phone loudly and began to dance in room four, security remains outside room. Pt exited room after approx one minute stating that [he/she] wanted to get a look around [his/her] hospital. Asked pt to return to room four, pt declined, and continues walking with security following. CGPD contacted out of concern for pt safety. Pt making threats to medical floor CNA who was attempting to keep pt out of other people's (sic) rooms. Pt did enter two rooms on the medical floor and was heading into another room in the ED stating, 'I can go anywhere I want.' Pt states to staff, 'Back up off of me. Do you know who I am? I'm God.' CGPD arrives and is currently speaking with patient. While speaking with MD, pt states, 'I do want to kill myself. I asked for help, but you brought me here.'"
* At 1816 the RN recorded that Zyprexa, an antipsychotic, was administered to the patient by an IM injection.
* At 1830 an RN recorded "Patient resting in bed. Security remains outside of the room. Will continue to monitor."
* At 1830 an MD electronically signed a noted that reflected that Patient 13 "... presents with suicidal ideation. Paramedics state that the patient called [him/her] today because [he/she] is feeling suicidal. [He/she] had no plan on (sic) hurting [him/herself], but was sad because people were leaving [him/her]. Upon arrival here, the patient initially denied suicidal thoughts and then walked from [his/her] room. [He/she] walked around the hospital including into inpatient patient's (sic) rooms. [He/she] was then brought back to the emergency room and again reported suicidal thoughts ... The crisis team has been contacted as I do have concern regarding [his/her] reported suicidal ideations and willingness to leave [his/her] room. When they arrive, we will consider placing [him/her] on a hold. [He/she] has been sedated with Zyprexa ... [His/her] care will be signed out for further psychiatric and laboratory evaluation ... Clinical Impression ... Suicidal ideation ... Agitation ... Disposition Pending Re-evaluation."
* At 1832 the MD recorded "Orders Placed Violent Patient Restraint-Seclusion ... (Ativan) [anti-anxiety, sedative] injection ..."
* At 1834 an RN recorded "1:1 Observation/Safety ... Initiated."
* At 1836 the RN recorded "Pt exits room, rushes past security and approaches nurse at nurse's station demanding food. Pt yelling and calling staff members '[expletives].' Asked pt to return to room. Pt. states, 'Do your job.' [He/she] ambulated back to room four where [he/she] was placed in seclusion with order from [MD]."
* At 1839, 1840, 1845, 1851, 1859, 1915 RNs described the patient's physical and verbal behaviors from within the seclusion room that included escalating yelling, screaming, jumping, banging on door, crying and urinating on floor.
* At 1845 an MD signed a "Authorization for 12-Hour Custody Transport" hold form on which he/she recorded "The condition of the above named person, as set forth in writing below, cause the undersigned to believe the person is dangerous to self or others and in need of emergency care or treatment for mental illness. Pt here with suicidal thoughts, agitation, verbally assaulting staff, walking into other patients rooms, yelling. Do not feel [he/she] is safe to be discharged or make decisions for [him/herself] in this state."
* At 1912 the RN recorded that Ativan was administered by mouth.
* At 1931 a QMHP electronically signed a "ED Behavioral Health Evaluation Note" that reflected "When this writer arrived PT was in lock-down ... in room 4 wearing green scrubs ... ranting ... screaming, punching the walls, and yelling ... would not communicate at all other than [his/her] screaming ... [Friend of Patient 13's] reported none of Pt's family will have anything to do with [him/her] because [he/she] has threatened to kill them ... reported [patient] does have a firearm at [his/her] apartment and [friend] felt unsafe to visit [patient] there because of it ... Suicide Risk Assessment: ... high risk ... Violence Risk Assessment: Pt has displayed violence behaviors in hospital room, ranting and punching walls, screaming, and threatening to harm and/or kill others as well as [him/herself] ... Pt needs inpatient hospitalization for suicidal ideation and medication management ... [He/she] is on a 12 hour transport hold and currently on lock-down."
* On 06/26/2020 at 0158 the the MD recorded "ED Disposition set to Eloped."
* At 0213 an RN recorded "Pt speaking with Provider. Security x2 standing by. Pt increasingly agitated. Yelling and pacing around room just prior to pushing past security and provider. Pt ran out ambulance doors. CGPD contacted immediately."
* At 0215 the RN recorded "CGPD dispatch called. Pt located at nearby business. Pt safe and talking with CGPD."
* At 0222 the RN recorded "CGPD came to ED in person to advise they will not bring patient back to this ED. Pt agreed to go to [SHUD] ED with them. Belongings released to CGPD at their request. Provider notified. [MD] called [SHUD] and spoke with ED provider on duty."
* At 0225 an MD electronically signed a note that reflected "Patient woke and requested to speak to a physician. I tried to engage with the patient ... I tried to redirect the conversation multiple times ... patient continued to be disorganized ... The patient made attempts to leave the room multiple times, and eventually ran at the door, striking the security officers, then ran through the ambulance bay doors at the back of the emergency department. Security attempted to stop the patient but [he/she] fled. CGPD was notified and was able to make contact with the patient at a nearby business. Per CGPD, patient is cooperative, but refusing to return to [PHCG]; they plan to take [him/her] to [SHUD], which per CGPD, patient is willing to go to. I offered to re-evaluate the patient here given [his/her] mental health hold, but CGPD told me their plan was to bring [him/her] to [SHUD] ..."

