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Based on hospital policy review, medical record reviews, physician and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 25 sampled DED patients who presented to the DED (Patient #5) with complaint of chest pain.

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

2. The hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure an appropriate transfer by failing to complete a written physician's certification for transfer documenting the increased risks associated with the transfer for the specific Emergency Medical Condition (EMC); failing to send to the receiving facility copies of all medical records available at the time of the transfer; and failing to ensure the written physician's certification was signed and/or dated and timed by the transferring physician to closely match the time of transfer for 6 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #1, #23, #24, #25, #7 and #6).

~ Cross refer to §489.24(e)(1)-(2) Appropriate Transfer, Tag A2409.

Based on hospital policy and procedure review, medical record reviews, grievance file review and physician and staff interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 1 of 25 sampled patients who presented to the DED (Patient # 5) with complaint of chest pain.

The findings include:

Review of the facility's (Hospital A) EMTALA Policy and Procedure, revised March 2015 revealed: [the "Medical Screening Examination" or "MSE" means the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist]...the (named) facility "will provide an appropriate medical screening examination within the capability of the hospital's dedicated emergency department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists and (named) facility will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as required to stabilize the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility in accordance with procedures ...IV. PROCEDURE: A. Triage and Registration 1.Triage a. As soon as practical after arrival, individuals who come to the emergency department should be triaged in order to determine the order in which they will receive a medical screening examination ... B. Medical Screening Examination ...1. (Hospital A) shall provide a medical screening examination to any individual who comes to the emergency department ...3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. The medical screening examination, and ongoing patient assessment, must be documented in the medical record.

Review of Hospital A's STEMI (ST cardiac wave elevated myocardial infarction) Protocol, revised 2015, revealed " PURPOSE: STEMI Protocol will be utilize (sic) for patients presenting with symptoms indicative of a cardiac event. PROCEDURE: 1. Walk-in Patient: A. Patients presenting with coronary symptoms will be treated as STEMI until ruled out for acute event by EKG interpretation ...C. An EKG should be completed ASAP with target time goal of 10 minutes of arrival ...upon completion it will be taken to the ED physician for interpretation. A. If the EKG is STEMI, the ED physician will activate the STEMI protocol ...the following will be initiated ...Medical and Pharmacological Regimen: ...Heparin 60 IU/kg bolus, Chest X-ray, Cath Lab Staff will receive report from patient nurse ... " .

Review of Hospital A's Assessment, Documentation and Nursing Process-Emergency Department Policy and Procedure, revised 11/2014 revealed ...REASSESSMENT a. Reassessment will be based on patient's vital signs and assessment, triage and the patient's condition as diagnostic tests and therapies are completed ...d. Those patients who have been triaged and placed in the waiting room will be re-assessed according to their assigned triage category as follows: ...ESI Level 3- approximately every hour. 5. Nursing Interventions/Patient Response a. Will be documented in the medical record as they occur by qualified nursing personnel. B. Narrative notes will be required in the following circumstances: ...4. Change in the patient ' s condition ... "

Review of Hospital A's Pain Management Policy, revised 8/2015 revealed "POLICY: A. All patients will have a comprehensive pain assessment completed on admission ... PROCEDURE: A. Each patient will be assessed and monitored for the presence of pain 1. On admission ...5. With each new report of pain ...7. Immediately for unexpected intense pain ...C. All licensed staff will be responsible for the education of the patient and/or family in regard to pain and pain management ...D. Comprehensive pain assessment includes: 1.Location of pain 2. Intensity of pain, using a 0-10 pain scale or other appropriate scale. 3. Quality of pain 4. Alleviating factors ...5. Aggravating factors. 6. How the pain affects the patient ' s quality of life. 7. Associated symptoms (nausea, vomiting, shortness of breath, etc.) 8. Identification of any barriers that may affect pain relieving measures ...9. Physical examination of the pain site and referring patterns ...12. Document pain assessment on the nursing flowsheet or electronic medical record ... I. It is the responsibility of all hospital employees to facilitate the pain relieving process and expedite interventions needed".

