HospitalInspections.org

Based on interview, review of Transfer Center documentation of a request from another hospital to transfer a patient to SHRB for specialty services (Patient 21), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure its on-call physicians fulfilled their on-call duties, to accept patients for whom the hospital had capability and capacity to treat.

Findings include:

1. Refer to the findings identified under Tag A2411, CFR 489.24(f) that reflects on-call Vascular surgeon Physician A refused to accept Patient 21 from another hospital's ED. SHRB had capability and capacity to treat Patient 21.

Based on interview, review of central log and medical record documentation for 3 of 15 encounters of individuals who presented to the hospital for emergency services (Patients 6, 9 and 11) and review of policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured that every individual who presented to the hospital for emergency services received an MSE within the hospital's capability and capacity by qualified practitioners, and that hospital staff did nothing to dissuade patients from staying at the hospital for the provision of an MSE:
* Patients 6, 9 and 11 who presented to the hospital for emergency services left the hospital before receiving an MSE for reasons that were unclear or unexplained or without attempts to provide the patients with information about the risks of leaving.


Finding include:

1. a. The P&P titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance Policy" dated as revised 10/15/2019 was reviewed and included the following:
* "The purpose of this policy is to acknowledge PeaceHealth's responsibility to provide Medical Screening Examinations, stabilizing treatment, and an appropriate transfer where indicated, as required by the Emergency Medical Treatment and Active Labor Act (EMTALA)."
* "It is the policy of PeaceHealth that when an individual comes to the Emergency Department and requests treatment, the Medical Center provides a Medical Screening Examination (MSE) ..."

b. The P&P titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance Procedure" dated as revised 10/15/2019 was reviewed and included the following:
* "The Medical Center provides an appropriate MSE by physicians or qualified medical persons (QMP) as defined by the Governing Board, within the capability and capacity of the Medical Center, regardless of the person's insurance status or ability to pay when:
- An individual comes to a dedicated ED or L&D and requests examination or treatment. The request for services may be made by the Patient or by another person on the Patient's behalf."
* "Patients have a right to refuse any offered MSE and stabilizing treatment. Medical Center Workforce members:
- Explain the risks and benefits of screening and treatment.
- Make reasonable attempts to obtain the Patient's signed written refusal of examination and treatment, but the Patient's signature is not required;
- Do not suggest to Patients that they cannot leave the ED waiting room or treatment areas or go elsewhere for care; and
- Do not require the Patient to sign a waiver of liability prior to leaving without being seen."

c. The P&P titled "Informed Refusal Policy" dated as revised 06/09/2021 was reviewed and included the following:
* "The purpose of this policy is to establish clear guidelines for the informed refusal of care process."
* "PeaceHealth recognizes that every person with capapcity for decision-making (or their legal representative) has the right to make informed decisions regarding medical care. Except for certain circumstances, a person has the right to refuse or withdraw consent for treatments, preventative care, diagnostic studies, and/or transfer care to another provider ..."
* "In accordance with Federal Law (EMTALA), the hospital must provide a medical screening examination to any person presenting at the Emergency Department or OB Triage to determine whether the patient suffer from an emergency medical condition ... If an emergency medical condition or pregnancy with contractions is present, the hospital must provide such additional medical examination and treatment ..."
* "If the patient refuses the medical screening exam:
i. The care team comprised of a supervisor, the assigned nurse and the emergency department or obstetrics provider will discuss the refusal with the patient to learn more about the reason for refusing the medical screening exam.
ii. The care team as directed by the physician will work to answer the patient's questions to the best of their abilities and to the patient's satisfaction.
iii. The discussion of the refusal and the patient's ultimate decision is documented in the medical record.
iv. If the patient (or the patient's legal representative) sill refuses the recommended care, the refusal of care form is completed noting 'Refusal of the medical screening exam,' and signatures as specified on the form are obtained. If the patient refuses to sign the form, that refusal is noted in the medical record."

