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Based on observation, observation of digital security recordings, interviews, review of medical records documentation for 1 of 21 individuals who presented to the hospital seeking emergency services (Person 21), review of the central log, and review of policies and procedures, it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure:
* The posting of required EMTALA signage; and
* That all individuals who presented to the hospital seeking emergency services received a MSE.

Findings included:

1. Refer to findings identified under Tag A2402, CFR 489.20(q) which reflects the hospital's failure to fully develop and enforce its EMTALA policies and procedures to ensure the posting of required EMTALA signage.

2. Refer to findings identified under Tag A2406, CFR 489.24(a) and (c) which reflects the hospital's failure to fully develop and enforce its EMTALA policies and procedures related to the provision of MSEs for Person 21.

Based on observation, interview and review of policies and procedures it was determined the hospital failed to fully develop and implement policies and procedures that ensured the posting of signage that specified patients' EMTALA rights in all areas likely to be noticed and where patients wait for examination and treatment.

Findings include:

1. Review of the PWFMC policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated as last revised "01/2018" included only the following reference to EMTALA signage:
* "Each Hospital will post signage in the dedicated emergency department specifying the rights of individuals with emergency medical conditions and women in labor who come to the dedicated ED for health care services, and indicate on the signs whether the hospital participates in the Medicaid program."

2. The ED entrances, waiting areas, and treatment areas were observed during a tour on 02/05/2018 at 1055 with the ED ANM. The following observations were made:
* In the ED revealed there was one large sign posted to the immediate right of the ED registration desk that could be read if a person was facing the desk. However, the major portion of the ED waiting area was to the left of, and behind the ED registration desk and the sign was not visible from that area. The sign was only visible to a few waiting seats directly in front of and facing the ED desk.
* There were no signs posted in any of the three ED triage rooms. This was observed directly in Triage 2, and as Triage 1 and Triage 3 were occupied at the time of the tour, the ANM confirmed at that time that there were no signs in those rooms.

Based on observation of digital security recordings, interviews, review of medical records documentation for 1 of 21 individuals who presented to the hospital for emergency services (Person 21), review of the central log, and review of policies and procedures, it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure all individuals who presented to the hospital seeking emergency services received a MSE:
* Person 21 was brought to the hospital in a private vehicle for emergency services;
* Four hospital ED staff responded to the parking lot but did not bring Person 21 into the hospital;
* The ED physician on duty did not see Person 21 but recommended that he/she be sent to another hospital;
* Person 21 did not receive a MSE;
* Person 21 was not entered onto the Central Log nor was a medical record initiated;
* Person 21 was in the hospital's parking lot for 29 minutes before being sent to another hospital in an ambulance that was called to the hospital's parking lot at the direction of hospital staff.

Findings include:

1. During interview with the ED NM on 02/05/2018 at 1015 he/she reported that on 01/29/2018 Person 21 presented to the hospital's parking lot and was not brought into the hospital for an MSE. Person 21 was subsequently transported to OHSU by EMS who was called to the parking lot at the direction of hospital staff. The ED NM confirmed that the ED TN and the ED CN responded to the parking lot, and that the ED physician on duty did not respond to the parking lot and did not see Person 21.

2. The ED TN on duty on 01/29/2018 who responded to Person 21 in the parking lot was interviewed onsite by telephone on 02/05/2018 at 1135. He/she reported the following:
* Had worked at PWFMC in the ED for 12 years and has had "many" EMTALA trainings.
* In the early morning a PO reported to the ED registration desk and said that he/she needed a wheelchair to get someone out of their car.
* The ED TN proceeded outside with the PO to assess what was happening and whether a wheelchair or gurney was required.
* The ED CN had also proceeded to the parking lot.
* Person 21 was the passenger in a "little truck" driven by his/her friend.
* The truck was parked in one of the handicapped parking spaces in front of the ED entrance.
* Person 21's parent was on scene in a second private vehicle.
* Person 21 was sitting upright and was alert and oriented.
* Person 21 had no visible injuries, there was no visible blood, there was no respiratory distress, but he/she was covered with mud.
* Person 21 said he/she had intended to "jump" but didn't jump out far enough and so "rolled" 60 feet down an embankment, he/she had not lost consciousness, and had "crawled" back up the embankment.
* Person 21's condition did not change during the ED TN's encounter with him/her.
* The two RNs were concerned about preventing injury while getting Person 21 out of the truck so decided that they should call EMS to assist them in "extricating" him/her from the truck.
* The PO offered to initiate that communication and contacted the dispatch to request EMS.
* The ED CN went back inside the hospital to discuss with the ED physician on duty.
* When the ED CN returned to the parking lot he/she said that the ED physician was concerned Person 21 might be a "trauma" and "needed to go to OHSU."
* Person 21 asked "What am I waiting for?" to which the ED TN explained to him/her that it was determined he/she needed to go to OHSU.
* Person 21 said "I can get out" of the truck, to which the ED TN told him/her "No, no, no."
* The ED TN went back into the hospital before Person 21 left the parking lot. When he/she returned inside the ED CN, two POs, fire personnel, ambulance personnel and Person 21 and his/her friend/family remained in the parking lot.
* ED staff "usually" don't need ambulance and fire personnel to assist with transporting of patients from private vehicles into the ED. The need to do that "hasn't happened in years."
* Person 21 was not brought into PWFMC.
* The ED physician did not come out to see Person 21.
* Person 21 did not refuse any care and did not refuse to come into the hospital.
* Person 21 was not entered in the ED system, into the ED log, nor was a medical record or any other documentation initiated.
* Once both RNs were back in the hospital there was discussion about whether they should call OHSU and it was decided that it wasn't necessary because EMS would do that.
* In response to the question "What is your understanding of the hospital's EMTALA obligation?" he/she stated that the "patient should have been brought into the hospital to be thoroughly examined by the doctor." Further, he/she stated that if the patient refused to come in they should sign an AMA form and if they refuse to sign the AMA form that should be documented.