Closed DED (Dedicated Emergency Department) medical record review of Patient #5 revealed a 50 year old male who presented ambulatory to Hospital A DED with his wife on 01/10/2016 at 0737 with a chief complaint of chest pain. Record review revealed triage was started by a Registered Nurse (RN) at 0738. Review revealed a 12 lead ECG (electrocardiogram) was done upon arrival and read by the physician at 0739. Review revealed results were normal sinus rhythm and normal ECG, NSTEMI (non-elevated ST wave Myocardial infarction). Review of triage notes revealed vital signs at 0752 were recorded as blood pressure 185/104 (normal 90-140/60-90), heart rate 85, respirations 22 (normal range 14-20), temperature 97.7 F (Fahrenheit) (normal range 98.0-100.5) and oxygen saturation 98% (room air). Triage set an urgent level of ESI 3. Chief complaint was documented by the Triage nurse as chest pain since last night, also nausea, vomiting and diarrhea. No other nursing or physician documentation was found until 01/10/2016 at 1121 (3 hours and 44 minutes after arrival) recording a disposition of LWOT (left without treatment) with the patient's condition recorded as unchanged. No physician orders were found, no lab tests found and no radiology orders found for this DED visit.

Review revealed Patient #5 presented to Hospital E DED on 01/10/2016 at 1125 (four minutes later). Review of the triage assessment from Hospital E dated 01/10/2016 at 1323 revealed Patient #5 presented with chest pain that started "last night" at approximately 2300 with nausea, vomiting and SOB (shortness of breath) after waiting 4 hours and failing to receive treatment at Hospital A. Patient #5 was triaged at 1125 and assessed as alert, skin color was pink, respiratory pattern was unlabored, placed on continuous cardiac monitoring, a STAT (immediate) ECG was initiated, pulse oximetry and lab set were obtained. Vital signs at 1125 were: temperature 97.5 F, blood pressure 192/97, heart rate 99, respiratory rate 18 and oxygen saturation of 97% on room air. Pain was assessed using a verbal range of 0-10, intensity was 7 with a comfort goal of 4. Aspirin 325 milligrams was administered for pain. Review of lab results at 1146 revealed troponin (lab study that can indicate cardiac damage) of 6.180 (high). A cardiovascular consult was ordered. The Cardiologist assessed Patient #5 at 1330 and ordered an immediate cardiac catheterization which revealed three vessel coronary artery disease. Review of the physician's Discharge Summary dated 01/10/2016 at 1519 revealed a call placed to a cardiovascular surgeon, following the cardiac catheterization, determined an urgent coronary artery bypass was indicated. Patient #5 was transported via ambulance with continuous cardiac monitoring and oxygen back to Hospital A at 1448, where cardiac surgery is available.
Review of Hospital A's closed medical record revealed Patient #5 was transferred from Hospital E via ambulance to Hospital A for cardiovascular surgery on 01/10/2016 at 1628 with a diagnosis of severe coronary artery disease. Review of Discharge Summary dated 01/11/2016 revealed Patient #5 underwent a coronary bypass graft x 3 and was discharged home on 01/14/2016. Review of a physician progress noted dated 01/10/2016 at 1700 revealed "Incident Report- [Patient #5] presented to (Hospital A) ED early AM 01/10/2016 with complaints of CP (chest Pain)/Nausea/Vomiting/Diaphoresis. Nurse in ED does EKG which is interpreted as WNL (within normal limits). Patient sent to waiting room. After 2-3 hours of not being seen, patient goes to (Hospital E) where he has + (positive) Troponins. Multiple other patients apparently left as well. LHC (Left Heart Catheterization) done at (Hospital E) with critical 3 vessel CAD (Coronary Artery Disease). Patient transferred back to (Hospital A) for CABG (Coronary Artery Bypass Grafts). Patient and family extremely upset they were turned away while having AMI (Acute myocardial Infarction). Please evaluate/investigate situation as this is unacceptable care" signed by the cardiovascular surgeon.
Review of Patient Complaint /Grievance Form dated 02/15/2016 at 1148 revealed the wife of Patient #5 called to complain about her husband's 3 hour long wait in the ED waiting room on 01/10/2016 that necessitated her having to take him to Hospital E's DED for treatment.

Telephone interview with the wife of Patient #5 on 03/16/2016 at 0835 revealed a nurse who finally came out after requesting help at the front desk "several times", told complainant "other people were in the ED dying too and that they would have to wait". The nurse was described as older, with short blonde hair and skinny". The interview further revealed complainant asked for help because her husband (Patient #5) was having increased chest pain and was lying on the floor in the waiting room. Complainant revealed she did finally "leave without treatment because no one would come out and they had waited over 3 hours and saw 2 other couples leave without treatment for the same reason."

