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Based on interviews, the review written policies and procedures and the review of 61 medical records for patients who presented to the hospital's ED and/or OB departments it was determined that the hospital failed to fully develop and enforce their EMTALA policies and procedures in the area of appropriate patient transfers.

Findings include:

Appropriate Transfer: Refer to the findings identified under Tag C2409, CFR 489.24(e)(1-2) which reflects the hospital's failure to enforce their policies and procedures related to the risks and benefits of an appropriate patient transfer.

Based on interviews, the review of written policies and procedures, and the review of documentation in 25 records of patients who presented to the Emergency and/or the OB Departments for evaluation and treatment and were subsequently transferred to other facilities, it was determined that 12 records (Records #2, #14, #18, #19, #31, #37, #38, #39, #47, #48, #55, and #61) lacked appropriate documentation of the patient-specific medical risks and benefits of the transfers.

Findings include:

Record #61: The review of documentation in the OB Department "Emergency Room Register" log revealed a pre-printed label with Patient #61's name, DOB, account number, and medical record number. A hand-written entry made on this label dated 5/4/2015 at 6:55 AM reflected, "Late Entry Came to Front Registration: 'my dr. sent me in to be checked' L&D staffed to capacity and not seeing new patients-Registration staff gave Providence name & address [pt. name] left before being seen." This entry was signed by Employee #1. During an interview on 5/11/2015 at 8:30 AM Employee #1 stated that a medical record had not been generated for Patient #61 as a result of his/her presentation to the Registration desk.

Video surveillance documentation presented for review revealed Patient #61 and his/her spouse walk into the Registration office. This office was adjacent to the main entrance of the hospital. Observation revealed that Patient #61 sat in a chair while his/her spouse spoke with Registration personnel. Video documentation revealed that Patient #61 and his/her spouse were in the Registration office for 8 minutes. Observation revealed that Patient #61 and his/her spouse exited the Registration office, unassisted, through the main entrance of the hospital.

During an interview with Employee #5 on 5/12/2015 at 11:05 AM he/she stated that he/she had been notified by an OB PNA that there was an OB patient in the Registration office who did not speak English. Employee #5 stated that she told the PNA to tell Registration personnel to "get an interpreter and find out why [he/she] is here." Employee #5 stated that this notification occurred during "the morning huddle and quick prayer". Employee #5 stated that he/she went out to the nursing station within "a few minutes" of the original notification and called Registration back and was told by Registration personnel, "We sent [him/her] to Providence". Employee #5 stated her response to Registration was, "You did what?". Employee #5 stated she notified the department manager immediately after being told that Patient #61 had been sent to PPMC.

Employee #5 stated during this interview that the OB Department was "on divert" at the time he/she was notified the patient was in the Registration office. Employee #5 stated that when the OB department was divert no procedures, such as labor inductions or C-section deliveries were scheduled. He/she stated that the OB department had been on divert "since the night before".

Employee #5 stated that PPMC called the PAMC OB department "about 2 hours later" and the "Prenatal Form" for Patient #61 was sent to PPMC. He/she stated that these forms contained patient information received from OB physicians when their patients were "at about 20 weeks" and contained general patient information that was kept on file in the event a patient came to the OB department any time during their pregnancy. He/she stated, "It saves time at registration and we have an idea who's out there."

Employee #5 stated that anytime the OB department was on divert, all of the physician practices who provided OB services at the hospital were notified. In addition, he/she stated that the nursing supervisor was also notified. Documentation presented for review included the OB department "Divert Checklist/Log Date 5-4-15 Time On: 0815 Time Off: 1530". Additional documentation revealed a "Call:" notation, followed by a list of 19 physician names and/or practice names. Documentation revealed that Patient #61's physician was included on this list and had been called regarding the OB department divert status at "0825".

An interview with Employee #4 on 5/12/2015 at 11:30 AM revealed that on 5/4/2015 a pregnant individual and his/her spouse presented to the Registration office of the hospital. Employee #4 stated that the spouse did all the communicating with him/her. Employee #4 stated, "The one thing I did wrong, I should have asked 'Is [he/she] in labor'. I usually do ask that, but I didn't this time. [He/she] [pt's. spouse] did all the talking and said their doctor had sent them in to be checked and that they were 'going to have a baby today'. [He/she] [Patient #61] didn't appear in any distress and didn't have a suitcase. I thought [he/she] was here to be checked or for an NST so I looked in the computer but there wasn't an appointment for [him/her]".

