HospitalInspections.org

Based on observation, interview, review of central log and medical record documentation for 15 of 28 encounters of individuals who presented to the hospital for emergency services (Patients 1, 2, 3, 4, 6, 11, 12, 13, 15, 17, 19, 22, 25, 27 and 29), review of internal investigation documentation, 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 that ensured it met its EMTALA obligations in the following areas:
* To conspicuously post signs that specified individual's rights under EMTALA in all areas individuals waited for examination and treatment.
* To provide MSEs within the hospital's capability and capacity for all individuals who presented for emergency services.
* To ensure the provision of MSEs by medical personnel designated as qualified, and approved, to perform MSEs.
* To obtain or attempt to obtain written and informed refusal of MSEs in the cases of individuals who left the hospital during the ED encounter and to ensure hospital staff did or said nothing to dissuade the individuals from staying.
* To affect appropriate transfers to other hospitals for further exam and stabilizing treatment not within GSRMC's capability and capacity.

Findings included:

1. Refer to the findings identified under Tag A2402, CFR 489.20(q) that reflects the hospital's failure to conspicuously post required EMTALA signs in all areas individuals waited for examination and treatment.

2. Refer to the findings identified under Tag A2406, CFR 489.24(a)&(c), that reflects the hospital's failure to ensure all individuals who presented for emergency services received MSEs, within the hospital's capability and capacity, by medical personnel designated as qualified, and approved, to perform MSEs.

3. Refer to the findings identified under Tag A2409, CFR 489.24(e) that reflects the hospital's failure to affect appropriate EMTALA transfers to other hospitals with the necessary capability and capacity for patients for whom an EMC had not been ruled out, removed or resolved.

Based on observations, interview and review of policies and procedures it was determined the hospital failed to enforce EMTALA policies and procedures that ensured the posting of signage, that specified individuals' EMTALA rights with respect to examination and treatment for emergency medical conditions and women in labor, in all areas likely to be noticed and where individuals waited for examination and treatment.

Findings include:

1. The P&P titled "Emergency Medical Treatment and Labor Act (EMTALA)" dated as revised 09/18/2018 was reviewed and included the following:
* "EMTALA required signage will be posted conspicuously in the hospital. See Appendix A for requirement locations".
* "Appendix A - EMTALA Required Posting - Signs should be posted in public and ambulance entrance, ED lobby, registration areas for emergency and obstetric patients, patient entrances to emergency and obstetric departments, emergency and obstetric department treatment rooms (including psychiatry)."

2. During tour of the OB department while onsite at the hospital utilizing "Facetime" on 08/19/2020 beginning at 1245 it was observed that required EMTALA signs were posted at two locations, one outside the 4South secured OB Department entrance door and the other outside the 4North secured OB Elevator door.

During interview with the OB Manager at that time he/she stated that those were the only two signs for the OB department. He/she stated that there were no waiting rooms or waiting areas in use at this time. The Manager further confirmed there were no separate triage rooms and that there were six LDR rooms in the department where patients waited for examination and treatment. He/she stated there were no signs in those rooms.

3. During tour of the ED while onsite at the hospital utilizing "Facetime"on 08/19/2020 beginning at 1430 it was observed that required EMTALA signs were posted at ED entrances including the ambulance entrance, waiting areas, the registration desk, and at entrances to triage rooms.

During interview with the ED Manager at that time he/she stated that there were no signs posted inside triage rooms nor inside any of the treatment rooms or spaces inside the ED where patients waited for examination and treatment.

Based on interview, review of central log and medical record documentation for 10 of 28 encounters of individuals who presented to the hospital for emergency services (Patients 1, 3, 4, 6, 11, 13, 17, 22, 27 and 29), review of internal investigation documentation 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:
* Patient 29 who presented by ambulance to the hospital for emergency services did not receive an MSE as upon arrival, the ambulance was directed by hospital staff to take the patient to another hospital.
* Patient 22 who was sent to the ED from a private physician clinic for stabilizing treatment of an EMC was not provided an MSE.
* Patients 4, 6, 11 and 27 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.
* MSE documentation for Patient 1 who presented with chief complaints that included "Suicidal," and was subsequently discharged to home, was not clear or complete. P&PS and other documents lacked clear reference to mental health evaluations conducted as part of the MSEs including the qualifications of the individuals who conducted those mental health evaluations.
* Patients 3, 13 and 17 who presented with pregnancy-related potential EMCs did not receive MSEs from hospital staff who were designated as qualified to conduct MSEs. Although the EMTALA P&P reflected that "qualified OB RNs" could conduct MSEs for "isolated pregnancy related complaints," Medical Staff bylaws and rules and regulations lacked any reference to MSEs by OB RNs, including specifying the qualifications necessary for those RNs. OB P&PS, OB RN Job descriptions, and OB RN training documentation lacked reference to the provision of MSEs to rule out EMCs by OB RNs.