Interview with RN #1 on 03/15/2016 at 1430 revealed a thin, older nurse with short blonde hair who recalled working with the Patient #5 and his wife. RN#1 described Patient #5 as "not gray or diaphoretic and with a normal EKG." This nurse was assigned as Charge Nurse on 01/10/2016 between 0700 and 1900. Interview revealed a busy morning in the ED during that time. Interview further revealed that nurses will come to the waiting room to reassess waiting patients unless the ED was backed up with other patients. RN #1 did not recall being asked to reassess Patient #5 for increased pain.

Interview with Patient Access Rep #1 on 03/17/2016 at 1000 revealed she recalled overhearing Patient #5's wife being very upset with RN #1, that the wife stated her husband was "having chest pain so why are we still sitting her versus going back. I want a doctor to see him." Patient Access Rep could not recall how RN #1 responded but did recall that no reassessment was done by the nurse.

Interview with AS (administrative staff) #1 on 03/15/2016 at 1250 revealed Patient's with "chest pain and a normal EKG are assessed as ESI Level 3 and placed in the waiting room. Triage nurse or charge nurse is expected to reassess this patient every hour, reassess pain level or change in condition and document in the medical record. For patients with ongoing pain and escalating symptoms, the triage or charge nurse will place that patient in a hallway bed in the ED". Expectations for Patient #5 are that he would have been placed in a hallway bed, been prioritized and the house supervisor would have been called to alert for needed additional staffing (also known as a Code Purple).

Interview with AS #3 on 03/16/2016 at 1049 revealed expectation would have been for a Code Purple to have been activated by the DED charge nurse or physician on 01/10/2016 to ensure nursing assessment and reassessment needs of DED patients were met. Interview regarding waiting room patients not being assessed hourly and as needed further revealed "this complacency is something that needs to be addressed ... I spoke with the complainant (Patient #5's wife) personally and am very concerned."

Interview with Physician C (DED Medical Director) on 03/16/2016 at 1540 regarding Patient #5 who was not given a medical screening exam (MSE) and left without treatment, revealed that a "patient presenting with chest pain should have an EKG which is read ASAP (as soon as possible) so a determination for STEMI versus non-STEMI can be made. A change in condition, like increased pain, should bring the waiting room patient to the DED room for a medical screening exam".

Interview with Physician B (DED physician on duty when Patient #5 presented) on 03/17/2016 at 0850 revealed no MSE (medical screening examination) was performed for Patient #5 on 01/10/2016. The expectation is that in the case of a patient's deteriorating condition, the doctor would be notified by the nurses assessing these patients and a MSE would be performed. Regarding how patients are prioritized to be given an MSE, an electronic, real time display is watched by each "physician to monitor ESI levels along with pertinent details like age and presenting symptoms in order to select appropriately. We also rely on nursing assessments and reassessments to catch changes in a patient's ESI-level."

Based on policy review, closed medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure an appropriate transfer by failing to complete a written physician's certification for transfer documenting the increased risks associated with the transfer for the specific Emergency Medical Condition (EMC); failing to send to the receiving facility copies of all medical records available at the time of the transfer; and failing to ensure the written physician's certification was signed and/or dated and timed by the transferring physician to closely match the time of transfer for 6 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #1, #23, #24, #25, #7 and #6).

