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Based on observation, interviews, documentation reviewed in 5 of 29 emergency department (ED) records for patients who presented to the hospital's ED (Patient #s 1, 4, 8, 9 and 17), and review of hospital policies and procedures, it was determined the hospital failed to fully develop and enforce appropriate EMTALA policies and procedures related to all EMTALA requirements, including the provision of medical screening exams (MSEs) and appropriate transfers.

Findings include:

1. Review of hospital EMTALA policies and procedures revealed they did not address the following required EMTALA subjects at all:

a. Maintenance of a central ED log.

b. Reporting of suspected incidents of inappropriate transfers.

c. Whistleblower protection.

d. Posting of Signs. Refer to findings identified under Tag A2402 CFR 489.20(q) which reflects the hospital's failure to adopt and enforce policies and procedures for the required posting of EMTALA signs.

An interview was conducted with the Chief Nursing Officer on 02/13/2013 at 0950. He/she stated the hospital did not have "Whistleblower Protection" specific to EMTALA in current hospital policies.

An interview was conducted with the Chief Financial Officer on 02/15/2013 at 0815. He/she expressed being unaware of any EMTALA policies adopted by the hospital which addressed the reporting of suspected incidences of inappropriate transfers, the maintenance of central ED logs, and the required posting of signs. The Chief Financial Officer stated he/she checked with the Chief Nursing Officer on 02/14/2013 who had indicated to him/her also being unaware of the development of any such policies.


2. Review of hospital EMTALA policies and procedures revealed that the hospital failed to enforce its own policies and procedures in the following areas:

a. Appropriate Medical Screening Exam. Refer to findings identified under Tag A2406, CFR 489.24(c) which reflects the hospital's failure to provide an appropriate MSE for a patient who presented to the ED to determine whether or not an Emergency Medical Condition (EMC) existed.

In addition, the findings under Tag A2406 reflected that a paramedic had been assigned to perform MSEs which was not allowed by MSE policies and procedures.

b. Appropriate Transfer. Refer to findings identified under Tag A2409, CFR 489.20(e)(1-2) which reflects the hospital's failure to effect appropriate transfers for patients who presented to the ED with an EMC.

3. These findings were shared during the exit conference conducted on 02/15/2013 at 0845 and no additional information was provided. The Chief Financial Officer was the only hospital representative in attendance at the exit conference.

Based on observation, interviews, and review of policies and procedures, it was determined that the hospital failed to adopt a policy and procedure for the posting of the required EMTALA signs and failed to post the required EMTALA signs conspicuously in a place or places likely to be noticed by all individuals entering the ED as well as those individuals waiting for examination or treatment in areas other than the traditional ED as required by this regulation.

Findings include:

1. A tour of the facility was conducted on 02/11/2013 at 1410 with the Chief Nursing Officer present. The main entrance to the hospital is located on the north side of the facility at the approximate midpoint. Approximately 14 feet to the south from that entrance is an entrance to the ED. An "L" shaped ED waiting room that is approximately 14 feet on the north wall and 12 feet on the east wall holds five chairs and is separated from the main entrance to the north, by double glass doors to the west, and the north/south wall that separates the two entrances to the east. Chairs placed in the ED waiting room were arranged in an "L" shape, with 4 chairs along the north wall and a single chair along the east wall. Just west of the ED waiting room is a larger triangular waiting room. An admitting area separates the two waiting rooms and is accessible to both waiting rooms. There was a sliding glass window with an admitting desk that is on the west wall of the smaller ED waiting room.

2. The hospital tour began at the patient walk-in entrance to the ED waiting room. Signage specifying the EMTALA rights of individuals was posted on the north to south wall, just south of the sliding glass window. However, it was determined that the signage was not visible from any one of the four chairs that occupied the north wall of the ED waiting room. The single chair on the east north to south wall was occupied at the time of the tour and the visibility of the signage was not verified.

3. The ED was toured at 1420. It was determined that an ambulance entrance existed on the east wall of the ED. For any patients arriving via ambulance, there was no EMTALA signage in the ambulance entrance, the hallway from the ambulance entrance, treatment room #3, or the trauma room. This was confirmed by the Chief Nursing Officer who stated "I am not seeing any [EMTALA signage]." Interviewee P, a registered nurse (RN) was seated behind the nursing station inside the ED. He/she was asked if patients were ever brought to the ED by ambulance, then taken to the ED waiting room to wait for treatment. He/she stated: "They're not routed out to the lobby to wait for treatment." Therefore, patients who came in by ambulance did not see the EMTALA signage.