Finding include:

1. a. The P&P titled "Emergency Medical Treatment and Labor Act (EMTALA)" dated as revised 09/18/2018 was reviewed and included the following:
* "Patients who present to the hospital with an emergency medical condition will be provided a medical screening examination and stabilizing treatment prior to transfer in compliance with the Emergency Medical Treatment and Labor Act (EMTALA), regardless of ability to pay and regardless of the individual's eligibility under the Financial Assistance Policy."
* "All individuals requesting examination and treatment of a medical condition, or has such a request made on his or her behalf, will be screened by qualified medical personnel authorized by the Medical Staff Bylaws and approved by the governing body to determine if they have an emergency medical condition (exception: pregnant women of more than 20 weeks gestation who present with isolated pregnancy-related complaints may be triaged directly to obstetrics and be screened by a qualified obstetric nurse, provided that the hospital governing body allows for this.)"
* "When the patient or person acting on the patient's behalf refuses treatment and/or the recommendation to transfer, all reasonable steps will be taken by hospital staff to secure the person's written refusal. The risks and benefits of examination and treatment or transfer will be explained and documented in the medical record. If a patient refuses to sign the consent form, all factors surrounding the refusal will be documented in the medical record."

The P&P was not clear or complete in regards to MSEs for pregnant women. For example:
* It did not specify the "isolated pregnancy-related complaints" that a "qualified obstetric nurse" was permitted to provide MSEs for.
* It did not specify what the criteria was for a "qualified obstetric nurse."
* It did not specify whether the GSRMC's governing body allowed for that MSEs by obstetric RNs.

1. b. The "Medical Staff Bylaws" dated "Approved by GSRMC Board of Directors" on 12/17/2019 and the associated "Medical Staff Rules and Regulations" were reviewed and included the following found under Section 2.2 of the R&Rs:
* "Consistent with the [EMTALA], if an individual presents on Hospital property seeking emergency services ... the Hospital must provide an appropriate [MSE] within the capability of the hospital's [ED], including ancillary services routinely available to the [ED], to determine whether or not an [EMC] exists."
* "Pregnant patients, greater than twenty (20) weeks' gestation, who present with a primary obstetrical complaint can have the MSE done in Women's Services."
* "MSEs shall be performed by Qualified Medical Personnel (QMPs) as defined in Samaritan Health Services' (SHS) EMTALA policy."

The bylaws and rules and regulations were not clear. For example:
* They included no references to, and provisions for, MSEs to be performed by obstetric RNs.
* Section 2.2 reflected that MSEs could be performed in the OB department, however, it did not specify by whom.
* As indicated in Section 2.2 the EMTALA P&P did not define "QMPs" for the purpose of MSEs in the ED or OB, nor did the bylaws and rules and regulations include a definition of "QMP."

1. c. The P&P titled "Obstetric triage of patients" dated as revised 02/15/2019 was reviewed and included the following:
* "Obstetric triage is a process of care that enables early discovery and intervention for pregnant patients who are in labor and for those who may be experiencing some type of complication ..."
* "The most common evaluations performed during obstetric triage are determining whether the patient is in active labor, determining the current stage of labor, evaluating the status of the amniotic membranes, and determining the effects of labor on the fetus. Patients with signs and symptoms of pregnancy complications, such as vaginal bleeding or discharge, abdominal pain, premature uterine contractions, and decreased fetal movements, as well as patient who have experienced abdominal trauma, domestic violence, hypertensive disorders, seizure, or a motor vehicle accident are also evaluated. Such patients should receive priority status, careful assessment, and prompt intervention because of the increased risk of an unfavorable outcome for
both the patient and fetus."
* "Having specific procedures for obstetric triage ensures compliance with [EMTALA] regulations, which require health care practitioners to examine a patient to determine whether an [EMC] exists, to provide necessary stabilizing treatment when
an [EMC] is identified ... Under EMTALA, a physician, certified nurse-midwife, or other qualified medical professional (acting within the scope of practice and state law) is required to certify all patient assessment and dispositions."
* "Facilities may have slight variations in their protocols related to obstetric triage. Usually, these variations involve the point in the pregnancy (gestational age) at which the patient would be triaged in an obstetrics department versus an emergency department."
* "If your facility uses acuity systems or algorithms, assign and communicate a shared obstetric triage severity rating based on the assessed acuity level."

The "triage" P&P provided in response to requests for P&PS related to MSEs for OB patients was not clear. For example:
* It did not distinguish between the process of triage for the purpose of prioritizing the severity of patients' conditions and the order in which they were to be treated, versus MSEs for the purpose of ruling out EMCs.
* It did not specify the qualifications of the "health care practitioners" referenced who were "to examine a patient to determine whether an [EMC] exists."
* It did not specify the qualifications of "other qualified medical professional ... required to certify all patient assessment and dispositions."
* It did not clearly reflect what the specific processes were for GSRMC. For example where it stated "Facilities may have slight variations ... If your facility uses ..."