The findings include:
Review of the hospital's policy, "EMTALA (Emergency Medical Treatment and Active Labor Act)", revised 03/2015, reviewed 08/2015, revealed "... (Hospital A's) use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). ...IV. PROCEDURE: H ... 1 .... b. With certification: The individual may be transferred if a physician... 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 ... 2. c. (Hospital A) must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2) records related to the individual's emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; (8) the written patient consent or physician certification to transfer; and (9) the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. (Name of hospital) must forward relevant records, pending lab work and test results to the receiving facility that was not available at the time of transfer ... "
Review of the hospital's form "Request for Transfer/Consent to Transfer/Certification for Transfer", revised 02/2014, revealed "...Risk of Transfer: Medical condition could worsen during transport, Transportation risks, and Risk related to condition________________. "
1. Closed medical record review of Patient #1 revealed a 27 year-old female who presented to Hospital A's labor and delivery unit on 02/12/2016 at 2323 with a chief complaint of "vaginal bleeding." Record review revealed Patient #1 was seen by Physician A on 02/13/2016 at 0018. Review of Physician's orders dated 02/13/2016 at 0115 revealed a verbal order for transport to Hospital B. Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 05/2009, with the risks of transfer section of the form blank. Further record review revealed no documentation in the medical record by the physician that the risks for transfer were explained to Patient #1. Review of transfer form revealed no documented date and time of Physician A's certification of the patient's condition at the time of transfer. Review of the transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital B for Patient #1. Record review revealed Patient #1 was transferred to Hospital B on 02/13/2016 at 0145.
Telephone interview on 03/17/2016 at 1350 with Physician A revealed "I have never had EMTALA (Emergency Medical Treatment and Labor Act) training." Interview revealed risk of transfer "delivery enroute". Interview revealed "I would have reviewed with the patient".
Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form".
Interview on 03/17/2016 at 1105 with AS #2 (administrative staff) confirmed that there was no documentation in the medical record or on the transfer form for the risks of transfer for Patient #1. Interview revealed that there was no documentation in the medical record or on the transfer form for the date and time of the physician's certification to transfer for Patient #1. Interview revealed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital B.
2. Closed DED (dedicated emergency department) medical record review of Patient #23 revealed a 70 year-old male who presented to Hospital A's DED on 12/28/2015 at 1519 with a chief complaint of "found supine on ground by wife, pt (patient) responsive, lac (laceration) to back of head, coded (breathing and heart stopped) in front of first responders and cpr (cardio-pulmonary resuscitation) initiated". Record review revealed Patient #23 was seen by Physician D on 12/28/2015 at 1520. Review of Physician D's dictated notes on 12/28/2015 at 1554 revealed "History of Present Illness: The patient presents following fall ...Posterior Scalp ...symptoms is swelling and bleeding ....intubated (breathing tube placed), CPR, and transcutaneous pacing ...for severe bradycardia (heart rate less than 60) ...Impression and Plan...Multiple fractures of skull ...Acute subdural hematoma Calls-Consults - Spoke with Physician E who accepted her for transfer to Hospital B. Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 02/2014, with the risks of transfer related to condition checked with no written documentation of the risks for Patient #23. Further record review revealed no documentation in the medical record by the physician that the risks for transfer were explained to Patient #23. Review of transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital B for Patient #23. Record review revealed Patient #23 was transferred to Hospital B on 12/28/2015 at 1701.
Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form".
Interview on 03/17/2016 at 1105 with AS #1 confirmed that there was no documentation in the medical record or on the transfer form for the risks related to condition for Patient #23. Interview revealed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital B for Patient #23.
3. Closed DED (dedicated emergency department) medical record review of Patient #24 revealed a 62 year-old male who presented to Hospital A's DED on 11/27/2015 at 1258 with a chief complaint of "neck pain r/t (related to) right side. fell a week ago". Record review revealed Patient #24 was seen by Physician B on 11/27/2015 at 1607. Review of Physician B's dictated notes on 11/27/2015 at 1619 revealed "History of Present Illness: ...The patient presents with thoracic pain, upper back injury and neck pain ...Type of injury: fall and from a height ...On the CXR (chest x-ray) they identified compressed vertebrae concerning for possible fractures. Wife reports that this morning he was hallucinating and he now has no control of his legs and cannot stand or walk on his own ...Plan: Condition: Guarded Disposition: Transfer to other location: Hospital C ...Notes: Patient has findings consistent with epidural abscess at multiple spinal levels. Cervical cord compression. I have discussed with ortho (orthopedics service) at Hospital A and spine surgeon is unavailable. Patient will need transfer to tertiary care center for further evaluation and management. He has finding that suggest sepsis, with delirium. Possible meningitis/encephalitis. Call placed to Hospital C to arrange transfer". Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 02/2014, with no documentation of the pertinent medical records copies sent to Hospital C for Patient #24. Further review of medical record revealed no documentation of the pertinent medical records copies sent to Hospital C for Patient #24. Record review revealed Patient #24 was transferred to Hospital C on 11/27/2015 at 2106.
Interview on 03/17/2016 at 1105 with nursing management confirmed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital B for Patient #24.
4. Closed DED (dedicated emergency department) medical record review of Patient #25 revealed a 72 year-old male who presented to Hospital A's DED on 03/14/2016 at 0056 with a chief complaint of "Family reports pt (patient) has Rt (right) sided weakness for one hour". Record review revealed Patient #25 was seen by Physician F on 03/14/2016 at 0100. Review of Physician F's dictated notes on 03/14/2016 at 0102 revealed "History of Present Illness: The patient presents with vision changes. ...Was staggering and falling to one side ...Reexamination/Reevaluation: CT with bleed FFP (fresh frozen plasma) ordered and will transfuse when available Given IV (intravenous) meds (medications) to lower BP (blood pressure 0126 hrs (hours): Calls being placed to Hospital C to arrange transfer Spoke to Physician G, transfer arranged". Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 12/2008, with the risks of transfer related to condition blank with no written documentation of the risks for Patient #25. Further record review revealed no documentation in the medical record by the physician that the risks for transfer related to the condition were explained to Patient #25. Review of transfer form revealed no documented date and time of Physician F's certification to transfer. Review of transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital C for Patient #25. Record review revealed Patient #25 was transferred to Hospital C on 03/14/2016 at 0235.
Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form".
Interview on 03/17/2016 at 1105 with AS #1 confirmed that there was no documentation in the medical record or on the transfer form for the risks of transfer for Patient #25. Interview revealed that there was no documentation in the medical record or on the transfer form for the date and time of physician's certification to transfer for Patient #25. Interview revealed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital C.