Employee #4 stated that he/she called the OB department and asked if they were expecting any patients and stated, "I didn't ask [his/her] name [OB personnel], but I know the person I talked to up there had an accent. [He/she] told me they weren't expecting anyone and they couldn't take any patients because they were on divert. [He/she] told me [he/she] would call me back after [he/she] checked with the CRN. [He/she] called me back in a couple of minutes and told me to send [him/her] [Patient #61] to PPMC." Employee #4 stated that prior to this incident he/she "had no idea" that the OB department was on divert status. Employee #4 stated that he/she did not know that the OB department had a divert mechanism.

When asked if he/she would ever make the determination to send a patient to another hospital Employee #4 stated, "Absolutely not. I do whatever the department tells me to do. They're in charge". Employee #4 reiterated multiple times during the interview that he/she was directed by OB staff, specifically, "someone with an accent" to direct Patient #61 to PPMC. He/she stated that he/she gave Patient #61's spouse the telephone number and address for PPMC.

Employee #4 stated that he/she did not obtain an interpreter for Patient #61 because "[He/she] [spouse] did all the talking and I could easily understand what [he/she] was saying."

Interviews with Employees #7, and #8 on 5/12/2015 at 3:10 PM revealed that the OB department had 24 beds. Employee #8 stated during this interview that OB beds were available on 5/4/2015 but the department was on divert due to staffing needs. Employee #8 stated that multiple OB staff were off-site attending a mandatory education session and that the department was on divert for "most of the weekend".

Based on information obtained during these interviews this divert mechanism was unique to the OB department and was utilized "if we don't have enough nursing staff". Employee #8 stated during this interview, "Any OB patient who presents to the hospital, even if we're on divert, would be evaluated and treated as needed". Both employees stated "We just make it work". Employee #8 stated, "We have to take whoever comes through the door. We just have to figure out how to take care of them".

During an interview with Employee #3 on 5/13/2015 at 8:30 AM he/she stated that he/she received a call from Registration personnel on 5/4/2015 informing him/her that there was an OB patient in their office "who looks like she's wanting to check-in. [He/she] [Patient #61]looks like [he/she] might be in labor and [he/she] doesn't speak any English. I told them I needed to talk to the CRN and would call them back. When I called back and told them the CRN said to bring [him/her] [Patient #61] up, they told me they had told [him/her] to go to Providence".

Interviews with OB staff and Risk Management personnel and the review of documentation revealed that at the time of the complaint investigation there were no written policies and procedures for the OB divert mechanism. Employee #1 stated, "I had no idea that OB could go on divert".

An interview with Employee #1 on 5/12/2015 at 10:00 AM revealed that OB nurses are trained and certified to conduct the MSE in the OB department. Employee #1 also stated during this interview that as part of the internal review process of the above event, he/she had interviewed Patient #61's physician. He/she stated that the physician stated that he/she had not told Patient #61 to present to the hospital and had not told Patient #61 that he/she was going to have a baby that day. Employee #1 stated that the physician told him/her that the first he/she became aware that Patient #61 had gone to a hospital was when he/she was notified of Patient #61's admission to PPMC.

Record #55: The review of documentation revealed that Patient #55 presented to the OB Department on 3/18/2015 with a chief complaint of "ruptured membranes". Additional documentation made by OB staff revealed that Patient #55 was at 32 weeks gestation and this was a premature membrane rupture. Documentation reflected that Patient #55 was having contractions "every 1-4 minutes". A physician entry made on 3/18/2015 included, "Plan: It has been advised to patient that [he/she] be transferred to Emanuel for a higher level of neonatal care. I have spoken to [receiving physician] who agrees to accept the transfer." Documentation failed to reflect that the risks and benefits of the transfer had been explained to Patient #55.

The review of documentation on the "Authorization /Certification for Transfer" form failed to reflect the identification of any transfer risks, including pertinent medical risks to Patient #55.

Record #31: The review of documentation revealed that Patient #31 presented to the ED on 4/25/2015 with a chief complaint of left hand and left leg burns. Documentation revealed that these burns were 2nd degree burns and covered 10% of Patient #31's total body surface area. An entry made by the physician on 4/25/2015 in the "Emergency Department Reports" reflected, "On account of [his/her] difficult to control pain, I spoke with the provider at the Emanuel burn center. This patient [sic] kindly agrees to accept the patient for further evaluation and management". This entry failed to delineate the risks and benefits of the transfer, including the pertinent medical risks to Patient #31. This entry also failed to reflect that the risks and benefits of the transfer had been explained to Patient # 31.

