HospitalInspections.org

Based on observation, review of recorded video footage, interview, review of documentation for 13 of 22 patients who presented to TCH's on-campus and off-campus EDs for emergency services (Patients 1, 4, 5, 6, 8, 9, 11, 13, 16, 17, 18, 20 and 21), review of central log documentation, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce clear and complete EMTALA policies and procedures to ensure compliance in the following areas:
* Provision of MSEs;
* Provision of further exam and stabilizing treatment within the hospital's capability and capacity, including on-call physician responsibilities;
* Provision of appropriate transfers of patients;
* Maintenance of a central ED log; and
* Required posting of EMTALA signs.

Findings included:

1. Regarding provision of MSEs:

* Refer to the findings for Patient 20 identified under Tag A2406, CFR 489.24(a) & 489.24(c).

* The written policies and procedures were not clear. For example: There were no p/ps specific to MSEs. Reference to MSEs were contained in the hospital's p/p titled "Transfer of Patients with Emergency Medical Conditions or Labor (EMTALA)," dated as last revised "[September] 2009," under the section "The Medical Screening Exam." The only references to the provision of an MSE that was not related to who may perform an MSE was: "The patient shall receive the care, treatment, and surgery by a physician necessary to relieve or eliminate the condition within the capability of the hospital. TRIAGE IS NOT A MEDICAL SCREENING EXAM (MSE)...Components of MSE are: * Triage record, with presenting complaint and vital signs * Complete vital signs [blood pressure, pulse, respirations, temperature] * Oral history * Physical exam of affected systems." There were no other p/ps provided related to MSEs.

The p/p reflected that "The RN may perform the MSE, in the context of EMTALA, provided the following criteria are met: The hospital/facility board of directors or governing body must approve the plan...The RN must function under protocols/algorithms that are approved...There must be a provider with authority to independently medically diagnose and treat...The hospital/facility must have a training program...The RN must be able to demonstrate competency..." The p/p did not clearly stipulate whether TCH currently permitted RNs to perform MSEs.

2. Regarding the provision of further medical examination and treatment to stabilize the medical condition within the hospital's capabilities:

* Refer to the findings for Patients 1 and 8 identified under Tag A2407, CFR 489.24(d)(1-3).

* The written policies and procedures were not clear. For example: The hospital's p/p titled "Transfer of Patients with Emergency Medical Conditions or Labor (EMTALA)" dated as last revised "[September] 2009" was reviewed. It reflected that "Within the capability of the facility means those capabilities, which the hospital is required to have as a condition of its emergency medical services permit." It is not clear what an "emergency medical services permit" refers to and there is no such permit required for an Oregon hospital.

The hospital's p/p titled "Medical Staff On-Call EMTALA Requirements" dated as last revised on 08/27/2015 was reviewed. The p/p reflected that "When a physician is on-call for the hospital and seeing patients with scheduled appointments in his private office, it is generally not acceptable to refer emergency cases to his or her office for examination and treatment of an EMC. The physician must either come to the hospital to examine the individual if requested by the treating emergency physician or if the physicians office is better equipped with specialized equipment to be able to provide treatment more quickly then the patient could be transferred following EMTALA transfer procedures." That language did not accurately reflect the language in the EMTALA guidelines under CFR 489.20(r)(2) and 489.24(j), Availability of On-call Physicians, that specifies: "When a physician is on-call for the hospital...The physician must come to the hospital to examine the individual if requested to do so by the treating physician. If, however, it is medically indicated, the treating physician may send an individual needing the specialized services of the on-call physician to the physician's office if it is a provider-based part of the hospital (i.e., department of the hospital sharing the same CMS certification number as the hospital) It must be clear that this transport is not done for the convenience of the specialist but that there is a genuine medical reason to move the individual, that all individuals with the same medical condition, regardless of their ability to pay, are similarly moved to the specialist's office, and that the appropriate medical personnel accompany the individual to the office."

In addition, the above p/p reflected "After consultation with the on-call physician and as determined by the emergency department physician the following actions may be taken. If the on-call physician is able to meet the patient at another hospital and the patient consents, transfer the patient following EMTALA provisions." However, the EMTALA guidelines referenced in the above paragraph direct that "...if a physician who is on-call typically directs the individual to be transferred to another hospital instead of making an appearance as requested, then that physician as well as the hospital may be found to be in violation of EMTALA."

3. Regarding appropriate transfers:

* Refer to the findings for Patients 1, 8, 9, 16, 17, and 18 identified under Tag A2409, CFR 489.24(e)(1)-(2).

* The written policies and procedures were not clear. For example: The hospital's p/p titled "Transfer of Patients with Emergency Medical Conditions or Labor (EMTALA)" dated as last revised "[September] 2009" was reviewed. The policy purpose included: "To meet the requirements of EMTALA...when the patient is being transferred (including to doctors offices or clinics, or going home in the case of a woman having contractions or other signs of labor) and meets the following criteria...undelivered patient, who may or may not be in active labor." The p/p further reflected that "...transfer means to send the patient anywhere, except within the hospital, such as: other hospitals, doctors' offices, clinics, and discharged home for undelivered patients having any contractions or other signs of labor..." It further reflected under the "Patient Transfer" section that "Patients having contractions or other signs of labor who are discharged home are considered a transfer and all elements of EMTALA must be satisfied."