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5. Closed DED (dedicated emergency department) medical record review of Patient #7 revealed a 74 year-old female who presented to Hospital A's DED on 10/31/2015 at 1730 with a chief complaint of "Patient fell in bathroom. States fell and slipped onto floor when she heard a 'pop' in her right lower leg. States only has pain during movement, otherwise no pain". Review of Physician H's dictated notes on 10/31/2015 at 1940 revealed "History of Present Illness: The patient presents following fall. ... Location: right lower extremity. The character of symptoms is pain. The degree at present is moderate. ... Diagnosis: femur fracture, right. ..." Record review revealed an orthopedic consult was conducted. Review of the consult notes recorded on 10/31/2015 at 2202 revealed "... We feel the patient will likely need surgical fixation with open reduction and internal fixation using a locked distal femoral plate. ... I would recommend transfer to one of the trauma centers ..." Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 02/2014, with the risks of transfer related to condition blank with no written documentation of the risks for Patient #7. Further record review revealed no documentation in the medical record by the physician that the risks for transfer related to the condition were explained to Patient #7. Review of the transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital B for Patient #7. Record review revealed Patient #7 was transferred to Hospital B on 10/31/2015 at 2350.
Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form".
Interview on 03/17/2016 at 1205 with AS #1 confirmed that there was no documentation in the medical record or on the transfer form for the risks related to condition for Patient #7. Interview revealed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital B for Patient #7.
6. Closed DED (dedicated emergency department) medical record review of Patient #6 revealed a 14 year-old male who presented to Hospital A's DED accompanied by his parent on 01/19/2016 at 1015 with a chief complaint of "Has been thinking about SI (suicide ideations) since Thursday, no hx (history) of same, started with a bad dream, planned to hang yourself, denies previous attempts ..." Record review revealed Patient #6 was seen by Physician I on 01/19/2016 at 1202. Review of Physician I's dictated notes on 01197/2016 at 1202 revealed "History of Present Illness: ... The patient presents with psychiatric problem and suicidal ideation. The onset was six days ago. The course/duration of symptoms is worsening. Character of symptoms depressed. The degree of symptoms is severe. Self injury: none. ... Patient states plan to hang himself. ... Diagnosis: Depression, Suicide Intent. ... Plan: Transfer to other location. ..." Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 02/2014, with the risks of transfer related to condition blank with no written documentation of the risks for Patient #6. Further record review revealed no documentation in the medical record by the physician that the risks for transfer related to the condition were explained to Patient #6's parent prior to transfer. Review of the transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital D for Patient #6. Review revealed the physician signed the Certification of Transfer on 01/19/2016 at 1315 (5 hours and 41 minutes prior to the patient's departure). Record review revealed Patient #6 was transferred to Hospital D via law enforcement on 01/19/2016 at 1856.
Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form".
Interview on 03/17/2016 at 1220 with AS #1 confirmed that there was no documentation in the medical record or on the transfer form of the risks associated with transfer. Interview revealed there was no documentation of pertinent medical records copies sent to Hospital B for Patient #6. Interview revealed the physician certified the condition of the patient at 1315 and the patient departed at 1856. Interview confirmed the physician failed to certify the condition of the patient as close to the time of departure as possible.

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