1. d. The "GSR LDRP" RN Job description was reviewed and found to contain no reference to, or provisions for, performance of MSEs to rule out EMCs by the OB RN. Nor did it reference "triage" duties for OB patients. Further, it contained the
following qualifications for OB RNs that reflected that all OB RNs would not have the same qualifications at any given time:
* Oregon RN license required.
* BLS required.
* NRP required within six months of hire.
* STABLE required within one year of hire.
* Perinatal related RNC certification preferred.
* For L&D RNs additionally:
- ACLS required within six months of hire.
- Basic fetal monitoring skills preferred.
- Labor and Delivery experience preferred.
- OR/C-section circulation experience preferred.
* There were additional "preferred" qualifications for the "Special Care Nursery" and "Mother Baby Unit" RNs.

1. e. The P&P titled "Management and Treatment guidelines for Care of Mentally Ill and Substance Abuse Patients Policy" dated as approved 05/08/2017 was reviewed and included:
* "All persons presenting to [GSRMC] for treatment are provided with a medical screening by a physician in the [ED]."
* "Consultation and referral to County Mental Health Departments will be initiated by the attending or [ED] physician."

The P&P was not clear in relation to EMTALA. For example:
* It indicated the procedure applied to persons presenting to the hospital for "treatment" and did not include any reference to individuals who presented with potential psychiatric or mental health EMCs.
* It did not identify which individuals at "County Mental Health Departments" would be requested for "consultation."
* It did not indicate whether the consultation was related to, or included, identifying or ruling out psychiatric or mental health EMCs.

1. f. "Confidentiality Agreements" between the hospital and two different County Mental Health Departments were each signed and dated as approved in 2004. Those agreements were provided under a file name of "Professional Services Agreements." They were reviewed and found to contain identical language.

The agreements were not clear in relation to the individuals who presented to the hospital with potential psychiatric or mental health EMCs. For example:
* Both contracts lacked language related to consultative services for individuals who presented to the hospital's ED with potential psychiatric or mental health EMCs.
* Both contracts lacked language related to the qualifications of "mental health workers."

1. g. The P&P titled "Emergency Department Registration Procedure" dated as revised 10/24/2017 was reviewed and included:
* "Obtain the patient's name, DOB and chief complaint."
* "Immediately call for Triage. It is not appropriate to delay the call for Triage to begin or complete the registration process."
* "Begin the registration, using the Emergency Routine. Continue with verifying information until the nurse arrives. EMTALA ... does allow for the registration process to progress as long as it is not delaying assessment of the patient."
* "Patient identification must be verified and current Photo ID scanned. Scan all available Insurance Cards."
* "Insurance information can be gathered prior to Triage, while waiting for Triage Nurse to arrive. However any discussion regarding financial obligations or co-pays must wait until after the patient is medically screened. Within Samaritan Health Services the financial discussion does not occur until the patient is ready for discharge."
* "Co-pays and deposits are collected upon discharge for ED patient."
* "Co-pays and deposits may be collected prior to the visit if the patient or their representative offers payment."
* "If a patient presents to the Emergency Room but leaves without being seen, or prior to completion of treatment. Notify Nursing staff that the patient is leaving. Obtain signature as required at your site. Do not cancel the Account."

The P&P was not clear. For example:
* It did not specify what steps were performed to "complete the registration process" and if those steps included obtaining co-pays and deposits.
* It was not clear what "Obtain signature as required at your site" meant.

1. h. The P&P titled "Discharge against medical advice" dated as revised 11/15/2019 was reviewed and included the following:
* "Discharge against medical advice (AMA) can present an ethical dilemma for health care teams in various medical settings. A patient who decides to leave a facility AMA is at significant risk for readmission and mortality. Practitioners and nurses who don't properly assess, evaluate, intercede, and document a patient's reason for leaving AMA may suffer legal and ethical consequences. Therefore, before a patient leaves AMA, health care team members must carefully evaluate the patient's decision-making capacity and provide information to the patient regarding the ramifications of leaving the facility AMA. Certain factors identified that place the patient at risk for discharge AMA include low-health literacy of the patient, cultural insensitivity by staff, and substance abuse issues. By identifying and addressing factors, discharge AMA dilemmas may be prevented. If a patient is released AMA, you must provide written instructions for the patient's care, including the risks associated with leaving AMA."
* "If you discover a specific problem that has motivated the patient's decision to leave AMA, try to resolve it. If the problem lies outside your scope of practice, notify the practitioner and your supervisor. Resolving the problem may reverse the patient's decision to leave the facility AMA."
* "Document assessment of the patient's decision-making capacity. Record that the patient was made aware of the risks associated with refusing treatment and leaving AMA. Note the patient's understanding of those risks. Record the instructions given ... Note the date and time of discharge; the person with whom the patient was discharged ..."

1. i. The form titled "Leaving the Hospital Against Medical Advice (AMA) Certification" contained the following language in its entirety:
"This is to certify that I am leaving the hospital against the advice of my physician. I have been advised of my diagnosis and condition; I understand that leaving may cause my condition to worsen and place my health (or the health of y unborn child in case of pregnancy) at risk; I have been advised that I may return to the Emergency Department and/or that I should see a physician if my symptoms get worse or do not improve; The decision to leave the hospital against medical advice is mine, and I accept full responsibility for the consequences of this action; I hereby release the hospital, its employees and officers, and my attending physician from liability and responsibility for the consequences of leaving against medical advice."