The p/p excerpts above that describe an EMTALA transfer to include the movement of patients who presented for emergency services, including women in labor, to doctors office, clinics, and discharge to home does not accurately reflect the EMTALA requirements. Discharging a patient for whom an EMC has not been ruled out or resolved, including women for whom labor has not been ruled out, to anywhere other than another hospital with appropriate capability and capacity is potentially an EMTALA violation.

4. Regarding the central log refer to the findings for Patients 4, 5, 6, 11, 13, 20, and 21 identified under Tag A2405, CFR 489.20(r)(3).

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

37402

Based on observation, interviews, and review of policies and procedures, it was determined the hospital failed to enforce its policies and procedures to ensure that EMTALA signage was posted conspicuously in those places that could be seen by all individuals who presented to the hospital for emergency services, including women in labor, and by those who waited for examination and treatment. EMTALA signage at TCH's on-campus and off-campus EDs were posted in one place at each of the ED waiting areas and were not viewable to all individuals waiting for exam or treatment in the ED.

Findings include:

1. The p/p titled "Transfer of Patients with Emergency Medical Conditions or Labor (EMTALA)" revised "[September] 2009" was reviewed. It stipulated that "Signs will be posted, as directed by the Secretary of Health and Human Service, which are visible from 20 feet, in English and Spanish in the Emergency Department, Admitting Departments, and Birth Center unit and state: 'IT'S THE LAW! If you have a medical emergency or are in labor you have the right to receive (within the capabilities of this hospital's staff and facilities): an appropriate medical SCREENING EXAMINATION, necessary STABILIZING TREATMENT (including treatment for an unborn child) and, if necessary an appropriate TRANSFER to another facility, even if YOU CANNOT PAY or DO NOT HAVE MEDICAL INSURANCE or YOU ARE NOT ENTITLED TO MEDICARE OR MEDICAID. This hospital does participate in the Medicaid program."

2. A tour of the TCH on-campus ED was conducted on 06/20/2016 beginning at 1045 with the NM. During interview at the time of the tour he/she stated that the ED had a waiting area, registration area, 16 beds in the main treatment area, 4 rapid care beds in a separate room off of the main treatment area, one walk-in entrance from the outside of the hospital, one entrance from inside the hospital, and one ambulance entrance.

Observations during the tour revealed one EMTALA sign in both English and Spanish located in the main waiting area. The waiting area was divided into two distinct areas by a wall. The EMTALA sign was placed on one side of the wall and was not visible to individuals who waited in chairs on the opposite side of the wall. No signs were observed in any other areas or rooms throughout the ED. During the tour of the ED the NM indicated there used to be more signs posted but they had not been put back up after a recent remodel.

3. On 06/20/2016 at 1415 during interview with the NM he/she stated that EMTALA signs in English and Spanish were posted in the waiting area at the TCH off-campus ED and that no other EMTALA signs were posted in any other areas or any of the 6 exam rooms throughout the ED.

Based on observation, review of recorded video footage, interviews, review of central logs and medical records and other documentation for 7 of 22 patients who presented to TCH's on-campus and off-campus EDs for emergency services (Patients 4, 5, 6, 11, 13, 20, and 21), and review of policies and procedures, it was determined the hospital failed to enforce its EMTALA policies and procedures to ensure maintenance of a central log that contained complete and accurate information about each patient who presented to the hospital for emergency services, including Patient 20 for who there was no entry on the log.

Findings include:

1. The hospital's p/p titled "Transfer of Patients with Emergency Medical Conditions or Labor (EMTALA)" dated as last revised "[September] 2009" was reviewed. It stipulated that "A Central log system is maintained and consists of departmental logs in TCH Birth Center, [TCH on-campus ED] and [TCH off-campus ED]...Each department log must, at a minimum, indicate for each person seeking care for a medical emergency or having contractions or other signs of labor, whether he or she refused treatment or voluntarily left without receiving a medical screening exam or treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged."

2. Review of the ED central log revealed no entry for Patient 20 on 06/04/2016. Refer to the findings for Patient 20 identified under Tag A2406, CFR 489.24(a) & 489.24(c), Medical Screening Exam.

3. Review of the ED central log revealed that the entries for all patients were not complete or clear as follows:
* The log reflected Patient 4 was admitted to the ED on 04/13/2016, however the log did not reflect the disposition. The discharge/disposition section of the log was blank.
* The log reflected Patient 5 was admitted to the ED on 04/14/2016, however the disposition from the ED was not clear. It reflected the patient both went home and was discharged to an unidentified hospital.
* The log reflected Patient 6 was admitted to the ED on 04/15/2016, however the log did not reflect the disposition. The discharge/disposition section of the log was blank.
* The log reflected Patient 11 was admitted to the ED on 05/04/2016, however the disposition from the ED was not clear. It reflected the patient both went home and was admitted.
* The log reflected Patient 13 was admitted to the ED on 05/10/2016, however the disposition from the ED was not clear. It reflected the patient both went to PSVMC and was admitted to TCH.
* The log reflected Patient 21 was admitted to the ED on 06/06/2016, however the log did not reflect the chief complaint and the disposition. The chief complaint and discharge/disposition sections of the log were blank.