4. The tour continued to the Labor and Delivery (L&D) area of the facility at 1430. It was noted that the entrance to the L&D was locked and L&D staff opened the entrance. No EMTALA signage was observed either outside the L&D or within the L&D department. A 02/19/2013 E-mail from the Chief Nursing Officer stated: "Our OB medical screening exam can take place in the ED or the OB[,] however it is normally the ED."

On 02/11/2013 at 1500, the tour ended at the admitting desk that occupied the juncture of the two waiting rooms west of the clear glass door to the ED waiting room. The Chief Nursing Officer stated that patients could come to the ED waiting area from the Clinic. On the counter of the admitting desk was a clear stand-up sign holder, which held an 8.5 X 11" paper. One side contained an "It's the Law" sign consistent with EMTALA signage. The other side contained a document titled "Harney District Hospital Laboratory Department, Outpatient Testing" schedule of operational hours. These two documents were back-to-back in the clear stand-up sign holder. When observed on 02/11/2013 at 1630, the side containing the Laboratory draw times faced the public and the EMTALA signage faced the wall. When observed on 02/12/2013 at 0730, 1048 and 1221, the side containing the Laboratory draw times faced the public and the EMTALA signage faced the wall. In a 02/12/2013 at 1500 interview, Interviewee M, an Admitting Clerk, was asked if he/she realized that the Laboratory draw hours sign was more prominent than the EMTALA signage over repeated observations. Interviewee M stated that he/she had removed the EMTALA signage from the clear stand-up sign holder and attached it to the admitting desk and didn't realize that it had since been returned to the clear stand-up sign holder.

5. Hospital policies and procedures were reviewed. It was determined the hospital failed to include the required posting of signs in its policies and procedures.

Based on interviews, review of documentation in 1 of 4 ED records (Patient 9) of patients who were brought to the ED by law enforcement personnel, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to ensure that the patient received a MSE to rule out whether an EMC existed, and that the hospital failed to ensure that staff assigned to provide MSEs were qualified to do so.

Findings include:

1. Review of the ED central log titled "ER Log History Report", on which patients were entered as a result of presenting to the ED for emergency services, revealed that Patient 9 was registered on 12/29/2012 at 1502. The entries further reflected that the patient's diagnosis was "Intoxicated" and "Routine Medical Exam". The chief complaint was identified as "Intoxicated". The log entry reflected the patient was discharged on 12/29/2012 at 1925, 4 hours and 23 minutes after being registered.

2. Review of the record of the ED visit for Patient 9 reflected that he/she was admitted to the ED on 12/29/2012 at 1502 and had diagnoses listed as "Intoxicated" and "Routine Medical Exam." There was no documentation to reflect that the patient had been seen by an RN or a physician, that vital signs had been taken and triage performed, that a MSE had been conducted, and that an EMC had been ruled out. There was no documentation to reflect why the ED log reflected that the patient had a "routine medical exam" and had been in the ED for 4 hours and 23 minutes in the absence of provision of any triage or MSE.

3. Review of a policy titled "EMTALA", published on 04/20/2012 reflected the following internal requirements: "All patients presenting to Harney District Hospital's Emergency or Labor and Delivery departments and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. In the absence of an actual request for services, if a "prudent layperson" observer would believe, based on the individual's appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment. All patients shall receive a medical screening exam that includes providing all necessary testing and on call services within the capability of the hospital to reach a diagnosis...Prior authorization may be obtained after medical screening and stabilization services are completed..."

Review of a policy titled "Medical Screening Exam (MSE)", published on 04/20/2012, reflected the following internal requirements: "All individuals presenting to the hospital premises requesting emergency examination or treatment shall be offered a medical screening examination to determine if the individual has an emergency medical condition. An MSE shall be offered regardless of the individual's ability to pay and shall not be denied or delayed pending inquiry as to the individual's method of payment or insurance status. The MSE must be sufficient to determine if an emergency medical condition exists...All resources available to the hospital will be used to perform an MSE..." The medical screening exam policy further identified that "Registered Nurses who have been oriented to the Emergency Department may perform an MSE. The nurse must first undergo training and demonstrate competency in performing an MSE."