2. During interview on 08/19/2020 at 1240 the AVPPCS stated that on 02/09/2020 Patient 29 who had a suspected STEMI presented to the hospital by ambulance. He/she stated that upon arrival of the ambulance, nursing staff went out to the ambulance bay and informed the EMS staff that the "cath lab team was in an emergent case" and they needed to take the patient to Salem Hospital. The AVPPCS confirmed the following:
* Patient 29 was not brought into the hospital for an MSE.
* Patient 29 was not entered on the ED log.
* There was no medical record for Patient 29's 02/09/2020 encounter at GSRMC.
* Patient 29 should have been brought into the ED for an MSE and stabilizing treatment within the hospital's capability and capacity.
* GSRMC was at capacity on that date but GSRMC ED does not go on "divert" and no one should get turned away.
* When hospital leadership was informed of the incident on 02/10/2020 an internal investigation was conducted and corrective actions, that included staff education, were planned and implemented.

An EMS ambulance report provided by the hospital was dated 02/09/2020 and reflected "Upon arrival to Good Sam ED we are met at the ambulance bay by staff who report that 'The Cath lab is full, and we are on divert. We are not taking this patient. You are taking them to Salem hospital and they know.' When trying to discuss that that is an inappropriate decision the staff worker stated again they are not taking this patient."

An Internet distance calculator reflected that Salem Hospital in Salem, Oregon is approximately 35 miles and 46 minutes drive-time from GSRMC in Corvallis, Oregon.

3. a. The central log for Patient 22 reflected that he/she presented to the ED on 06/22/2020 at 1055 with chief complaint of "Sent by doctor." The ED disposition on the log was blank.

3. b. The medical record for Patient 22's 06/22/2020 ED encounter was reviewed and included:
* At 1055 "Arrival Complaint" as recorded as "Sent by doctor."
* At 1101 "Triage Started."
* At 1104 "Registration Completed."
* AT 1104 "Triage Completed."
* At 1127 "Patient dismissed."
* An untimed note recorded under "Discharge Disposition" reflected "Ed Dismiss - Diverted Elsewhere."
* A "Conditions of Admission" consent form contained the following language written on the "Patient or Patient Representative" signature line: "Verbal Consent Given by [Patient 22's name]." It was dated 06/22/2020 and the "Time" of the consent was blank.

There was no other triage, physician, or MSE documentation in the record to describe why the doctor "sent" Patient 22 to the ED and to explain this encounter.

3. c. The OB log reflected that Patient 22 presented to the OB department on 06/22/2020 at 1128. The "Chief Complaint" was blank. The "Discharge Disposition" was recorded as "Home or Self Care."

3. d. The medical record for Patient 22's 06/22/2020 OB encounter was reviewed and included:
* At 1131 an RN recorded "Previous Encounter Weight (kg) 65.77" and "Weight 65.8 kg (145 lb)."
* At 1132 a physician's order for "methotrexate 85 mg / 3.4mL chemo IM injection" was initiated. The order reflected "Admin instructions: Chemotherapy - use appropriate precautions. Must be administered and handled by 2 ONS Chemo/Bio Provider RNs (see policy) and then disposed of properly."
* At 1136 the RN recorded vital signs.
* At 1138 the RN recorded an "Abuse Assessment" in the "Flowsheets" record.
* At 1303 the "All Medication Administrations" record reflected that the methotrexate was administered.
* At 1324 the RN recorded "Copy of AVS provided to Patient." A copy of the AVS reflected that it included an attachment titled "Ectopic Pregnancy" and included generic information that "An injection of a medicine (methotrexate) may be given to cause the pregnancy tissue to be absorbed."

There was no other triage, physician, or MSE documentation in the record to describe and explain the patient's OB encounter.

3. e. During record review with several hospital team members on 08/27/2020 at 1540 the AVPPCS and the WSM stated that prior to arrival to the ED Patient 22 had been seen in a physician's office and diagnosed with an ectopic pregnancy, that the physician directed the patient to the hospital's ED for the methotrexate injection, and that when the patient presented to the ED it was determined that the patient would be sent to the OB department for the injection. During the interview it was revealed that a physician's note about the encounter had been located and it was provided for review.

The physician note was electronically signed by the physician on 08/23/2020 at 1229, four days after Patient 22's record had been selected for review during this EMTALA investigation on 08/19/2020. The note was reviewed and included the following:
* "Date of Service: 06/22/20 1322."
* "Patient seen in the office and sent to the ER for [methotrexate]."
* "... presents for evaluation for vaginal bleeding in pregnancy. Last menstrual period was 4/30/20 ... vaginal spotting ... mild cramping which is worse on the right ... admits that [his/her] bleeding picked of (sic) this weekend ... reports mild nausea."
* "... beta HCG appears be (sic) rising inappropriately ... formal ultrasound today ... concerning for ectopic. PAR Q was reviewed for methotrexate versus surgical intervention ... no signs of rupture at this time. Plan to do IM methotrexate ... Rupture precautions were discussed patient plans to go to the emergency room to get the medication. Dosing and indications were discussed with the charge nurse."