Based on observation of recorded video footage, interviews, review of medical records and other documentation for 1 of 22 patients who presented to TCH's on-campus and off-campus EDs (Patient 20), and review of policies and procedures and other documents, it was determined the hospital failed to enforce its EMTALA policies and procedures to ensure that all patients who presented to the hospital were provided a MSE. Patient 20 did not receive a MSE as a result of discussion about insurance with ED registration staff.

Findings include:

1. The hospital's p/p titled "Discussing Insurance with Patients" dated as last revised "[June] 2013" was reviewed. It stipulated that for the TCH ED "Discussions initiated by patients about insurance must occur after the patient has been seen by the provider...If asked whether or not Tuality Healthcare is a provider for their particular insurance, admitting staff will state, 'We will not refuse service to anyone regardless of his or her insurance but each insurance carrier is different and I cannot predict what they will cover'...If the patient specifically asks to call their insurance company they will be directed to a courtesy phone. If they request that we call, staff will tell them, 'By law we cannot contact your insurance company about coverage until after you have been seen by a physician for a medical screening exam'."

The hospital's p/p titled "Emergency Patients" dated as last revised "[June] 2013" was reviewed. It stipulated that "It shall be the policy of the Admitting Department to register patients presenting to the [ED] in a manner consistent with EMTALA regulations and corporate policy...When a patient presents to the [ED] window the Admitting staff do a STAT registration, verify two patient identifiers and place the armband on the patient. The face sheet, labels and charge sheet will be placed in the appropriate area for the ER nurse...Admitting staff will complete the registration...when appropriate; once they are in an ER room and have been screened by the provider, but not impeding the patient's treatment..."

The hospital's p/p titled "Transfer of Patients with Emergency Medical Conditions or Labor (EMTALA)" dated as last revised "[September] 2009" was reviewed. It stipulated that "Hospital personnel may not register persons who come to the [ED] requesting emergency services before the person receives a medical screening exam and any necessary stabilizing treatment if the person has an [EMC] unless...the registration does not include any inquiry into the person's method of payment or insurance status..."

2. The TCH CCO and RM were interviewed on 06/20/2016 at 1000. During the interview they revealed that prior to this survey, it had been reported to TCH that Patient 20, a child, had presented to the TCH on-campus ED with his/her parent on 06/04/2016, had not received a MSE at TCH, and subsequently presented to KWMC ED for a MSE. The RM stated that he/she had contacted the parent upon receiving the report. The RM stated that the parent reported that he/she had approached the registration staff person in the ED check-in and the registrar entered the child's name in the hospital's system. The parent reported communication with the registrar about the family's Kaiser insurance plan, including that he/she was told by the registrar that the hospital didn't take Kaiser insurance and the parent would have to pay more to be seen at TCH. The CCO and RM confirmed that the parent and the child left TCH and the child did not receive a MSE.

3. Review of the ED central log revealed no entry for Patient 20 on 06/04/2016.

4. Review of records revealed no ED medical record for Patient 20 on 06/04/2016.

5. An undated memo to "All employees of ED Admitting" was titled "Notification of Policies and Expectations regarding [EMTALA] and Admitting Policies..." It reflected "Due to an incident that was reported by patient on June 4, 2016 it has come to our attention that a reminder of EMTALA rules, as well as Admitting Policies...regarding when it is appropriate to discuss insurance information, is needed...As noted in [policy and procedure AD-070] due to EMTALA laws and regulations; even if a patient requests that you discuss insurance or financial information upfront, you must advise the patient you are unable to do so. A patient is to be triaged by a provider before being asked to provide any type of financial information and before being counseled on the cost associated with possible care."

6. On 06/21/2016 at 1300 the CCO stated that a DVD contained video-footage of Patient 20 and his/her parent's encounter with the TCH on-campus ED registration staff on 06/04/2016. On 06/21/2016 at 1320 the DVD footage of Patient 20's encounter at the TCH on-campus ED was observed. It revealed an adult and a child approaching the TCH on-campus ED registration desk. The adult was observed to speak with a person behind the window at the desk. The adult and child turned away from the window and walked out of the ED registration and lobby area. The encounter was less than two minutes.

Based on interview, review of documentation in 2 of 7 medical records of patients for whom the central log reflected were transferred from TCH's on-campus and off-campus EDs (Patients 1 and 8), review of central log documentation, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce clear and complete EMTALA policies and procedures to ensure that within the capabilities of the staff and facilities available at the hospital, it provided for further medical examination and treatment as required to stabilize the patient's medical condition. Transfers were conducted for further examination and treatment where the hospital had the capability and capacity to provide the further examination and treatment.

Findings include:

1. a. The 56-page TCH "Hospital Plan for Patient Care" dated as last revised "March, 2015" was reviewed. The document contained descriptions of the hospital's scope of services, capabilities, and capacity. It reflected that the capabilities of the hospital included obstetric services and orthopedic surgical services.

b. The hospital's p/p titled "Transfer of Patients with Emergency Medical Conditions or Labor (EMTALA)" dated as last revised "[September] 2009" was reviewed. The p/p reflected that "Emergency services and care means medical screening, examination, and evaluation by a physician...to determine if an [EMC] or active labor exists and, if it does, the care, treatment, and surgery by a physician necessary to relieve or eliminate the [EMC], within the capability of the facility...Any undelivered patient experiencing contractions or having other signs of labor is to be managed as an EMTALA patient."