The procedures section of the "Medical Screening Exam (MSE)" policy required that all patients who presented would be registered and would have a MSE performed.

Review of Medical Staff Rules & Regulations titled "General Rules for Admissions & Patient Care", effective 11/2007, reflected the following internal requirements: "Patients presenting to the Emergency Department will be given a timely Medical Screening Examination (MSE) to determine if the patient requires treatment for an emergency medical condition as defined by EMTALA obligations...An MSE, including necessary tests and stabilization measures, will be performed prior to determining a patient's financial ability to pay for the care." In addition, the above policy required: "The initial MSE may be conducted by an RN competent in ED protocols, with consultation with the on-call physician".

4. An interview was conducted with the ED physician on 02/12/2013 at 1300. The ED physician indicated he/she was on duty in the ED on 12/29/2012 when Patient 9 presented to the hospital. He/she stated "I never saw the patient". The ED physician indicated he/she was told by staff that the patient only needed an alcohol level and neither the patient nor the parole officer had a medical concern. He/she told the staff that if there was a medical problem we'd be happy to see the patient, but if the patient was "just intoxicated then I'm not sure it's appropriate." He/she stated it was the job of the triage nurse to determine if a MSE was necessary and that would've been [name of a paramedic] and/or an RN. He/she stated that no nurses were assigned in the ED on 12/29/2012 which was why a paramedic was "helping out." The ED physician was asked if paramedics were authorized to conduct MSEs in the ED. He/she stated "I don't know." During the interview the ED physician stated that he/she had worked in the hospital's ED for 2 years and that he/she had not received any EMTALA related training from the hospital.

An interview was conducted on 02/12/2013 at 1500 with the admitting clerk who was on duty when Patient 9 presented to the hospital on 12/29/2012. He/she indicated the patient presented to the admissions desk outside the ED with a parole officer and another law enforcement officer. The clerk stated that the parole officer reported that the patient was intoxicated and needed a blood alcohol test. The clerk stated that the patient didn't seem to know what to do and "was confused". According to the clerk the patient also stated to him/her "look how yellow I am" and "I have liver problems". The clerk stated he/she told the parole officer that he/she wasn't sure what to do and that he/she would "go talk to the doctor". The clerk stated that he/she talked to the paramedic on duty who was working in place of an RN because the hospital was "short on nurses". The clerk stated that the paramedic then talked to the doctor and the paramedic reported back to the clerk that the doctor had declined to perform any tests. The clerk stated he/she reported this back to the parole officer who stated the patient needed to be seen and be tested to make sure the patient doesn't die in jail. The clerk stated he/she then called his/her supervisor, who is the hospital business office manager, for direction. The clerk stated that the supervisor told him/her that the patient would have to go to the jail to be "booked" before the patient could have the tests run.

An interview was conducted on 02/12/2013 at 1430 with a second admitting clerk who arrived on duty after Patient 9 had presented to the ED on 12/29/2012. The clerk stated that he/she observed the patient to be "very intoxicated". He/she stated that the smell of alcohol was "very, very strong" and that it smelled like the patient had drank a "whole bottle" of alcohol. The clerk also stated that the patient's speech was slurred, that the patient kept leaning on the counter, that the patient's skin and eyes were yellow, and the patient kept pointing out his/her "yellow skin".

An interview was conducted on 02/12/2013 at 1545 with the paramedic who was on duty in the ED on 12/29/2012. He/she stated the admitting clerk had informed him/her that Patient 9 and a parole officer had presented to the ED. The paramedic stated he/she spoke to the ED physician who declined to have the patient tested. The paramedic stated he/she then spoke to the parole officer and the patient in the ED waiting area. The paramedic stated that during the interaction the parole officer requested a blood alcohol level for the patient and indicated that the patient had a past history of alcohol abuse. The paramedic said the patient stated to him/her that the patient did not want to have any tests conducted. The paramedic described the patient as intoxicated with slurred speech, with exaggerated hand movements, and an alcohol odor. The paramedic confirmed that the patient did not receive a MSE.