3. f. In an email dated 08/27/2020 at 1849 from the physician to the WSM the physician wrote that Patient 22 was "sent to the ER for the injection of methotrexate. The charge nurse for the ER that day, whom I spoke with, was given specific instructions regarding the dose and administration method and was told the patient did not need further evaluation as [he/she] was completely evaluated in my office. Following the methotrexate, [Patient 22] had specific instructions to follow up with me for beta hCG
monitoring."

3. g. In an email dated 08/31/2020 at 0758 received from the AVPPCS the ED charge nurse wrote "I recall a phone call from [physician] regarding a patient that needed to come to the hospital for methotrexate administration on June 22, 2020. As charge nurse in the emergency department that day, at no point did I take verbal orders from [physician] regarding this patient."

3. h. During interview on 08/31/2020 at 1330 the AVPPCS confirmed that the physician for Patient 22 practiced at "The Corvallis Clinic," a private physician practice that was not State licensed or Federally Medicare certified as part of GSRMC.

3. i. As Patient 22 was not receiving GSRMC outpatient services during the office visit to "The Corvallis Clinic" and was sent to the ED to receive stabilizing treatment for a potential EMC of an ectopic pregnancy, the hospital had an EMTALA obligation to provide an MSE to Patient 22 who presented to its ED.

Further, it was unclear why this patient who did not meet the greater than 20 weeks gestation criteria for an MSE in the OB department in accordance with the EMTALA P&P was "diverted" from the ED to OB.

4. a. The central log for Patient 4 reflected that he/she presented to the ED on 02/18/2020 at 1417 with chief complaints of "Headache, Dizziness." The ED disposition on the log was recorded as "LWBS after Triage."

4. b. The medical record for Patient 4's 02/18/2020 encounter was reviewed and included:
* At 1422 the "arrival complaint" was recorded as "vomiting, dizzy, head pain."
* At 1438 an entry reflected that "Registration Completed."
* At 1450 an RN recorded the patient's vital signs.
* At 1451 the RN recorded "Ready for Provider" and "Patient Acuity 3."
* At 1455 the RN recorded "Specimen Collection."
* At 1541 and 1547 urine and blood tests were "resulted" and included "abnormal" results.
* At 1712 the RN recorded the patient's pulse.
* At 0009 on 02/19/2020 the ED provider electronically signed a note that reflected "The patient left without being seen at 1751."
* An untimed note under "ED Disposition" reflected "Per Registration, Pt no longer wanted to wait to be seen and left ED lobby."

There was no other documentation in the record by the ED provider to reflected that Patient 4 received an MSE. Although entries reflected that the patient "no longer wanted to wait" there was no evidence that "reasonable steps" were taken to inform the patient of the risks of leaving prior to the MSE, that he/she was informed that lab tests had "abnormal" results, and to "secure the person's written refusal" in accordance with the hospital's P&PS identified under Findings 1.a. and 1.h. above. The documentation did not reflect that hospital staff did or said nothing to dissuade the patient from staying for an MSE.

4. c. In an email from the AVPPCS received on 08/27/2020 at 1058 he/she wrote that Patient 4 "left from triage after waiting 3.5 hours ... Very busy day in ED high census of 92 - from 1400 to 1900 ..." No other information was provided related to attempts to inform the patient of the risks of leaving or to obtain written refusal.

5. a. The central log for Patient 6 reflected that he/she presented to the ED by ambulance on 02/24/2020 at 1739 with chief complaint of "Hypertension." The ED disposition on the log was recorded as "LWBS after Triage."

5. b. The medical record for Patient 6's 02/24/2020 encounter was reviewed and included:
* At 1739 the "arrival complaint" was recorded as "Hypertension."
* At 1743 an entry reflected that "Registration Completed."
* At 1750 an RN recorded the patient's vital signs. The BP was denoted as "(!) 171/75."
* At 1750 the RN recorded "Ready for Provider" and "Patient Acuity 3."
* At 1754 an ECG was performed.
* At 1817 a "Leaving the Hospital Against Medical Advice (AMA) Certification" form was signed by the patient and the RN.
* At 1933 the ED provider electronically signed a note that reflected "Patient left without being seen after triage."
* An untimed note under "ED Disposition" reflected "Pt left WBS after triage. AMA paperwork signed."

There was no other documentation in the record related to the circumstances and reasons Patient 6 gave for wanting to leave. Although the patient signed an AMA form there was no documentation in the record that included an "assessment of the
patient's decision-making capacity," that the patient was informed of the risks of leaving prior to the MSE and his/her "understanding of those risks, and what "diagnosis and condition" the patient was advised of in consideration that he/she had not had an MSE by the ED provider. The documentation was not in accordance with the hospital's P&PS identified under Findings 1.a. and 1.h. above and did not ensure that hospital staff did or said nothing to dissuade the patient from staying for an MSE.

