HospitalInspections.org

Based on interview, review of documentation in the medical records of 2 of 2 pediatric patients (Patient 5 and 21) who were transferred from ATRMC to other hospitals for services not available at ATRMC, 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 compliance in the following areas:
* Appropriate transfers of patients.

Findings included:

1. Regarding appropriate transfers refer to the findings identified under Tag A2409, CFR 489.24(e).

Based on interview, review of documentation in the medical records of 2 of 2 pediatric patients (Patient 5 and 21) who were transferred from ATRMC to other hospitals for services not available at ATRMC, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to develop and enforce its 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:
* For Patient 21, there was no documentation that reflected the receiving facility was notified of the transfer, had accepted the patient for transfer and had available space and resources necessary to care for the patient.
* Physician certification of medical benefits vs risks were not documented or were not patient specific and individualized for Patients 5 and 21.
* Appropriate mode of transfer was not effected and documented for Patient 21.
* There was no documentation that patient medical records were sent to the receiving facility for Patient 21.

Findings include:

1. The p/p titled "Emergency Medical Treatment & Labor Act (EMTALA) Policy and Procedure (ATRMC)," dated effective 02/01/2019, was reviewed. It reflected:
* "Purpose...To ensure compliance with the Emergency Medical Treatment & Labor Act (EMTALA)...To outline the requirements for an Appropriate Transfer of a patient with an unstabilized emergency medical condition (EMC) to another facility."
* "EMTALA Definitions...Appropriate Transfer means a transfer of an individual with an EMC that is implemented in accordance with EMTALA standards...Emergency Medical Condition (EMC) means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy; or...Serious impairment to bodily function; or...Serious dysfunction of any bodily organ or part...Medical Screening Examination (MSE) means the screening process required to determine, with reasonable clinical confidence, whether or not an EMC exists...The MSE is an ongoing process, including monitoring of the individual, until the individual is either stabilized or transferred...Physician Certification means the written certification by the treating physician ordering a transfer and stating, based on the information available at the time of transfer, that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual...Transfer means the movement, including the discharge, of an individual outside the Hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with the Hospital..."
* "Required documentation...An individual's medical record shall reflect MSE findings...including the determination that an EMC exists or does not exist."
* "Appropriate Transfer Of An Individual With An EMC...The hospital will not transfer an individual with an unstabilized EMC unless...The Hospital does not have the present Capability or Capacity to Stabilize the patient's EMC and the treating physician executes the written Physician Certification that the medical benefits reasonably expected from treatment at another facility outweigh the increased risks to the patient of the transfer, which should be recorded in the patient's medical record and the Transfer
documentation, or...After being informed of the risks of Transfer and of the Hospital's obligation to treat the EMC, the individual requests a Transfer...The individual's request must be in writing and signed by the patient or the patient's legally authorized representative for medical decision-making...The written request must include a brief statement of the Hospital's EMTALA obligations...The written request must include the reasons for the Transfer and describe the benefits and risks discussed with the patient...The written request must be placed in the patient's medical record and a copy forwarded to the receiving hospital."
* "...Requirements of an Appropriate Transfer. The Hospital will comply with the following requirements when conducting an Appropriate Transfer of an individual with an unstabilized EMC...A physician at the receiving hospital must agree to accept the patient, and the receiving hospital must have the current Capability and Capacity to provide Stabilizing treatment for the patient...All medical records related to the EMC must be transferred with the patient...Qualified personnel, equipment, and mode of transportation must be used to transport the patient...The Hospital will continue to provide additional examination and treatment within the Capacity and Capability until the individual leaves the Hospital...Hospital will conduct and document a timely reassessment of the patient prior to the patient's departure from the Hospital."
* "Transfer of a patient admitted under observation status. Hospital will comply with the EMTALA requirements for an Appropriate Transfer when an individual admitted under observation status is transferred to a receiving facility, because EMTALA applies to observation patients per CMS."