3. The ED CN on duty on 01/29/2018 who responded to Person 21 in the parking lot was interviewed onsite in person on 02/05/2018 at 1500. He/she reported the following:
* Had worked at PWFMC in the ED for 7 and 1/2 years and had regular EMTALA training.
* The ED CN and the ED TN responded to the parking lot as a result of a PO presenting to the ED registration desk requesting assistance.
* Person 21 was sitting upright in the pickup truck, had no visible injuries, was alert and oriented, did respond to questions.
* The ED CN was concerned about "pulling" Person 21 from the vehicle due to the "fall" and thought that they needed to call EMS for help and equipment.
* The ED CN went back into the hospital to discuss with the ED physician on duty.
* The ED physician did not come out to see Person 21.
* The ED physician stated if Person 21 fell 60 feet they needed help "extricating" him/her and "[He/she] sounds like [he/she] could have traumatic injury. [He/she] should be seen at trauma center."
* The ED CN returned to the parking lot and reported what the ED physician said.
* EMS "agreed" that it sounded like a trauma.
* The ED CN was "surprised" when EMS didn't use any equipment to assist Person 21 from the truck and had him/her stand and take two or three steps to get on the gurney.
* Person 21's parent stated "don't let [him/her] leave" to which the EMS personnel responded that they were taking him/her to OHSU and the PO reported they were putting a police officer hold on him/her.
* The ED CN returned to the ED when EMS was putting Person 21 into the ambulance.
* PWFMC staff did not call OHSU about Person 21 as they were unclear whether they should in this case as EMS was taking him/her to OHSU and therefore EMS would be calling OHSU.
* Before EMS arrived to PWFMC one of the PARs came out to the parking lot to get Person 21's name but he/she wouldn't give it to them and neither the friend/family members with him/her would provide it.
* Person 21 did not refuse to come into PWFMC, he/she just wouldn't give his/her name.
* Before the end of the shift the ED CN did email the ED NM a summary of the event because it was unusual.
* The ED CN stated "In hindsight I'd have said let's bring [him/her] inside."
* In response to the question "What is your understanding of the hospital's EMTALA obligation?" he/she stated that "Every patient that presents needs an MSE by a licensed practitioner." He/she stated that he/she now understands that if they're on the hospital's property they need to have them seen.

4. The ED physician on duty on 01/29/2018 was interviewed onsite by telephone on 02/05/2018 at 1645. He/she reported the following:
* Had worked at PWFMC for "several years."
* The physician did not see Person 21 inside the ED nor outside the hospital.
* The ED CN reported Person 21 had fallen from a 60 foot embankment.
* I told ED CN "Wow, [he/she] needed to go to a trauma center."
* "I had no idea what the scene was outside...if indeed true...[he/she] should go to a trauma center...it was a dialog with the nurse."
* "All I know from my end I learned after...don't know sequence but charge nurse reported EMS took [him/her] to OHSU...they said [he/she] had no visible injuries...I asked 'Did [he/she] appear to have physical signs of trauma?' They said 'no' and that [he/she] was sitting upright and talking.'"
* The physician stated it was an "instant knee-jerk response to have [him/her] go..."
* The physician stated that he/she did not request or direct the staff to bring Person 21 into the ED for examination and there was "no thought given to bring [him/her] in and assess [him/her] here based on if the history is true."
* Person 21 was not registered and there is "no documentation of any of this."
* In response to the question "What is your understanding of the hospital's EMTALA obligation?" he/she stated he/she has been in practice for almost 20 years and has a "good understanding of EMTALA." The physician stated that "every person needs an MSE...we were not trying to violate EMTALA...intent was how to get patient fastest most appropriate care...didn't want time to be lost...didn't want to waste time to see [him/her] here...in [his/her] best interests to get [his/her] transfer expedited with that mechanism...would be best served in a trauma center...the definition of EMTALA is MSE...but still feel like it was based on what is best for the patient although I didn't see the patient...not done to dump a patient...but why decision was made was in best interest of patient not made to dump the patient...have seen patients in parking lots and garages and elevators...I have good understanding."

5. Digital security footage, without audio, was observed of three camera views as follows:
* View of parking lot in front of the ED entrance on 01/29/2018 from 0155 to 0304.
* View of exterior ED entrance on 01/29/2018 from 0212 to 0234.
* View of interior ED desk on 01/29/2018 from 0213 to 0248.