5. c. In an email from the AVPPCS received on 08/27/2020 at 1058 he/she wrote that Patient 6 "left after triage and waiting just over one hour. RN does not recall patient, unable to give details about [his/her] leaving." No other information was provided.

6. a. The central log for Patient 11 reflected that he/she presented to the ED by ambulance on 04/02/2020 at 0835 with chief complaint of "Diplopia: Generalized Body Aches." The ED disposition on the log was recorded as "LWBS after Triage."

6. b. The medical record for Patient 11's 04/02/2020 encounter was reviewed and included:
* At 0835 the "arrival complaint" was recorded as "Double vision, left side more weak than right side."
* At 0840 an RN recorded the patients vital signs that included a pulse rate of "(!) 113" and BP of "(!) 176/93."
* At 0842 the RN recorded "Ready for Provider" and "Patient Acuity 3."
* At 0844 an entry reflected that "Registration Completed."
* At 0848 the ED provider electronically signed a note that reflected "Pt not seen by MD. [He/she] decided that no visitor Covid policy was not acceptable and left without being seen."
* At 0855 the RN recorded a note that reflected "This nurse was triaging pt. Pt states at the beginning that [he/she] is very unhappy that [his/her] spouse can not come and be with [him/her] ... Let pt. know that these are the rules in place to protect [him/her] ... during the COVID-19 pandemic ... Upon completing triage, went to bring pt back to the room ... Pt stated that ... 'does this mean my [spouse] can still not come?' Let the pt know that yes, the rule still applies ... Pt replies 'this is not ok' and that 'I am not doing this, I am out of here if [he/she] doesn't come back with me.' let (sic) pt know that is [his/her] choice, but that the rule still applies whether or not [he/she] chooses to be seen. Pt grabs [his/her] stuff and storms out of triage room
and walks out the front doors."
* An untimed note under "ED Disposition" reflected "Please see note. Pt left due to [spouse] not being able to come back."

There was no other documentation in the record by the ED provider to reflect that Patient 11 received an MSE. Although the RN documentation described the circumstances in which the patient left, there was no documentation to reflect that the RN attempted to de-escalate the situation or obtain the assistance of other staff to speak with the patient about the challenges of the COVID-19 pandemic that included visitor restrictions. The record did not reflect that "reasonable steps" were taken to inform the patient of the risks of leaving prior to the MSE and to "secure the person's written refusal" in accordance with the hospital's P&PS identified under Findings 1.a. and 1.h. above. The documentation did not reflect that hospital staff did or said nothing to dissuade the patient from staying for an MSE.

6. c. During interview with the AVPPCS on 08/19/2020 at 1400 he/she confirmed that Patient 11 left the hospital without receiving an MSE and that other strategies to respond to the patient's stated concerns had been discussed with the RN.

7. a. The central log for Patient 27 reflected that he/she presented to the ED on 08/04/2020 at 1230 with chief complaints of "Abdominal Pain." The ED disposition on the log was recorded as "LWBS after Triage."

7. b. The medical record for Patient 27's 08/04/2020 encounter was reviewed and included:
* At 1230 the "arrival complaint" was recorded as "Stomach cramps."
* At 1235 an entry reflected that "Registration Completed."
* At 1235 an RN recorded the patient's vital signs that included a BP denoted as "(!) 147/98."
* At 1236 the RN recorded "Ready for Provider" and "Patient Acuity 3."
* An untimed note under "ED Disposition" reflected "1333 pt told front registration staff they were tired of waiting and were leaving."

There was no other documentation in the record to reflect that Patient 27 received an MSE. Although an entry reflected that the patient was "tired of waiting" there was no evidence that "reasonable steps" were taken to inform the patient of the risks of leaving prior to the MSE and to "secure the person's written refusal" in accordance with the hospital's P&PS identified under Findings 1.a. and 1.h. above. The documentation did not reflect that hospital staff did or said nothing to dissuade the patient from staying for an MSE.

7. c. In an email from the AVPPCS received on 08/27/2020 at 1058 regarding Patient 27 he/she wrote "pt left after triage. Nurse documented in the LWBS section in the triage tab. Pt was tired of waiting." No other information was provided related to attempts to inform the patient of the risks of leaving or to obtain written refusal.

8. a. The central log for Patient 1 reflected that he/she presented to the ED on 02/09/2020 at 1043 with chief complaints of "Delirium Tremens (DTS); Suicidal." The ED disposition of the log was recorded as "Discharge."