2. The p/p titled "Emergency Services - Operational and Staffing Plan (ATRMC)," dated effective 06/05/2018 reflected "...When a patient is transferred to another facility, a COBRA Transfer Form is completed..."

3. Review of the "Asante Three Rivers Medical Center Medical Staff Rules and Regulations," dated "Approved by the Asante Board of Trustees: 4/2/2018," reflected:
* Article XIII "13.B EMTALA TRANSFERS...The transfer of a patient with an emergency medical condition from the Emergency Department to another hospital will be made in accordance with the Hospital's applicable policy and in compliance with all applicable state and federal laws, such as EMTALA...Before any such transfer occurs, the transferring physician will verify in the record that the medical benefits to be received at another medical facility outweigh the risk to the patient of being transferred..."

4. The following documents were received in response to a request for a list of all hospital inpatient departments and services with description and scope effective June 2019:
* "Emergency Services - Operational and Staffing Plan (ATRMC)," dated effective 06/05/2018.
* "Critical Care Operational and Staffing Plan - (ATRMC)," dated effective 01/09/2018.
* "Medical/Surgical/Cardiac A/B Units Operational and Staffing Plan (ATRMC)," dated effective 05/22/2019.
* "Family Birth Center - Operational and Staffing Policy (ATRMC)," dated effective 08/14/2018.
* "Ortho Surgical C/D Unit and Ortho Surgical Overflow - Operational and Staffing Plan (ATRMC)," dated effective 05/22/2019.
* "Medical/Surgical Pediatric E Unit, - Operational and Staffing Plan (ATRMC)," dated effective 05/22/2019.
Review of the documents reflected no pediatric psychiatric inpatient services were provided at the hospital.

5. a. The medical record of Patient 21 was reviewed with multiple hospital staff including the CSN, VPMA and VPGC on 06/25/2019 at 1015. The record reflected the patient presented to the ED by ambulance on 06/12/2019 at 1308 with a chief complaint of altered mental status.

* The "ED Arrival Information" section reflected the acuity was "Urgent" and the "Admission Type" was "Emergent Severe or Life Threatening."

* RN triage notes on 06/12/2019 at 1331 reflected "Per the emts, the pt ingested psychedelic mushrooms today, then drove a car to a random home that had a pool. The owners found [him/her] in the pool naked and the [EMTs] were called. Pt is alert though unable to answer simple questions...When asked what city [he/she] resides in [he/she] replied 'earth'..."

* Documentation by the RN on 06/12/2019 at 1400 reflected the patient's blood pressure was "128/62 (Abnormal)!" and on 06/12/2019 at 1401 reflected the patient's Sp02 was 83% (Abnormal)!"

* The record reflected a physician order dated 06/12/2019 at 1444 for "Implement emergency hold." The physician order reflected the emergency hold was discontinued on "06/12/2019 [at] 2157 (Patient Discharged)."

* ED Technician notes on 06/12/2019 at 1445 reflected "PSA at bedside..."

* Physician notes electronically signed by the physician and dated 06/12/2019 at 1450 reflected:
- "16-year-old [male/female] with past medical history of psychiatric disturbance and drug use presents the (sic) ER via EMS for evaluation of bizarre behavior...reports using meth a few days ago. I do see that [he/she] was seen in the ER at Rogue within the last year for auditory hallucinations, paranoia. [He/she] was on Zyprexa in the past but not currently..."
- "...After getting some more information from the patient's [family member] it sounds like there is a family history of mental illness and this is not the first time [he/she] has had a psychotic break. In fact [he/she] has been decompensating progressively over the last 6 weeks...grades plummeted abruptly and [he/she] has been found locked in the bathroom screaming and responding to internal stimuli. Yesterday [he/she] ran away from home...was on Zyprexa briefly last year and [his/her] psychosis improved significantly and [he/she] self discontinued it...[family member] does not feel safe bringing [him/her] home...I have placed [him/her] on a mental health hold and I am concerned about [his/her] well-being...If CRC is unable to find suitable placement...[he/she] may need admission overnight to pediatrics for psychiatric stabilization. Medically cleared."