2.c. During interview on 10/26/2020 at 1445 the CEO stated the hospital had "debriefed" and "looked at" this incident, that there was documentation of that and there was no video to review.
* A follow-up email received on 10/27/2020 at 1208 from the RM reflected "No video-recording of event found."
* During further interview with the CEO and RM staff on 10/28/2020 beginning at 1300, they confirmed that an investigation had not been completed. For example:
- Unclear information was provided about whether video recording had been reviewed at the time of the incident.
- They were unable to provide detailed information about where staff were positioned in Patient 13's room that allowed the patient the opportunity to elope.
- They stated that the patient was "continually monitored" but they hadn't identified the name(s) of the staff persons and confirmed that the monitoring had been "continual."
- They acknowledged that all individuals involved in the care of the patient had not been interviewed.

2.d. A document titled "Patient Number 13" was received by email from the RM on 10/28/2020 at 1636. It was not dated or signed and included a "brief" summary of the elopement incident on 06/25/2020 as described by one security officer. The report concluded with the following:
* "Contributing Factors
- Action by Patient
- Agitated/Confused/Disoriented
- Current Diagnosis/Condition
- Inappropriate Behavior (e.g., loss of temper, exposure, yelling, profanity)
- Instructions Disregarded
- Mental Status/Capacity
- Patient - Lack of Compliance/Adherence
- Unlocked/Unsecured Area
- Workplace Violence"
* "Immediate Actions
- Escalated to Management/Administrator
- Security Notification
- EMS/Fire/Police Activated"
* "Follow-Up Actions
- Crisis Prevention Institute (CPI) [safe management of disruptive and assaultive behavior] training for all ED staff and Security"

2.e. Documentation review and interviews related to Patient 13's encounter did not clearly reflect the provision of effective and appropriate stabilizing treatment that protected this patient from potentially harming him/herself and others. For example:
* Although the patient was changed into "paper scrubs" he/she was allowed to retain his/her coat which is a potentially unsafe item.
* Although the patient's behaviors were initially erratic, concerning and threatening he/she was allowed to leave the ED and wander freely through the inpatient unit and into inpatients' rooms while staff simply followed him/her. Hospital staffs' interventions were primarily to call the local police to manage the patient's behaviors, and to then chemically restrain the patient with antipsychotic medication.
* Although the patient was eventually placed on a "hold" and roomed in the seclusion room for his/her safety and the safety of others he/she was allowed to elope from the seclusion room, from the ED, out of the hospital and off of the hospital campus. It was unclear how hospital staff "attempted to stop the patient" and there was no indication that behavior interventions aimed to prevent the elopement were utilized.
* The "Contributing Factors" that led to the elopement identified on the "Patient Number 13" report did not include hospital or staff policy, procedure and practice factors related to the management of, and provision of stabilizing treatment for, a patient with a psychiatric EMC.
* The "Follow-Up Actions" on the "Patient Number 13" report reflected a plan to provide CPI training for hospital staff as follow-up to the incident.

Based on interview, review of documentation in 3 of 6 medical records of patients who were transferred from PHCG, a CAH, to another hospital for specialty services not available at PHCG (Patients 3, 6 and 9) and review of hospital policies and procedures, it was determined that the hospital failed to fully 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:
* The physician certification of transfer benefits versus risks lacked individualized and patient-specific risks of transfer and evidence that the patients had been informed of those.
* Patents who required further examination and stabilizing treatment by specialty services not available at the CAH were transferred by POV with no evidence that they had been informed of the additional risks of such transfer.