8. b. The medical record for Patient 1's 02/09/2020 encounter was reviewed and included:
* At 1130 an RN note reflected "Pt reports current SI, thoughts of wanting to be dead. Hx of suicide attempts in the past. No current plan but intrusive thoughts of death ... Pt contracts for safety. Pt changed into paper scrubs, belongings secured,
room ligature risks identified and minimized. Per [ED NP], no 1:1 needed at this time ..."
* At 1205 a CSSRS screening was conducted by an RN. The patient answered "Yes" to the following questions: "Wish to be Dead" and "Suicidal Thoughts." The patient answered "No" to the remaining screening questions related to suicidal plans and intent.
* At 1205 the RN documented "Positive Suicide Screen Documentation: Suicide Precautions Yes."
* At 1749 an RN note reflected "Discharge instructions reviewed with Patient" and "AVS Handed Directly to Patient."
* At 1836 an RN note reflected "Pt discharged via cab. Belongings returned to pt. Pt to go home to pick up medications, then to Janus House. Pt agrees to plan."
* On 02/11/2020 at 0927 an MD electronically signed an "ED Provider Note" that reflected "Date of Service" as 02/09/2020 at 1837 and "Original Note by [ED NP] filed at 02/11/20 0100." The note reflected the following:
- "Delirium Tremens ... [Parent] passed away last week, has drank nonstop for a week. Prior alcoholic with 2 years of sobriety, last drink yesterday afternoon."
- "Suicidal occasional thoughts of wanting to die since [parent] died last week; no current plan but has hx of suicide attempts."
- "HPI ... Patient states at times when [he/she] is drinking [he/she] feels suicidal. [

Based on interview, review of documentation in 5 of 7 medical records of patients who were transferred from GSRMC to other facilities for further examination and stabilizing treatment that was not within the hospital's capabilities or capacity at the time (Patients 2, 12, 15, 19 and 25 ) and review of hospital policies and procedures, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that it affected appropriate transfers for patients who required further examination and stabilizing treatment to rule out, remove or resolve potential EMCs as follows:
* Physician certifications of risks and benefits of transfer lacked identification that the physician certified, and that the patient was informed of, individualized and patient specific risks.
* A transfer was made to a residential care facility versus another hospital.
* Medical records were not sent to a receiving facility.
* Appropriate transportation with qualified personnel was not used for a transfer.

Findings include:

1. The P&P titled "Emergency Medical Treatment and Labor Act (EMTALA)" dated as revised 09/18/2018 was reviewed and included the following:
* "Determine the need for and initiate transfer to another acute care facility ... For an unstable medical condition (medical condition which is not stabilized, including obstetrical, psychiatric or ophthalmologic condition), the transferring LIP will:
- Certify, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual from being transferred, or in the case of a woman in labor, to the unborn child ...
- Determine transportation requirements (mode, skill level of personnel, equipment necessary)."
* "Regardless of stable or unstable medical condition, nursing staff will:
- ... Arrange appropriate transportation as ordered by the transferring LIP ...
- Copy and send all pertinent medical record available at the time of transfer to the receiving facility ..."

There were no other P&PS or other written documents provided pertaining to transfers and medical transportation.

2. The medical record of Patient 2 reflected that he/she presented to the ED on 02/14/2020 at 1539. The record reflected that the patient was brought to the hospital by police and had shortness of breath, suicidal ideations, suicidal behaviors and attempted self-injury, although the specific behaviors and self-injury attempts were not described. The patient received an MSE and was subsequently transferred to an inpatient psychiatric hospital for further examination and stabilizing treatment of "Suicidal ideation; Alcohol dependence with withdrawal with complication (HCC)."

"MD Documentation" in the transfer portion of the medical record was recorded on 02/15/2020 at 1339 and reflected that the "Risks of Transfer" were " Worsening symptoms MVA others." The risks were not individualized and patient specific. It was not clear what "worsening symptoms" or "others" meant for Patient 2. MVAs are not patient specific risks as those are inherent for all transfers.

An Internet distance calculator reflected that Cedar Hills Hospital in Portland, Oregon, to where the patient was transferred, was approximately 78 miles and one hour and 25 minutes drive-time from GSRMC in Corvallis, Oregon.

3. The medical record of Patient 12, a nine-year-old, reflected that he/she presented to the ED on 04/07/2020 at 1518. The record reflected that the patient was brought to the hospital by a parent as directed by a pediatrician who had seen the patient in his/her office that day where the patient was found to have an elevated blood sugar level of 648. The patient received an MSE and was subsequently transferred to a hospital with a pediatric ICU and a pediatric endocrinologist for further examination and stabilizing treatment of "Diabetic ketoacidosis without coma associated with other specified diabetes mellitus (HCC)."

"MD Documentation" in the transfer portion of the medical record was recorded on 04/07/2020 at 1645 and reflected that the "Risks of Transfer" were "Accident in transfer." The risks were not individualized and patient specific. MVAs are not patient specific risks as those are inherent for all transfers.

An Internet distance calculator reflected that LEMC Randall Children's Hospital in Portland, Oregon, to where the patient was transferred, was approximately 83 miles and one hour and 30 minutes drive-time from GSRMC in Corvallis, Oregon.

4. The medical record of Patient 15 reflected that he/she presented to the ED on 04/21/2020 at 1345. The record reflected that the patient presented to the hospital with complaints of double vision and headache. The patient received an MSE and was subsequently transferred to a hospital with a neurology and neurosurgery capabilities for further examination and stabilizing treatment of "Diplopia; Dissection of carotid artery (HCC) rule out; Ischemic stroke (HCC) rule out."