The p/p stipulated that "The [MSE] and evaluation shall include, if necessary, consultation with specialty physicians, to determine whether the patient is in labor, or has an [EMC]. The patient shall receive the care, treatment, and surgery by a physician necessary to relieve or eliminate the condition within the capability of the hospital."

The p/p further required that "Within the hospital's capacity to treat patients the hospital is required to have on-call specialists. Individual specialist groups are responsible for establishing who is going to be available to take call and provide the call list to the hospital...Physicians may take call simultaneously at more than one hospital, in which case the hospital has policies and procedures to follow when the on-call physician is not available to respond because he/she has been called to the other hospital to evaluate a patient...If a physician were on-call to provide emergency services or to consult with an [ER] physician, that physician would be considered to be available at the hospital..."

c. The hospital's p/p titled "Medical Staff On-Call EMTALA Requirements" dated as last revised on 08/27/2015 was reviewed. It reflected that "The hospital has on-call physician coverage for patients in need of specialized treatment within the hospital's capacity to treat patients...According to EMTALA regulations, the hospital is required to have on-call specialists...The hospital is required to keep a copy of the working on-call list for five (5) years...If a physician were on-call to provide emergency services or to consult with an emergency room physician, that physician would be considered to be available at the hospital...Response time is per the Rules and Regulations of The Medical Staff of Tuality Community Hospital...Communication occurs between the on-call physician and the ED such that the on-call physician is involved in planning for the care of the patient..."

d. The hospital's p/p titled "OB Patient: Fetal Monitoring" dated "05/14" was reviewed. It stipulated that "Patients who present to the ED and are over 20 weeks gestation with pregnancy related symptoms, will be immediately escorted to Birth Center for evaluation. Patients presenting to [TCH off-campus ED] will be transferred to [TCH on-campus ED] or Birth Center...Fetal heart tone assessment will be done on any ED patient stating she is 13 weeks or more pregnant and documented. If unable to obtain, that is documented as well."

e. The hospital's p/p titled "Patient Leaving Facility Against Medical Advice (AMA)" last "reviewed April 2010" was reviewed. It stipulated that "Patients will be advised of the risks of leaving [AMA]...An AMA - Leaving Facility Against Medical Advice - Patient's Release form...should be completed for any patient expressing the desire to leave [AMA]...The patient should be advised of the risks of leaving AMA and advised to seek care elsewhere, contact a physician, or return to the {ED} as needed if symptoms worsen or the condition does not improve...If the patient or designee refuses to sign, this will be stated on the form and signed by a witness who is an employee...After the form is signed and witnessed, it becomes part of the medical record...Document the chain of events, including discharge teaching, in the patient's record."


2. a. The central log for Patient 1, 46 years old, reflected he/she presented to the TCH on-campus ED on 04/03/2016 at 1220 with a chief complaint of "Arm injury - Major. Hip Injury - Major." The log reflected Patient 1's disposition was "Discharge to Short Term Hospital" on 04/03/2016 at 1608, and the destination was recorded as OHSU.

b. The TCH medical staff roster reflected that orthopedic specialists were included on the hospital's medical staff. The TCH medical staff call schedule from 03/01/2016 through 06/30/2016 reflected that orthopedic specialists were scheduled on-call on a 24/7 basis. Review of the TCH medical staff call schedule for April 2016 reflected that on 04/03/2016 one of the TCH orthopedic physicians was scheduled on-call. There was no indication on the schedule to reflect that had changed.

c. The ED medical record for Patient 1 reflected that on 04/03/2016 he/she was triaged by an RN and received a MSE by a physician. The "Emergency_DC Documentation" note recorded and signed by the physician on 04/03/2016 at 1549 contained the following notes: "Arm injury - Major...Humerus x-ray findings Compound fracture with displacement and shortening of left humerus. No bony abnormalitis (sic) of left elbow or forearm...Hip and pelvis xrays - no fracture...Based on history, physical exam findings and diagnostic studies performed today the patient has isolated left humeral fracture. No abdominal pain, LOC or neck pain to suggest traumatic injuires (sic) to head, abdomen. No back pain. Left hip with probable contusion, xray negative for fracture on ED read. No pelvis pain on exam. Labs unremarkable. When [he/she] was not moving [his/her] arm, pain was mild...Long arm splint applied by tech under my supervision...[MD] at OHSU Orthopedics accepting for transfer...Transfer to OHSU - Inpatient Orthopedic Ward."

The first section of a "Checklist & Physician Certification for Transfer" in the record was dated 04/03/2016 and contained the following documentation:
* The "List specific risk of transfer" space was blank.
* The "Summary of risks of transfer" space contained a list of generic risks of which the following were checked: "Possible worsening of condition during travel" and "Hazards of travel."
* In the "List specific benefits of transfer" space was recorded "trauma Orthopedics."
* The "Summary of benefits of transfer" space contained a list of generic benefits of which the following was checked: "Specialist available."
* The "Alternatives to transfer - must be completed" space was blank.
* The "Patient condition - must be completed" space was blank.
* The name and signature of the "Physician Certifying Transfer" was recorded.

The remaining sections on the form contained documentation that reflected an orthopedic physician at OHSU had accepted the patient in transfer, that medical records were sent, and that the patient was transferred by ambulance to OHSU.