2. a. The ED log for Patient 6 reflected that he/she presented to the ED on 11/29/2021 at 2251 with chief complaint of "Foot Pain." The ED disposition on the log reflected "Lwbs after triage."

b. The medical record for Patient 6's 11/29/21 ED encounter was reviewed and included:
* At 2259 an RN recorded "Pt presents to ED with c/o right foot pain after stepping off a ladder approx 3 steps up. Denies injuring any other body parts."
* At 2259 "Triage complete."
* At 2304 an RN recorded the patient's vital signs.
* At 2332 the PA placed an order for "X-ray Foot Right 3 views."
* At 0007 X-ray "Performed."
* At 11/30/2021 at 0053 "Lwbs After Triage."

There was no other documentation in the record by the ED provider that reflected Patient 6 received an MSE. There was no evidence the care team took any steps to inform the patient of the risks of leaving prior to the MSE or that the "refusal of care form" was discussed in accordance with the hospital's P&Ps identified under Findings 1.c. above.

c. During interview on 02/09/2022 during the medical record review the MD confirmed that there was no other documentation in the record that reflected ED staff spoke to the patient about leaving before receiving a MSE or having the patient sign the "refusal of care" form.

3. a. The ED log for Patient 9 reflected that he/she presented to the ED on 12/16/2021 at 1906 with chief complaint of "Head injury;head lac." The ED disposition on the log reflected "Eloped."

b. The medical record for Patient 9's 12/16/2021 ED encounter was reviewed and included:
* At 1906 "ED Arrival."
* At 1912 "Triage complete."
* At 1913 an RN recorded "Pulling on a drawer which came out and fell on his/her head. No LOC. Was bleeding from a laceration to the back of his/her head which has been controlled after direct pressure."
* At 1956 "ED Roomed."
*At 1957 "Eloped."

There was no other documentation in the record by the ED provider that reflected Patient 9 received an MSE. There was no evidence the care team took any steps to inform the patient of the risks of leaving prior to the MSE or that the "refusal of care form" was discussed in accordance with the hospital's P&Ps identified under Findings 1.c. above.

c. During interview on 02/09/2022 during the medical record review the MD confirmed that there was no other documentation in the record that reflected ED staff spoke to the patient or about leaving before receiving a MSE or having the patient sign the "refusal of care" form.

4. a. The ED log for Patient 11 reflected that he/she presented to the ED on 12/17/2021 at 1622 with chief complaint of "AMS." The ED disposition on the log reflected "Lwbs after triage."

b. The medical record for Patient 11's 12/17/2021 encounter was reviewed and included:
* At 1622 "ED Arrival."
* At 1625 an ED Tech recorded vital signs.
* At 1631 an RN recorded "Pt to ED demonstrating erratic physical behavior and tangential speech/thought. Pt states they need to calm down."
* At 1635 "Triage complete."
* At 1832 "Lwbs After Triage."

There was no other documentation in the record by the ED provider that reflected Patient 11 recieved an MSE. There was no evidence the care team took any steps to inform the patient of the risks of leaving prior to the MSE or that the "refusal of care form" was discussed in accordance with the hospital's P&Ps identified under Findings 1.c. above.

c. During interview on 02/09/2022 during the medical record review the MD confirmed that there was no other documentation in the record that reflected ED staff spoke to the patient about leaving before receiving a MSE or having the patient sign the "refusal of care" form.

Based on interviews, review of Transfer Center documentation of a request from another hospital to transfer a patient to SHRB for specialty services (Patient 21), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure its compliance with recipient hospital responsibilities to accept patients from referring hospital EDs for further examination and stabilizing treatment for whom it had capability and capacity to treat.

Findings include:

1. A document provided to reflect the hospital's scope of services included a section titled "Major Medical Services ... Oregon Heart & Vascular Institute." The document reflected that SHRB had capability for vascular surgical services where it reflected "Surgical Care - Recognized by the American College of Surgeons National Surgical Quality Improvement Program as one of 66 U.S. hospitals to achieve meritorious outcomes for surgical patient care."

2. Review of the p/p titled "On-Call Policy" dated last approved 07/21/2020 was reviewed. It reflected:
* "When an on-call physician is contacted by the Access PeaceHealth and requested to speak with a physician from another hospital, the physician must allow the Access PeaceHealth to connect him/her telephonically with the requesting physician Access PeaceHealth will remain on the line to listen to the conversation and facilitate any transfer that occurs thereafter."
* "On-call Medical Staff members must accept transfers from other emergency departments when SHMC has capability and capacity to treat a patient ... "

3. Review of the p/p titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance Policy dated last approved 08/13/2019 was reviewed. It reflected:
* "No Medical Center may refuse to accept the transfer of a Patient when the Medical Center has the medical and nursing Capability and Capacity to treat the Patient's emergency medical condition."