An interview was conducted on 02/13/2013 at 1050 with the business office manager who had been called by the admitting clerk when Patient 9 had presented. He/she indicated that the clerk called him/her at home the night of the incident to make sure he/she had done everything right. The manager stated that "anyone presenting to the emergency room is entitled to a medical screening exam." The manager indicated that if he/she has questions about EMTALA he/she goes "on-line and looks it up" and that there aren't any requirements for admitting staff to have EMTALA training.

After the interview the business office manager provided a one-page document with the heading "Please fill out when patients are brought in by law enforcement." He/she stated the document was from Patient 9's business office file and had been completed by the parole officer when the patient was brought to the ED on 12/29/2012. The document was not dated, timed or authenticated. The following information was written on the form: "Intoxicated...started drinking yesterday...Probation violation over a [0.32% blood alcohol content]..." (Note: A February 2013 article on the National Institute on Alcohol Abuse and Alcoholism website titled "Alcohol Overdose: The Dangers of Drinking Too Much" reflects that blood alcohol levels above 0.30% can result in "severe" to "deadly" symptoms and reactions.)

An interview was conducted on 02/12/2013 at 1345 with a manager who was the designated hospital administrator on call (AOC) when Patient 9 had presented. The AOC stated he/she received a call from the paramedic on duty in the ED on 12/29/2012 who reported the situation with Patient 9. The AOC stated he/she came to the hospital and reviewed the law enforcement document completed by the parole officer which reflected that the patient had been identified with a 0.32 blood alcohol level prior to coming to the hospital. The AOC stated he/she spoke with the parole officer and Patient 9 who were sitting in the ED waiting area. The AOC stated the parole officer told him/her that Patient 9 "blew a 0.32" and that he/she wanted to make sure the patient is not going to die in jail. The AOC told the parole officer that if he/she wanted the patient to have blood tests done the patient would need to be "booked" at the jail first. The AOC indicated that he/she left the ED for a time and returned at approximately 1700 that same day. Upon return the AOC observed Patient 9 at the admitting desk as the parole officer had returned the patient to the hospital and dropped him/her off. The AOC stated that Patient 9 said "I don't know why they brought me here...I know I shouldn't be drinking...I need to get in to see a doctor."

During the interview the AOC provided a document identified as his/her notes of the event. Those notes reflected that when the AOC observed Patient 9 after returning to the ED the patient was "confused". The notes reflected that hospital staff called a shelter who agreed to take the patient, and that shelter staff arrived at approximately 1800 and took the patient away.

The AOC stated that "I did not ask the patient if he/she wanted to be seen" and "If I could've done anything differently, I would've asked the patient." The AOC stated that he/she had been employed by the hospital for seven or eight months and that he/she had not received any EMTALA training. He/she stated "I was just told patients should have a medical screening exam a couple months ago."

A second interview was conducted with the paramedic on 02/14/2013 at 1530. The paramedic stated he/she was unaware that Patient 9's blood alcohol level was 0.32. He/she stated that "I was never given that information" and that therefore, he/she did not relay the patient's alcohol level to the ED physician. He/she further stated that if he/she had known the patient's alcohol level was 0.32, he/she would've made sure the ED physician was informed and would've tried to ensure the patient was seen. The paramedic reviewed the medical record for Patient 9 at the time of the interview. He/she acknowledged it lacked documentation that a MSE had been conducted and also lacked documentation that the patient had refused such.

An interview was conducted with the Chief Nursing Officer on 02/13/2013 at 0950. He/she acknowledged that Patient 9 presented to the hospital's ED on 12/29/2012 and confirmed that the patient's record lacked documentation that a MSE had been provided and lacked documentation that the patient had refused a MSE.

During the interview the Chief Nursing Officer stated that on 12/29/2012 a paramedic had been assigned to conduct MSEs instead of an RN because the hospital had been experiencing a shortage of ED RN staff. The Chief Nursing Officer was asked for documentation to reflect that paramedics had been determined qualified by hospital rules, regulations or by-laws to conduct MSEs in the ED. No documentation was provided.

5. Preliminary findings were shared during the exit conference conducted on 02/15/2013 at 0845 and no additional information was provided. The Chief Financial Officer was the only hospital representative in attendance at the exit conference.