There was no documentation in the record to reflect that the TCH on-call orthopedic specialist had been contacted to evaluate the patient as per the hospital's capabilities.

d. During interview with the NM on 06/21/2016 at 0955 he/she confirmed that TCH had orthopedic capability on 04/03/2016. He/she confirmed there was no indication in the record to reflect that the ED physician had called the TCH on-call orthopedic physician, and indicated he/she did not know why that wouldn't have been done. The NM also confirmed that there was no indication in the patient's medical record to reflect the patient was a "trauma" case, except for the word "trauma" recorded by the physician on the "Checklist & Physician Certification for Transfer" form. He/she further confirmed that TCH had capacity on 04/03/2016 and was not on divert.

During interview with the CCO on 06/21/2016 at 1115 he/she stated that TCH was not a "trauma" hospital so his/her "assumption" was that Patient 1 must have been a trauma patient so they would have to transfer.

There was no documentation in Patient 1's record to reflect that trauma protocols had been initiated for Patient 1.

3. a. The central log for Patient 8, 27 years old, reflected he/she presented to the TCH off-campus ED on 04/24/2016 at 2137 with a chief complaint of "Abdominal pain in pregnancy." The log reflected Patient 8's disposition was "Discharge to Short Term Hospital" on 04/24/2016 at 2210, however the space for the patient's specific destination was blank.

b. The TCH medical staff roster reflected that obstetrical specialists were included on the hospital's medical staff. The TCH medical staff call schedule from 03/01/2016 through 06/30/2016 reflected that obstetrical specialists were scheduled on-call on a 24/7 basis. Review of the TCH medical staff call schedule for April 2016 reflected that on 04/24/2016 one of the TCH obstetrical physicians was scheduled on-call. There was no indication on the schedule to reflect that had changed.

c. The ED medical record for Patient 8 reflected that on 04/24/2016 he/she was triaged by an RN and was examined by a FNP. The "Emergency_DC Documentation" note recorded and signed by the FNP on 04/24/2016 at 2205 contained the following notes: "The patient presents with flank pain. The onset was 3 hours ago. The course/duration of symptoms is constant and worsening. The character of symptoms is sharp. The degree at onset was severe. The Location of pain at onset was right, lower, abdominal and flank. The degree at present is severe. The Location of pain at present is right, lower, abdominal and flank. Risk factors consist of 20 [WEEKS] PREGNANT. Associated symptoms: nausea, vomiting and denies fever...Patient and husband see [obstetrical MD] at Providence Newberg so contacted and they will meet [him/her] in the ED there. Call placed to [MD] who accepted care...Probable kidney stone...By private car to Providence Newberg."

There was no documentation to reflect that the MSE included evaluation of the fetus within the hospital's capabilities. There was no documentation of fetal heart tone assessment, or that attempts made to assess those were not successful.

The first section of a "Checklist & Physician Certification for Transfer" in the record was dated 04/24/2016 and contained the following documentation:
* The "List specific risk of transfer" space was blank.
* The "Summary of risks of transfer" space contained a list of generic risks of which the following was checked: "Possible worsening of condition during travel."
* The "List specific benefit of transfer" space was blank.
* The "Summary of benefits of transfer" space contained a list of generic benefits of which the following were checked: "Condition likely to deteriorate unless transferred"; "Specialist available"; "For further evaluation & treatment"; and "Honor patient's choice."
* The "Alternatives to transfer" space contained a list of generic selections of which "Continue present care" was checked.
* The "Patient condition" space contained a list of generic selections of which the following was checked: "The patient has been stabilized such that within medical probability no material deterioration of the patient's condition or the condition of the unborn child(ren) is likely to result from transfer."
* The name and signature of the "Physician Certifying Transfer" was recorded by the FNP.

A progress note recorded by an RN prior to the transfer on 04/24/2016 at 2131 reflected that "Pt. to be transferred to TCH. Because they would have to go to OB first, they would prefer to drive to Newberg hospital and be seen there." However, there was no documentation in the record to reflect that the patient signed an AMA or refusal of continued examination and care at TCH.

There was no documentation to reflect that a MSE within the hospital's capabilities had been conducted, including monitoring of fetal heart tones to assess the health of the fetus, and diagnostic imaging testing to confirm the presence of kidney stones. There was no documentation to reflect that the TCH on-call obstetrical specialist had been contacted. There was no AMA documentation in the record to reflect the patient's written refusal for further examination at TCH.

d. During interview with the NM on 06/21/2016 at 1125 he/she confirmed that TCH has Ultrasound, CT Scan, and OB capabilities. He/she further confirmed that the TCH policy is that a pregnant woman 20 weeks or greater must be evaluated in the OB department and those patients who present to the TCH off-campus ED are to be transported to the TCH main campus.

Based on interview, review of documentation in 6 of 7 medical records of patients for whom the central log reflected were transferred from TCH's on-campus and off-campus EDs (Patients 1, 8, 9, 16, 17, and 18), review of central log documentation, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce clear and complete 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:
* Physician certification of patient specific, individualized medical benefits vs risks was not documented for all six cases; and
* Appropriate transportation was not utilized for one case.

Findings include:

1. The hospital's p/p titled "Transfer of Patients with Emergency Medical Conditions or Labor (EMTALA)" dated as last revised "[September] 2009" was reviewed. The policy purpose included: "To meet the requirements of EMTALA...To ensure that the patient, or responsible representative of the patient, has been informed of the risks and benefits and consents to the transfer...To ensure, in the case of a patient with an unstable emergency condition or having contractions or other signs of labor, that a physician certifies the transfer, including the risks and benefits, by his or her signature..."