* ED Technician notes on 06/12/2019 at 1530 reflected "[Patient] seems focused on [his/her] IV. [Patient] stated [he/she] 'does not like the idea of something in [his/her] body.' [He/she] said [he/she] doesn't like looking at it so I offered to wrap it and did so...[He/she] has unwrapped it and continues to play with it."

* ED Discharge Planner notes on 06/12/2019 at 1540 reflected "Met with pt...in role as crisis mental health. Patient was laying down and remained laying down for duration of interview...Answered prompts with short statements, inappropriate laughter...Expresses bizarre statements and bizarre behaviors, possible (sic) substance induced. Denies current substances with this writer but earlier note indicated that [he/she] endorsed use of hallucinogens...Would benefit from...med unit referral. Will provide safety plan to have in chart for when patient is ready to discharge." The record contained a "Safety and Crisis Support Plan" that was signed by the patient and dated 06/12/2019 but not timed. There was no further evaluation by the "crisis mental health" Discharge Planner in the record.

* ED Technician notes on 06/12/2019 at 1624 reflected "Pt is rubbing [his/her] toes on [his/her] nose. [He/she] asked if [he/she] could get out of here now so [he/she] can cut...[hair] off."

* Documentation by the ED Technician on 06/12/2019 at 1700 reflected the patient's blood pressure was "121/86 (Abnormal)!"

* RN notes on 06/12/2019 at 1722 reflected "Patient transferred...to room 114." During interview with multiple hospital staff including the CSN, VPMA, and VPGC on 06/25/2019 at the time of the record review, it was stated that ED room 114 was a "safe" room.

* The "After Visit Summary" printed on 06/12/2019 at 1754 reflected primarily information about follow up appointments and patient education related to "Psychosis." The summary was signed by the family member and dated 06/12/2019 but not timed.

* Physician notes electronically signed by the physician and dated 06/12/2019 at 1758 reflected:
- "I received this patient on signout (sic)...drug screen positive for marijuana, we do not test routinely for hallucinogens...has had bizarre ideation and acting bizarrely, laughing inappropriately...I do feel [he/she] is not medically cleared yet as [he/she] has impaired judgment. This may be an intoxication syndrome versus mental illness."
- "1624: CRC spoke with the patient and family, they feel this could be due to hallucinogens and doubt underlying mental illness...CRC feels there is no indication for mental health hold though [patient] will remain on a medical hold until I speak with admitting physician...I will speak with admitting pediatrics concerning overnight observational admission for safety. I do feel we cannot exclude schizophrenia or mental illness and disagree this is entirely drug-induced..."
- "1755: [Physician] was willing to admit the patient overnight for observation though felt the patient may have a prolonged admission here while awaiting transfer to definitive hospital. [He/she] felt if the [family member] is willing to take [patient] to Portland that is probably ideal. I spoke with my director who felt directly consulting psychiatry at Portland was not productive as there is always a long delay in transfer for inpatient pediatric psychiatry. For this reason, and the fact that the [family member] seems very reasonable and caring, I think [patient] will be discharged in [his/her] care and recommended that [he/she] continue with [his/her] plan for better pediatric psychiatric evaluation in Portland...[patient] will be discharged in care of [family member] for more definitive psychiatric treatment hopefully in Portland..."

* ED Technician notes on 06/12/2019 at 1850 reflected "[Patient] walking to the door and keeps trying to walk out the door or down the hallway. I have had to re-direct back to the room several times."

* RN notes on 06/12/2019 at 1901 reflected "...sitter remains at bedside...Awaiting return of pt's [family member] for PV transport to OHSU..."

* RN notes on 06/12/2019 at 1904 reflected:
- "Neurological Assessment...Orientation Level...Disoriented to place, Disoriented to situation; Disoriented to time"
- "Level of Consciousness: Awake; Confused"
- "Glascow Coma Scale...Best Verbal Response: Confused"
There was no further neurological assessment of the patient in the record.