Findings include:

1.a. The P&P titled "[EMTALA] Compliance Procedure," dated as reviewed 10/25/2019, included the following:
* "If the Medical center is not capable of providing stabilizing treatment, it provides an appropriate transfer, regardless of the Patient's ability to pay."
* "For purposes of transferring a Patient from one facility to a second facility for psychiatric conditions, the Patient is considered stable when they are protected and prevented from injuring themselves or others."
* "A transfer is 'appropriate' if:
- The transfer is accompanied by qualified Workforce members and by appropriate means of transport and transportation equipment, including the use of necessary and medically appropriate life support measures and devices during transfer. Emergency medical technicians may not always be 'qualified Workforce members' for purposes of transferring an individual.
- The physician at the transferring Medical Center has the responsibility to determine appropriate mode, equipment, and attendants for transfer."
* "An EMTALA Transfer Form is completed by the physician to document:
- The consent, request, or refusal of transfer by the Patient/legal representative.
- Physician's written certification that the physician explained the specific risks and benefits of the transfer for the Patient.
- Physician certification cannot simply be implied from the findings in the medical record.
- The written documentation must state the reasons for the individual's refusal."

1.b. Refer to Finding 1.b. under Tag C2407 that reflects the CAH provided limited services and did not provide surgical and other specialty services.

2.a. Review of the ED central log reflected that Patient 3 presented to the hospital on 04/18/2020 at 1104. The patient's chief complaint was recorded as "Shortness of Breath; Cough" and his/her disposition was recorded as "Diverted Elsewhere" on 04/18/2020 at 1621.

2.b. Review of the medical record for Patient 3's 04/18/2020 encounter reflected it included the following entries:
* At 1138 an RN recorded "Presents with sob/cough and chest pain mid sternal ... Brown productive cough per pt. Spo2 89% room air. 2LNC placed for spo2 94% ..."
* A MSE that included lab and imaging diagnostic testing was conducted.
* At 1605 the MD signed an EMTALA form that reflected:
- "Level of transportation ALS"
- "Patient information: Atypical pneumonia, possible aspiration, rule out COVID"
- "Risk(s) of transfer (In addition to deterioration of patient's condition/clinically specific): transport"
* At 1613 the MD signed the ED note that reflected "[Patient] with gastroparesis with retching yesterday now feeling that [he/she] has pneumonia with shortness of breath and productive cough. Noted to be hypoxic here. Work of breathing normal on nasal cannula. Clinically suspect aspiration pneumonia. [He/she] has a new leukocytosis and chronic anemia ... metabolic panel has chronic hypoalbuminemia ... Discussed with radiologist this is new patchy opacities on chest x-ray. This may represent atypical infection. Antibiotics were given ... Upon consulting with hospital administration, [PHCG Hospitalist] and I feel that [SHRB] would be better given COVID pandemic."
* At 1620 the RN recorded that patient left the hospital with EMS for transport to SHRB.

2.c. There was no documentation in the record that identified what the "clinically specific" risks of transfer were for Patient 3 who was being transferred from the CAH for specialty respiratory and infectious diseases services, and none that reflected he/she had been informed of those.

2.d. During interview at the time of the record review with staff that included the CEO, Medical Director and EDNM on 10/26/2020 beginning at 1300 they confirmed that there was no documentation of clinically specific risks of transfer in the record.

3.a. Review of the ED central log reflected that Patient 6 presented to the hospital on 05/27/2020 at 1103 and was discharged on 05/27/2020 at 1647. The patient's chief complaint was recorded as "Abscess; Foot Pain" and his/her disposition was recorded as "Home or Self Care."

3.b. Review of the medical record for Patient 6's 05/27/2020 encounter reflected it included the following entries:
* A MSE that included lab and imaging diagnostic testing was conducted.
* At 1326 the RN recorded "BP: 169/98 !"
* At 1339 the RN recorded "Peripheral IV 05/27/20 Left Antecubital Placed"
* At 1339 the RN's flowsheet documentation reflected "... base of toe nail to foot, open, scabbed, purulent wound ..."
* At 1420 the RN recorded "BP: 168/105 !"
* At 1421 "Final" lab results included "Glucose 332 Reference Range 70-99 mg/dL [high]"
* At 1530 the RN recorded "BP: 177/108 !"
* At 1624 the RN recorded "Pt requesting to home prior to transfer."
* At 1630 the RN recorded "BP: 164/109 !"
* At 1636 the MD signed the ED note that reflected "... presents for redness and pain to the left foot ... over the past 24 to 48 hours, erythema has increased to the left second digit and has progressed up [his/her] left foot ... Patient with evidence of gangrene to [his/her] left second digit with additional erythema extending from this digit to [his/her] left ankle ... On evaluation patient does have erythema and evidence of gangrene to the left second digit. Concern is for infected left second digit with associated cellulitis of the foot. Also considered osteomyelitis ... elevated glucose of 332 but no evidence of DKA ... CBC mild leukocytosis ... patient would be best suited at [SHRB], given the gangrene of [his/her] toe and likely need for surgery evaluation ... Patient is very adamant that [he/she] would like to drive [him/herself] to [SHRB] which appears safe at this time ... patient will be transferred via POV to [SHRB] for ongoing care. [He/she] remained (sic)"
* At 1639 the RN recorded "Wrapped IV. Reviewed POV transfer. Pt stated [good] understanding. Dressed and ready for transfer."
* At 1647 the RN recorded "Patient discharged."
* An undated and untimed EMTALA form signed by MD reflected:
- "Level of transportation Private Car"
- "Patient information: Cellulitus and gangrene of left foot"
- "Risk(s) of transfer (In addition to deterioration of patient's condition/clinically specific): Disruption of social tranquility"
* EHR RN flowsheet documentation for the "Peripheral IV 05/27/20 Left Antecubital," reflected five days after Patient 6's discharge from PHCG, "Removal Date: 06/01/20 ... Removal Time: 0001 ... Removal Reason: Infiltration ..."