4. Review of the p/p titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance Procedure" dated last approved 08/13/2019 was reviewed. It reflected:
* "The purpose of this procedure is to establish clear guidelines for complying with the federal Emergency Medical Treatment and Active Labor Act (EMTALA)."
* "A transfer is 'appropriate' if:
a. The tranferring Medical Center has provided stabilizing medical treatment within its capability, that minimizes the risks to the individual's health ...
b. The receiving facility has: Available space and qualified Workforce members for the treatment of the individual."
* "Medical Staff Bylaws, Rules and Regulations or policies and procedures, include a requirement for Medical Staff Member physicians to take call as part of their membership duties and responsibilities."

5. The undated document SHMC RiverBend and University District Campus "Rules and Regulations Of The Medical Staff" was reviewed. It reflected:
* Transfers - "Patients shall be admitted for the treatment of any and all conditions and diseases for which the Medical Center has facilities and personnel. Medical Staff members will comply with all EMTALA (Emergency Medical Treatment and Active Labor Act regulations)."

6. During an interview on 02/09/2022 at 1100 with hospital staff that included the DRM and QRC, the following information was provided:
* The patient did not arrive at SHRB.
* The patient presented to MWMC ED with complete arterial occlusion (bloodflow blocked) of lower extremity on 06/24/2020.
* The initial request to transfer to RiverBend was for a higher level of care for Vascular services.
* Vascular services was not a full time service at sending hospital (MWMC).
* PPMC contacted DRM at SHRB on 06/29/2020 of a potential EMTALA violation.

7. The document titled "OnCall Med Staff Schedule 6.1.2020-7.1.2020" reflected [Physician A] was on-call for "RiverBend - Surgery-Vascular" from "06/24/2020 0700" through "06/24/2020 1900."

8. During interview on 02/09/2022 at 1500 with RBMD, the following information was provided:
* Physician A from Vascular surgery was on call and took the call form MWMC.
* Physician A asked MWMC to talk to the patients original surgeon that did previous bypass graft (PPMC MD).
* When asked if Physician A accepted the patient for transfer, the RBMD replied "no." He/she said that physicians are encouraged to have conversations about the best care options for the patients with providers but saying "I'm not refusing" should be included in the conversation so it is clear.
* The surgeon that did the original procedure at PPMC was not on-call.
* He/she stated the recording system for the transfer center was not working properly at the time of the requested transfer and there are not any recordings for this incident.
* After this incident, the educator and RBMD began EMTALA education with an emphasis on reasons to not refuse patients and that the physician is on call for RiverBend Hospital not an individual practice.
* He/she also stated that any transfer request refusals will be directed immediately to the on duty house supervisor for escalation.

9. Review of the electronic Transfer Center document titled "Access PeaceHealth Pre-Admit Info Sheet" dated "Initiated 06/24/2020 1338" related to MWMC's request to transfer Patient 21 to the hospital for vascular surgery contained spaces for specified information. It reflected:
* "Transfer Type: ED Transfer Adult"
* "Age: 54 years"
* "Diagnosis #1: R Lower Extremity Occlusion;"
* "HPI Notes: 06/24/2020 1355: Pulseless right leg. H/O R Fem Bypass up in cholesterol. This is 4 days of pain. [Physician A] suggests to speak with the vascular surgery that did the fem bypass in Portland. "
* "Referring Location...McKenzie Willamette Medical Center"
* "Referring Provider [MWMC ED MD]"
* "Case Status: Transfer (Pt. not admitted to RB)"
* "Explanation: T - Patient Established with Another Provider"
* "Date/Time of Decision: 06/24/2020 1356
* "Notes: 06/24/2020 1356: [Physician A] suggested to [MWMC ED MD] to speak to vasular [sic] surgeon in Portland who did the patients original vascular surgery procedure, since he is known up there."

10. During interview on 02/09/2022 at 1100 the DRM confirmed that the hospital had capability for vascular surgical services and capacity on 06/24/2020 when MWMC requested to transfer Patient 21 to the hospital.