* RN notes on 06/12/2019 at 1905 reflected:
- "Psychosocial...Mood Elated; Euphoric; Labile...Affect Inconsistent with thought content...Patient Behaviors Affect inconsistent with mood...
- "...General Attitude...tangential thoughts"
- "Thought Process...Coherency Disorganized; Tangential...Content: Magical thinking...Perception: Hallucinations; Derealization...Confusion: Moderate"
- "Sleep Pattern: Difficulty falling asleep"
There was no further psychological assessment of the patient in the record.

* RN notes on 06/12/2019 at 1956 reflected "pT (sic) DISCHARGED WITH [FAMILY MEMBER]."

* RN notes on 06/12/2019 at 1956 reflected "Departure Condition "Mobility at Departure: Ambulatory." There was no further information related to the patient's condition at departure.

* An undated and untimed entry recorded under the "ED Records" section reflected "Diagnosis...Psychosis, unspecified type..."

The record lacked documentation that reflected a timely reassessment of the patient prior to departure as required by hospital policy. For example:
- There was no neurological or psychological reassessment with respect to the patient's altered mental status, confusion, hallucinations, disorientation and reported ingestion of hallucinogens.
- There was no reassessment of the continued need for a safe room, a personal safety attendant, and a sitter.
- There was no reassessment of vital signs. The last set of vital signs were recorded at 1700, and those reflected an abnormal blood pressure.
- Although the physician notes at 1450 reflected the patient was "medically cleared," subsequent physician notes at 1758 reflected "[patient] is not medically cleared...[patient] will remain on a medical hold..." There was no reevaluation of whether the patient was medically cleared or continued to require a medical hold. During an interview on 06/25/2019 at the time of the medical record review the VPMA confirmed there was no documentation that reflected the patient was medically cleared.

Although the physician documented that "the family member had a plan" for a pediatric psychiatric evaluation in Portland, there was no documentation that reflected the family member/responsible person was informed of the risks of the transfer and the hospital's EMTALA obligation. There was no documentation that a written request signed by the patient or family member/responsible person including a statement of the hospital's EMTALA obligation, the reasons for the transfer, and the benefits and risks discussed with the patient or family member/responsible person was completed in accordance with hospital policy.

Although the physician documented "if the [family member] is willing to take [patient] to Portland that is probably ideal," there was no documentation that reflected the physician arranged an appropriate transfer that included qualified personnel, transportation equipment including life support measures, and that the patient or patient/responsible person refused such arrangements. There was no documentation of a written refusal that reflected the patient or family member/responsible person was informed of the risks and benefits of the transfer and the reasons for refusal.

The record reflected an appropriate transfer was not carried out as follows:
* Although the record reflected the patient was "discharged," the physician recommended that the family member take the patient to "Portland" for pediatric psychiatric services, and the RN subsequently documented "Awaiting...pt's [family member] for PV transport to OHSU." There was no documentation that reflected OHSU had accepted the patient for transfer as required by this CFR and had available bed space and resources necessary to care for the patient's pediatric psychiatric needs.

* There was no documentation that a physician at OHSU agreed to accept the patient as required by hospital policy.

* There was no documentation of a physician certification of transfer with the risks and benefits as required by this CFR.

* There was no documentation that a Transfer Form was completed as required by hospital policy.

* There was no documentation that reflected the physician arranged an appropriate transfer that was effected through qualified personnel and transportation equipment, including the use of necessary and medically appropriate life support measures as appropriate, during the transfer as required by this CFR. The patient who was needing a sitter and was experiencing hallucinations, wandering behaviors, and confusion after ingesting psychedelic mushrooms, was transferred in a private vehicle with a family member.