"MD Documentation" in the transfer portion of the medical record was recorded on 04/21/2020 at 1733 and reflected that the "Risks of Transfer" were "decompesation (sic), worsening mental status." The risks were not individualized and patient specific. Is was not clear what those meant for Patient 15.

An Internet distance calculator reflected that Providence St. Vincent Medical Center in Portland, Oregon, to where the patient was transferred, was approximately 78 miles and one hour and 25 minutes drive-time from GSRMC in Corvallis, Oregon.

5. The medical record of Patient 19, a 15-year-old, reflected that he/she presented to the ED on 06/06/2020 1145. The record reflected that the patient was brought to the hospital by a grandparent as he/she had cut him/herself the previous day and continued to be threatening to "kill myself with pills or cut myself." The patient received an MSE, was diagnosed with "Suicidal Ideation" and attempts to transfer the patient to an inpatient psychiatric hospital with adolescent capabilities were initiated. The patient remained in the ED on suicide precautions until 06/10/2020 when he/she was transferred to a residential mental heath facility instead of one of the at least two hospitals he/she was on the wait list for.

The final note recorded by an ED physician electronically signed on 06/10/2020 at 1635 reflected that patient had "... self injurious behavior. Patient did not contract for safety and is currently on a guardian hold. [Pt.] reports continual SI and auditory command hallucinations ... has been accepted for transfer to the Farmhome today. Patient is boarded in the ED on observation status. 1:00 PM Transport here to take pt to the Children's Farm Home."

An appropriate transfer was not conducted for Patient 19 as he/she was not transferred to another hospital and there was no documentation in the record to reflect that the residential facility was an appropriate facility in consideration of his/her condition. There was no documentation by the physician to reflect a certification that the benefits of transfer outweighed patient specific risks of transfer and there was no documentation that medical records were sent to the receiving facility. The only document recorded as sent was an AVS, the hospital's discharge instructions provided to the patient when a patient is discharged.

An Internet distance calculator reflected that the Children's Farm Home in Corvallis, Oregon was approximately three miles and 11 minutes drive-time from GSRMC in Corvallis, Oregon.

6. The medical record of Patient 25 reflected that he/she presented to the ED on 08/01/2020 at 1750. The record reflected that the patient presented to the hospital with complaints of esophageal food bolus and pain in lower chest. The patient received an MSE and the on-call GI specialty physician was consulted who recommended endoscopy. However, the hospital did not have OR capacity at that time. The patient was subsequently transferred to another hospital for further examination and stabilizing treatment of "Esophageal obstruction due to food impaction."

The ED PA's note recorded on 08/10/2020 at 1915 reflected that the PA discussed the transfer with the patient. The note reflected "I recommended transfer via ambulance given that there is a potential for worsening symptoms on route with [his/her] esophageal obstruction. Patient refused ambulance transport and will go via private vehicle. [He/she] is instructed to go immediately to Albany ED where they are waiting for him."

"MD Documentation" in the transfer portion of the medical record was recorded on 08/01/2020 at 1930 by the PA and reflected that the "Risks of Transfer" were "Worsening condition en route." The risks were not individualized and patient specific. It was not clear what "worsening condition" meant for Patient 25.

"RN Documentation" in the transfer portion of the medical record was recorded on 08/01/2020 at 1935 and reflected "Transport by: POV."

The consent section of the transfer documentation was signed by Patient 25 on 08/01/2020 at 1940 and included:
* A paragraph preceded by a checkbox reflected "I hereby CONSENT to transfer ..."
- An "X" was recorded in that checkbox.
* A paragraph that followed was also preceded by a checkbox and reflected "I hereby REFUSE AMBULANCE TRANSFER and I am doing so against medical advice. I understand that my refusal may result in a worsening of my condition and could pose a threat to my life and health."
- That checkbox was blank and unchecked.

Although the PA wrote that the "patient refused ambulance transport" there was no indication that Patient 25 was further informed of the additional risks of transfer by POV and the patient's written refusal was not reflected in the transfer documentation.

An Internet distance calculator reflected that Samaritan Albany General Hospital in Albany, Oregon, to where the patient was transferred, was approximately 12 miles and 25 minutes drive-time from GSRMC in Corvallis, Oregon.

7. During record review with several hospital leadership staff on 08/26/2020 beginning at 1500 the AVPPCS stated that there were no hospital P&PS to address situations where patients refuse medical transportation with qualified personnel for transfers "except for the EMTALA" P&P. The AVPPCS stated that staff would use the "AMA form" to document that refusal.

Review of the EMTALA P&P identified under Finding 1 above, and the AMA P&P and AMA form (both referenced under Finding 1 of Tag A2406), reflected there was no language regarding refusal of appropriate medical transportation with qualified personnel for transfers.

In addition, in regards to Patient 25, described in Finding 6 immediately above, there was no evidence of an AMA form completed for refusal of appropriate medical transportation.