3.c. There was no documentation to reflect what the response to the patient's request to go home was, including an evaluation of how long he/she wanted to be home for. It was not evident who was going to be driving the POV and unclear what the RN meant by "Reviewed POV transfer." There was no documentation in the record that identified what the "clinically specific" risks of transfer for surgical services were for Patient 6 given his/her condition, and including with an intact IV line, elevated blood glucose and increasingly elevated BP, additional risk of self-transfer by POV and of potential delay in further examination and treatment by going "home prior to transfer."

3.d. During interview at the time of the record review with staff that included the CEO, Medical Director and EDNM on 10/26/2020 beginning at 1300 they confirmed that there was no documentation of clinically specific risks of transfer in the record, including the additional risks of POV transfer. Further, the Medical Director stated that the ED providers had been trained to use the statement "Disruption of social tranquility" as the EMTALA risk of transfer language. Staff also confirmed that the patient's IV line, removed five days after discharge from PHCG, had been removed at another hospital.

4.a. Review of the ED central log reflected that Patient 9 presented to the hospital on 06/05/2020 at 1032. The patient's chief complaint was recorded as "Abdominal Pain" and his/her disposition was recorded as "CAH" on 06/05/2020 at 1420.

4.b. Review of the medical record for Patient 9's 06/05/2020 encounter reflected it included the following entries:
* A MSE that included lab and imaging diagnostic testing was conducted.
* At 1137 an RN recorded insertion of "Peripheral IV 06/05/20 Right Antecubital"
* At 1247 the MD recorded on the EMTALA flowsheet that "level of transportation" was "BLS"
* At 1359 an RN amended the MD's 1247 flowsheet entry and recorded EMTALA "level of transportation" as "Private Car"
* At 1414 the MD signed an EMTALA form that reflected:
- "Level of transportation Private Car"
- "Patient information: Cholecystitis"
- "Risk(s) of transfer (In addition to deterioration of patient's condition/clinically specific): Disruption of social tranquility"
* At 1418 an RN recorded "IV remains in place and secured. Pt provided transfer paperwork."
* At 1840 the MD signed the ED note that reflected "... tenderness to right upper quadrant with positive murphy's sign ... US Gallbladder Impression: Cholelithiasis with some positive sonographic Murphy sign. Findings may represent early acute cholecystitis. Will discuss with surgery regarding these findings ... Spoke with [SHRB physician] who recommends sending the patient to [SHRB] for surgical intervention. [He/she] recommends holding on antibiotics at this time ... [His/her] pain is slightly improved but still reports right upper quadrant abdominal pain at this time. [He/she] will be kept n.p.o."

4.c. There was no documentation in the record that identified what the "clinically specific" risks of transfer for surgical services were for Patient 9 given his/her condition, including with an intact IV line and additional risk of self-transfer by POV. It was not clear that the patient had requested transfer by POV, who was going to be driving the POV and why the RN altered the MDs level of transportation entry from "BLS" to "Private Car." Further, it was not clear whether the MD was aware of the level of transportation change and that the patient was sent by POV with an IV line in place.

4.d. During interview at the time of the record review with staff that included the CEO, Medical Director and EDNM on 10/26/2020 beginning at 1300 they confirmed that there was no documentation of clinically specific risks of transfer in the record, including the additional risks of POV transfer.

5. According to an on-line distance tool, SHRB in Springfield, Oregon, to where Patients 3, 6 and 9 were transferred, is approximately 22 miles and 25 minutes drive-time from PHCG in Cottage Grove, Oregon.