* There was no documentation that medical records were sent to OHSU as required by this CFR.

b. Review of the hospital's investigation documentation titled "Subject: EMTALA Matter - ATRMC (#OR19467)," dated "Updated 6/25/2019" provided related to Patient 21's ED encounter on 06/12/2019 reflected:
* Attachment A "On June 13, 2019, [Patient 21] presented to OHSU Doernbecher Children's Hospital seeking treatment for mental health issues. [His/her] [family member] drove [patient] to OHSU for care after [he/she] was discharged from the Emergency Department at Asante Three Rivers Medical Center ('Three Rivers') on June 12, 2019."

c. Review of online driving directions reflected OHSU in Portland, Oregon is 247 miles and 4 hours and 5 minutes driving time from ATRMC in Grants Pass, Oregon.

6. a. The ED record of Patient 5 was reviewed with multiple hospital staff including the CSN, VPN, and VPGC on 06/25/2019 at approximately 1135. The record reflected the patient presented to the ED on 01/13/2019 at 1912 with an "Arrival Complaint" of "OD."

* RN notes on 01/13/2019 at 1950 reflected "Per pt...took the pills on Friday...states [he/she] does have a history of suicide attempts...had a small episode of emesis, and pt does voice the feeling of nausea...states since Friday...has felt 'groggy' and had about 4 episodes of emesis since [he/she] took the pills...PSA at bedside..."

* Documentation by the RN on 01/13/2019 at 2030 reflected the patient's Sp02 was 89% (Abnormal)!"

* RN notes on 01/13/2019 at 2214 reflected "Pt called complaining of nausea and uncomfortably (sic) stomach pain on top of feeling [he/she] can't breath...MD aware of this and states will go see patient."

* Physician notes dated 01/13/2019 at 2334 reflected:
- "...Patient is 14 years old....This evening [he/she] told [his/her] [family member] that 2 days ago almost 48 hours exactly [he/she] overdosed on Tylenol ibuprofen and Benadryl...has been nauseated and done some vomiting since ingestion..."
- "Labs are all obtained...Unfortunately [his/her] liver enzymes are significantly abnormal...AST 7800 and ALT greater than 5000...I did discuss the case with poison control nurses and ultimately discussed with toxicologist. Poison control does recommend N-acetylcysteine...Unclear if it's going to be helpful at all but is thought to be possibly protective of the ongoing radicles (sic) remained (sic) from the Tylenol..."
- "Consultation with organ (sic) health sciences University pediatric hospitalist who accepts the patient for admission...Patient is given IV fluids...Patient is given Zofran...feeling wheezy...given a (sic) albuterol Atrovent breathing treatment...vomiting is under good control...receiving N-acetylcysteine...starting maintenance fluids with lactated Ringer's for transport...has asthma and [he/she] may need a breathing treatment in (sic) route..."
- "Critical care 35 minutes not including any separate...procedures due to the acute nature and critical nature of this disease."
* "ED Disposition: Transfer to Another Facility"
* "Final Diagnosis...Tylenol overdose Presentation 48 hours after ingestion..."

* RN notes on 01/13/2019 at 2334 reflected "...Pt left via AMR with second dose of IV acetadote running. Third dose given to EMS crew and RN instructed how to give it...CBG done prior to leaving since acetadote was made with dextrose."

The "Patient Transfer Form" dated and timed by the physician on 01/13/2019 at 2320 was reviewed and reflected:
* "Service/treatment available at receiving hospital...Peds hospitalist, liver specialist"
* "Receiving Facility: OHSU..."
* The "Specific Risks of Transfer for this patient (must include description)" section reflected:
- "crash"
- "worsening in (sic) route, worsening for [illegible] not related to transfer."
There was no documentation on the transfer form or elsewhere in the record that reflected the individual risks of transfer for this acute pediatric patient with Tylenol overdose, significantly abnormal liver enzymes, who required IV medications during transport.

b. Review of online driving directions reflected OHSU in Portland, Oregon is 247 miles and 4 hours and 5 minutes driving time from ATRMC in Grants Pass, Oregon.