Under the section of the p/p identified as "Transfer of patient with an [EMC], or having contractions or other signs of labor" it specified "The risks and benefits must be explained to the patient and the risks and benefits must be listed in the medical record. A physician must certify the risks and benefits...Obstetrical documentation also requires clearly defining whether or not the patient is in labor...

The only reference in the p/p to transportation was "Appropriate personnel and equipment are utilized for the transfer."

2. The central log for Patient 1, 46 years old, reflected he/she presented to the TCH on-campus ED on 04/03/2016 at 1220 with a chief complaint of "Arm injury - Major. Hip Injury - Major." The log reflected Patient 1's disposition was "Discharge to Short Term Hospital" on 04/03/2016 at 1608, and the destination was recorded as OHSU.

The ED medical record for Patient 1 reflected that on 04/03/2016 he/she was triaged by an RN and received a MSE by a physician. The "Emergency_DC Documentation" note recorded and signed by the physician on 04/03/2016 at 1549 contained the following notes: "Arm injury - Major...Humerus x-ray findings Compound fracture with displacement and shortening of left humerus. No bony abnormalitis (sic?) of left elbow or forearm...Hip and pelvis xrays - no fracture...Based on history, physical exam findings and diagnostic studies performed today the patient has isolated left humeral fracture. No abdominal pain, LOC or neck pain to suggest traumatic injuires (sic) to head, abdomen. No back pain. Left hip with probable contusion, xray negative for fracture on ED read. No pelvis pain on exam. Labs unremarkable. When [he/she] was not moving [his/her] arm, pain was mild...Long arm splint applied by tech under my supervision...[MD] at OHSU Orthopedics accepting for transfer...Transfer to OHSU - Inpatient Orthopedic Ward."

The first section of a "Checklist & Physician Certification for Transfer" form in the record was dated 04/03/2016 and contained the following documentation:
* The "List specific risk of transfer" space was blank.
* The "Summary of risks of transfer" space contained a list of generic risks of which the following were checked: "Possible worsening of condition during travel" and "Hazards of travel."
* In the "List specific benefits of transfer" space was recorded "trauma Orthopedics."
* The "Summary of benefits of transfer" space contained a list of generic benefits of which the following was checked: "Specialist available."
* The "Alternatives to transfer - must be completed" space was blank.
* The "Patient condition - must be completed" space was blank.
* The name and signature of the "Physician Certifying Transfer" was recorded.

The risks and benefits of transfer were not complete or individualized for Patient 1.

2. The central log for Patient 8, 27 years old, reflected he/she presented to the TCH off-campus ED on 04/24/2016 at 2137 with a chief complaint of "Abdominal pain in pregnancy." The log reflected Patient 8's disposition was "Discharge to Short Term Hospital" on 04/24/2016 at 2210, however the space for the patient's specific destination was blank.

The ED medical record for Patient 8 reflected that on 04/24/2016 he/she was triaged by an RN and was examined by a FNP. The "Emergency_DC Documentation" note recorded and signed by the FNP on 04/24/2016 at 2205 contained the following notes: "The patient presents with flank pain. The onset was 3 hours ago. The course/duration of symptoms is constant and worsening. The character of symptoms is sharp. The degree at onset was severe. The Location of pain at onset was right, lower, abdominal and flank. The degree at present is severe. The Location of pain at present is right, lower, abdominal and flank. Risk factors consist of 20 [WEEKS] PREGNANT. Associated symptoms: nausea, vomiting and denies fever...Patient and husband see [MD] at Providence Newberg so contacted and they will meet [him/her] in the ED there. Call placed to [MD] who accepted care...Probable kidney stone...By private car to Providence Newberg."

There was no documentation to reflect that the MSE included evaluation of the fetus within the hospital's capabilities. There was no documentation of fetal heart tone assessment, or that attempts made to assess those were not successful.

The first section of a "Checklist & Physician Certification for Transfer" form in the record was dated 04/24/2016 and contained the following documentation:
* The "List specific risk of transfer" space was blank.
* The "Summary of risks of transfer" space contained a list of generic risks of which the following was checked: "Possible worsening of condition during travel."
* The "List specific benefit of transfer" space was blank.
* The "Summary of benefits of transfer" space contained a list of generic benefits of which the following were checked: "Condition likely to deteriorate unless transferred"; "Specialist available"; "For further evaluation & treatment"; and "Honor patient's choice."
* The "Alternatives to transfer" space contained a list of generic selections of which "Continue present care" was checked.
* The "Patient condition" space contained a list of generic selections of which the following was checked: "The patient has been stabilized such that within medical probability no material deterioration of the patient's condition or the condition of the unborn child(ren) is likely to result from transfer."
* The name and signature of the "Physician Certifying Transfer" was recorded by the FNP.

The risks and benefits of transfer were not complete or individualized for Patient 8. In addition to the incompleteness and the generic nature of the information on the form, the statement under patient condition that "The patient has been stabilized such that within medical probability no material deterioration of the patient's condition or the condition of the unborn child(ren) is likely to result from transfer" was inaccurate as an EMC had not been ruled out and the status of fetus had not been evaluated. Further, it was contradictory to the statement recorded under the benefit of transfer that "Condition likely to deteriorate unless transferred."