The identity of the staff in the footage was confirmed during viewing of the footage on 02/15/2018 at 1430 with the ED NM.

The footage revealed the following timeline and sequence of events on 01/29/2018 between 0211 and 0240:
* 02:11 - Small pickup truck arrives into parking lot parking space in front of ED entrance.
* 02:13 - Second private vehicle arrives into parking lot parking space immediately next to the passenger side of the pickup truck.
* 02:13 - Police car arrives into parking lot.
* 02:13 - PO proceeds to pickup truck.
* 02:14 - PO enters the ED through the ED doors located immediately in front of the ED registration desk. A verbal exchange occurs with PAR seated at desk.
* 02:15 - ED CN comes into camera view from behind the ED desk.
* 02:15 - PO, ED CN, ED TN, and ED Tech exit the building through the ED doors.
* 02:16 - In the parking lot multiple individuals are observed to be at the passenger side of the pickup truck.
* 02:17 - ED Tech re-enters the ED through the ED doors and verbal exchange with PARs at desk occurs.
* 02:18 - PAR picks up a pack of sticky notes and a pen from the desk and exits the building through the ED doors.
* 02:18 - ED CN and PAR re-enter the ED through the ED doors.
* 02:21 - ED CN exits the building through the ED doors.
* 02:25 - Fire truck arrives on scene and at least three fire personnel approach the passenger side of the vehicle.
* 02:25 - Ambulance arrives on scene and ambulance personnel approach the passenger side of the vehicle.
* 02:27 - ED TN re-enters the ED through the ED doors and lengthy verbal exchange occurs with PAR and other unidentified ED staff.

NOTE: Between 0225 and 0231 in the parking lot there are multiple individuals engaging at the passenger side of the pickup and around in the parking lot. A gurney is observed to be removed from the back of the ambulance and wheeled to the passenger side of the pickup. The images are a blur, and actions of specific persons and the activities occurring are not easily discernable.

* 02:31 - Ambulance personnel are observed wheeling the gurney to the ambulance and transferring the gurney into the ambulance.
* 02:31 - ED CN re-enters the ED through the ED doors.
* 02:34 - PO enters the ED through ED doors.
* 02:35 - PAR makes photocopies and hands PO two documents.
* 02:35 - PO exits building through ED doors.
* 02:40 - The ambulance leaves the parking lot followed by the pickup, the second private vehicle, police, and fire.

Person 21 is observed to not enter the hospital at any time and leaves the hospital parking lot in the ambulance 29 minutes after arrival to the parking lot.

6. Audio recordings between an AMR paramedic and the trauma system dispatch revealed the following:
* AMR paramedic to trauma system - "...currently just outside of Willamette Falls Hospital...patient is fully oriented...and is complaining of some back pain...ambulatory on scene was able to take a couple of steps to get onto the gurney...ETA to the University is approximately twenty, two zero, minutes...
* Trauma system to AMR - "Did [he/she] go to Willamette Falls?"
* AMR paramedic to trauma system - "[He/she] showed up in their parking lot...they did not want to see [him/her] in their hospital because of the possible mechanism..."

7. Review of the ED Central Log revealed that Person 21 was not identified on the log as having been registered in the ED on 01/29/2018.

8. Review of ED medical records revealed no medical record for Person 21 on 01/29/2018.

9. Review of the medical staff or "Professional Staff" policies and procedures dated as last revised 08/26/2017 reflected that "Medical screening examinations within the capability of the Hospital will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition."

10. Review of the PWFMC policy and procedure titled "EMTALA: Medical Screening Examination" dated as last revised 01/2018 stipulated:
* "Objective - To guide Emergency Department (ED) staff and other Providence...employees responsibilities, when an individual presents to the emergency department and/or hospital property seeking medical services."
* "A Medical Screening Exam (MSE) is an exam completed by qualified medical personnel to determine whether or not an emergency medical condition or active labor exists."
* "Hospital property includes the entire main hospital campus, the parking lots, sidewalks, driveway..."
* "Patients who present to the ED requesting medical services will receive a Medical Screening Examination, regardless of their ability to pay, to determine if an emergency medical condition exists. This examination is performed by qualified medical personnel as defined by Oregon Medical Staff policy. If an individual who is not a hospital patient comes elsewhere on hospital property (see definition above) employees will ensure they arrive to the Emergency Department where a Medical Screening Exam is offered if...The individual requests examination or treatment for an emergency medical condition. If a prudent layperson observer would believe that the individuals is suffering from an emergency condition."

11. Review of the PWFMC policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated as last revised "01/2018" stipulated:
* "A Medical Screening Examination (MSE) is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an Emergency Medical Condition or not...Patients who present to the ED requesting medical services will receive a MSE..."
* "A physician or designated care provider will perform a medical screening examination to determine whether or not an emergency medical condition exists and treat the patient or stabilize the patient's condition within the capability and capacity of the Emergency Department."

12. During interview with the QMC and the ED NM on 02/05/2018 at 1430 they reported that there were no policies and procedures for calling EMS to assist with "extricating" patients from their private vehicles.