Based on interviews, documentation reviewed in 4 of 4 medical records of patients who presented with an EMC and who were transferred to other facilities for stabilizing treatment (Patient #s 1, 4, 8 and 17), it was determined that the hospital failed to effect appropriate transfers of those patients. The hospital failed to ensure the required physician certification that the benefits of transfer outweighed the risks of transfer in all cases.

Findings include:

1. The hospital had a form titled "Certification of Transfer Harney District Hospital, Burns, Oregon. This form contained the following statements:
"* At the time of the patient's examination, the medical benefits reasonably expected from the transfer to the receiving facility outweigh the increased risks, if any, to the patient.
* The patient is medically stable so that within reasonable medical probability no medical deterioration of the patient's condition is likely to result from the transfer.....
8. Benefits/risks of transfer explained to patient/significant other as related to the patient's specific condition.
[checkbox] dictated by physician
[checkbox] written [followed by three lines for additional written material]."

2. On 02/13/2013 at 0845, the Chief Nursing Officer presented a copy of two forms; "Harney District Hospital Transfer Orders," and "Certification of Transfer Harney District Hospital, Burns, Oregon" and stated that this packet [the two forms] is for all transfers and the lines after "[checkbox] written" is where the risk versus benefits should be documented.

3. The facility had an Emergency Department Policy titled "EMTALA" that was created and published on 04/20/2012 and due for review on 02/27/2013. This policy stated: "If a patient is to be transferred for medical necessity the following guidelines must be followed:
? "The physician certification that the risks of transferring the patients are outweighed by the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these, or
? The patient gives written consent for transfer;....."

4. The medical record of Patient #4, who presented to the Hospital's ED on 09/21/2012 at 1340 was reviewed. This patient was transferred to a second hospital via "ground" ambulance. The patient had experienced a left leg open tibiofibular fracture and was transferred for an open reduction and internal fixation of the fracture. This medical record contained a "Certification of Transfer Harney District Hospital, Burns, Oregon" form. On that form, there was a checkmark in the checkbox preceding "dictated by physician." The "Emergency Department Note" was dictated but did not contain a statement of the individual risks and benefits anticipated as a result of the transfer. Additionally, the complete set of documents of this ED visit were reviewed and no statement of the individual risks and benefits was found on any of those documents.

5. The medical record of Patient #8, who presented to the ED on 01/21/2013 at 0450 was reviewed. The patient was experiencing an evolving inferior/posterior myocardial infarction. The patient was transferred to a second hospital at 0650 for possible stent placement. A "Certification of Transfer Harney District Hospital, Burns, Oregon" form was in the record. On that form, there was a checkmark in the checkbox preceding "written" and written on the lines following the checkbox was "worsening condition." A review of the "Emergency Department Note" determined that a list of individual risks and benefits was not included in that document. Additionally, the complete set of documents of this ED visit were reviewed and no statement of the individual risks and benefits was found on any of those documents.

6. The medical record of Patient #17, who presented to the ED 01/20/2013 at 0430 was reviewed. The patient, with a history of depression had overdosed on Effexor and while in the ED, experienced a generalized tonic-clonic seizure. The patient was intubated to protect the airway and transferred to a second hospital at 0650 for medical intensive care. A "Certification of Transfer Harney District Hospital, Burns, Oregon" form was in the record. On that form, there was a checkmark in the checkbox preceding "written" and written on the lines following the checkbox was: "determination of medical condition with continued seizures difficulty protecting airway." A review of the "Emergency Department Note" determined that a list of individual risks and benefits was not included in that document. Additionally, the complete set of documents of this ED visit were reviewed and no statement of the individual risks and benefits was found on any of those documents.

7. The medical record of Patient #1, who presented to the ED 08/11/2012 at 0548 was reviewed. The patient experienced respiratory failure and a respiratory arrest while in the hospital's ED. This patient was transferred to a second hospital at 1000. A "Certification of Transfer Harney District Hospital, Burns, Oregon" form was in the record. On that form, there was a checkmark on the line preceding "8" and a checkmark in the checkbox preceding "written" and written on the lines following the checkbox was: "worsening incident." A review of the "Emergency Department Note" determined that a list of individual risks and benefits was not included in that document. Additionally, the complete set of documents of this ED visit were reviewed and no statement of the individual risks and benefits was found on any of those documents.

These findings were discussed with the Chief Financial Officer on 02/15/2013 at 0815 during the exit conference.