Documentation on the "Checklist & Physician Certification for Transfer" reflected that on 04/24/2016 at 2200 the patient was "Transported by: Private Car." However, there was no documentation in the record to reflect the patient's written refusal for transfer by qualified personnel and medical equipment in consideration of the risks of transfer.

During interview with the NM on 06/21/2016 at 1125 he/she stated that the transfer of patients by private vehicle is a "bone of contention" in the TCH off-campus ED and that "for some time approximately 50% of transfers go by private vehicle" including patients with IV access intact. He/she indicated that there had been recent policy changes to address the transportation concerns.

The pregnant patient who was experiencing "severe" pain was transferred via a private vehicle late at night to another hospital that according to Mapquest was approximately 23 miles and 35 minutes drive time on a rural road.

3. The central log for Patient 9, 73 years old, reflected he/she presented to the TCH on-campus ED on 04/29/2016 at 1550 with a chief complaint of "Ankle pain-swelling." The log reflected Patient 9's disposition was "Discharge to Short Term Hospital" on 04/29/2016 at 2012, and the destination was recorded as LEMC.

The ED medical record for Patient 9 reflected that on 04/29/2016 he/she was triaged by an RN and received a MSE by a physician. The "Emergency_DC Documentation" note recorded and signed by the physician on 04/29/2016 at 1850 contained the following notes: "pt had ORIF left ankle in Mexico Feb 2016. pt states that 2 weeks ago while ambulating [his/her] foot deviated laterally. 6 days ago [his/her] skin opened over [his/her] left ankle...felt like the hardware from [his/her] previous surgery was coming out. pt currently unable to bear weight or ambulate on left foot...course/duration of symptoms is constant and worsening...degree at present is severe...risk factors consist of diabetes mellitus...Subacute, open left ankle dislocation Hyperglycemia [without diabetic keto-acidosis]...discussed with [TCH on-call orthopedic MD], no plastic service at [TCH] Plan to transfer to Legacy Hospital, ED to ED after discusion (sic) with [LEMC orthopedic MD] and [LEMC ED MD]. Attempt at reduction made but unable to reduce. Given chronicity of dislocation, post splint applied and will transfer for definitive care. Hyperglycemia [treatment] with insulin 12 units regular."

In regards to the physician's references to "hyperglycemia," laboratory results dated 04/29/2016 at 1643 reflected Patient 9's blood sugar level was 556, where the normal range was recorded as between 70 and 100.

The first section of a "Checklist & Physician Certification for Transfer" form in the record was dated 04/29/2016 and contained the following documentation:
* In the "List specific risk of transfer" space was recorded "Accident en route."
* The "Summary of risks of transfer" space contained a list of generic risks of which the following was checked: "Hazards of travel."
* In the "List specific benefits of transfer" space was recorded "Plastics, [Orthopedic] evaluation."
* The "Summary of benefits of transfer" space contained a list of generic benefits of which the following was checked: "Specialist available."
* The "Alternatives to transfer - must be completed" space was blank.
* The name and signature of the "Physician Certifying Transfer" was recorded.

At the time of transfer on 04/29/2016 at 1943 the "Checklist & Physician Certification for Transfer" form reflected the patient's blood pressure was elevated at 189/103 and his/her blood sugar remained significantly elevated at 354.

The risks and benefits of transfer were not complete or individualized for Patient 9.

4. The central log for Patient 16, 85 years old, reflected he/she presented to the TCH on-campus ED on 05/24/2016 at 0626 with a chief complaint of "Shortness of breath." The log reflected Patient 16's disposition was "Discharge to Short Term Hospital" on 05/24/2016 at 1130, and the destination was recorded as PSVMC.

The ED medical record for Patient 16 reflected that on 05/24/2016 he/she was triaged by an RN and received a MSE by a physician. The "Emergency_DC Documentation" note recorded and signed by the physician on 05/24/2016 at 1129 contained the following notes: "Medical Decision Making Differential Diagnosis: Pneumonia, bronchitis, congestive heart failure, chronic obstructive pulmonary disease, asthma, pulmonary edema, acute myocardial infarction...Unfortunately unable to admit to TCH ICU giving (sic) low staffing in our ICU, will need to transfer...Family requesting [PSVMC] Pt accepted by [PSVMC MD]...Impression and Plan [Right lower lobe] pneumonia Hypoxia Septic shock Anemia...Thrombocytonpenia (sic)...Acute on (sic) chronic renal failure [Clostridium difficile] colitis."

The first section of a "Checklist & Physician Certification for Transfer" form in the record was dated 05/24/2016 and contained the following documentation:
* The "List specific risk of transfer" space was blank.
* The "Summary of risks of transfer" space contained a list of generic risks. Although there were two checkmarks, they were recorded in the spaces between the risks listed so it was unclear which risks were intended.
* The "List specific benefits of transfer" space was blank.
* The "Summary of benefits of transfer" space contained a list of generic benefits of which the following were checked: "Specialist available" and "For further evaluation & treatment."
* The name and signature of the "Physician Certifying Transfer" was recorded.

The risks and benefits of transfer were not complete or individualized for Patient 16.

5. The central log for Patient 17, 2 months old, reflected he/she presented to the TCH on-campus ED on 05/29/2016 at 1923 with a chief complaint of "Fever, Radiation-Laboratory results addendum." The log reflected Patient 17's disposition was "Discharge to Cancer or Child Hospital" on 05/30/2016 at 0157, however the name of the hospital was not recorded.

The ED medical record for Patient 17 reflected that on 05/29/2016 he/she was triaged by an RN and received a MSE by a physician.

Vital signs records reflected that on 05/29/2016 at 1937 initial vitals signs included an elevated temperature of 39.2 C or 102.6 F; and an elevated pulse rate of 154, where the vital sign record reflected a normal pulse rate to be "60 - 100." On 05/29/2016 at 2022 the patient's temperature remained elevated at 38.4 C or 101.1 F; and pulse remained elevated at 164. On 05/30/2016 at 0052 the patient's pulse remained elevated at 174.

The "Emergency_DC Documentation" note recorded and signed by the physician on 05/30/2016 at 0057 contained the following notes: "This patient presents with fever and The pt was noted to have mild rash last night, today has spread throughout body, fever noted today, was low grade this morning and now higher on arrival...The onset was 1 days (sic) ago. The course/duration of symptoms is constant and worsening...has red macular rash over most of body, including palms and soles. Some of lesions have small darker component in center that is not blanching." Laboratory results incorporated into the ED physician's note reflected several UA and blood results that were not within normal limits including, but not limited to: UA Leukocytes, UA White Blood Cells, Blood sugar, BUN/Creatinine ratio, hemoglobin and hematocrit. The note continued: "Interpretation Labs unremarkable, Abnormal results elevated BUN/[Creatinine] ratio...Pt looks generally well, does have fever, rash with mostly macular component that is blanching, some of the lesions do have a central almost petechial appearance to them that is not blanching. Discussed with [OHSU MD]...given rash appears worsening and unlikely to be able to [follow-up] tomorrow they feel more comfortable having [patient] be observed at [OHSU children's hospital]...UA likely contaminated given not able to obtain a [catheter] specimen, will transfer to [OHSU children's hospital]...Don't feel that [lumbar puncture] is indicated at this time...Fever, rash."

The first section of a "Checklist & Physician Certification for Transfer" form in the record was dated 05/30/2016 and contained the following documentation:
* The "List specific risk of transfer" space was blank.
* The "Summary of risks of transfer" space contained a list of generic risks of which the following were checked: "Possible worsening of condition during travel" and "Hazards of travel."
* The "List specific benefits of transfer" space was blank.
* The "Summary of benefits of transfer" space contained a list of generic benefits of which the following were checked: "Specialist available" and "For further evaluation & treatment."
* The name and signature of the "Physician Certifying Transfer" was recorded.

The "Checklist & Physician Certification for Transfer" form reflected that at the time of transfer on 05/30/2016 at 0150 the infant's pulse remained elevated at 152.

The risks and benefits of transfer were not complete or individualized for Patient 17.

An addendum note in the ED record, recorded by an MD on 05/31/2016 at 0817 reflected: "Blood culture, Attempt at contact...[preliminary] blood [culture] last night showed [Gram-positive Cocci], today growing presumptive nisseria (sic) meningiditis (sic). pt still under observation at [OHSU children's hospital], spoke to [OHSU MD] and informed of [preliminary] results."

The Centers for Disease Control and Prevention (CDC) website contains the following information: "Meningococcal disease is a serious and potentially life-threatening infection caused by the bacterium Neisseria meningitidis Common symptoms of meningococcal disease include high fever, neck stiffness, confusion, nausea, vomiting, lethargy, and/or petechial or purpuric rash. Without appropriate and urgent treatment, the infection can progress rapidly and result in death."

6. The central log for Patient 18, 2 years old, reflected he/she presented to the TCH on-campus ED on 06/01/2016 at 2217 with a chief complaint of "Accidental drug overdose." The log reflected Patient 18's disposition was "Discharge to Short Term Hospital" on 06/02/2016 at 0118, however the name of the hospital was not recorded.

The ED medical record for Patient 18 reflected that on 06/01/2016 he/she was triaged by an RN and received a MSE by a physician. The "Emergency_DC Documentation" note recorded and signed by the physician on 06/02/2016 at 0104 contained the following notes: "The patient presents with accidental overdose and 2 [year old child] presents after ingesting several of [his/her grandparent's] pills. Parent found the child in the bathroom with [grandparent's] open daily pill container with pills scattered all over the floor. Parents state the child had some emesis of about 4 ml with pill fragments mixed with saliva...[Grandparent] recovered the remainder of the pills and reports the missing pills as Ultram...[hydrochlorothiazide]...Cymbalta...Neurontin...Buspar...Zocor...Poison control recomends (sic) 12 hour minimum [observation] and longer if [patient] becomes symptomatic. Will transfer to children's hospital for observation...Accepted by [LEMC MD]."

The first section of a "Checklist & Physician Certification for Transfer" form in the record was dated 06/02/2016 and contained the following documentation:
* The "List specific risk of transfer" space was blank.
* The "Summary of risks of transfer" space contained a list of generic risks of which the following were checked: "Possible worsening of condition during travel" and "Hazards of travel [Motor Vehicle Collision]."
* The "List specific benefits of transfer" space was blank.
* The "Summary of benefits of transfer" space contained a list of generic benefits of which the following was checked: "For further evaluation & treatment."
* The name and signature of the "Physician Certifying Transfer" was recorded.

The risks and benefits of transfer were not complete or individualized for two year-old Patient 18.