Further review of documentation revealed that the "Authorization/Certification for Transfer" form required to be completed by the ED physician prior to transfer was not in the medical record. The review of documentation revealed that Patient #31 had received conscious sedation prior to a procedure completed in the ED. Documentation in the medical record failed to identify that an appropriate method of transportation was used for the transfer of Patient #31.

Record #2: The review of documentation revealed that Patient #2 was brought to the ED by ambulance on 1/8/2015, arriving at 4:00 AM. Documentation reflected that Patient #2 admitted to an intentional overdose of medications in an attempt to commit suicide. Documentation reflected that Patient #2 had a past medical history that included but was not limited to schizoaffective disorder and previous suicide attempts.

Documentation in an ED physician's note written on 1/8/2015 included, "Assumed care from my colleague.......I reviewed the Pt's history and ED records. I spoke with the psychiatrist [physician's name] at Cedar Hills hospital who accepted the Pt for transfer." Additional documentation on the ED record reflected that at the time Patient #2 left the ED his/her condition was "guarded". Documentation revealed that Patient #2 was transferred on 1/8/15 at 1:15 PM.

An entry made on the "Nursing Documentation - Flowsheet" on 1/8/2015 at 1:06 PM indicated, "Transportation to destination Secure Transport". However, another entry made at 1:15 PM revealed, "Taxi arranged". Additional review of documentation revealed multiple entries by ED staff indicating that Patient #1 had "Thoughts of self harm".

Further review of the medical record failed to reveal a completed "Authorization/Certification for Transfer" form, a completed "Patient Transfer Acknowledgement or Refusal" form, a completed "Emergency Department Transfer Pause/Summary" form, or a completed "Transfer Check List Acute/Critical Patient" form. Documentation failed to reflect that an appropriate method of transportation had been used to transfer Patient #2.

Record #14: The review of documentation revealed that Patient #14 was brought to the ED by ambulance on 5/4/2015 with a diagnosis of AMS. Documentation also revealed that Patient #14 had a past medical history that included CHF, HTN, A-fib, pacemaker and previous cardiac surgery.

The review of documentation failed to reflect that an "Authorization/Certification for Transfer" form had been completed by the ED physician prior to transfer of Patient #14. Further review of documentation failed to reflect that a "Patient Transfer Acknowledgement or Refusal" form had been completed prior to Patient #14's transfer.

Review of documentation revealed a "Transfer Check List Acute/Critical Patient" form which was signed by a RN. Documentation on this form indicated that an "Authorization to Transfer (46126)" form had been completed by the physician and an "Acknowledgement/Refusal (46276)" form had been completed by the patient and/or family. Neither of these forms were included in Patient #14's medical record.

The section of the transfer check list indicating the admitting reservations for Patient #14 had been confirmed with the receiving facility was blank. The area designated for documentation that Patient #14 had left the ED and the receiving facility had been notified was blank. The area designated to reflect that Patient #14's family had been notified of the transfer was blank. Further review of this form indicated that
"History & Physical" documentation had been included with the records sent to the receiving hospital. However, review of the medical record failed to reflect that history and physical documentation had been completed prior to Patient #14's transfer. Documentation also failed to reflect if history and physical information had been discussed between the transferring physician and the receiving physician prior to Patient #14's transfer.

Record #18: The review of documentation revealed that Patient #18 was 16-months old and was brought to the ED on 5/10/15 by his/her parent. His/her admitting diagnosis included fever, decreased activity and decreased appetite. Documentation revealed that Patient #18 had been in the ED the previous day with similar symptoms. Patient #18 had been brought back to the ED with worsening symptoms. Documentation by the ED physician reflected that "Upon my initial evaluation the patient was mottled and cool and hypoxic" and "The course/duration of symptoms is worsening".

The review of documentation revealed a "Transfer Check List Acute /Critical Patient" form. Multiple areas of this form were blank including but not limited to the name of the receiving hospital, the name of the receiving physician, discharge notes/shift charting, history and physical documentation, and medication administration documentation. This form was signed by a RN. The "Emergency Department Transfer Pause/Summary" form included "5. Transfer Checklist Complete". This area was blank. In addition, the form reflected that the CRN and assigned RN should sign this form. The CRN had not signed this form.

Documentation in the record reflected that the mode of transfer for Patient #18 was by ambulance. However, documentation on the transfer check list failed to delineate any required elements to be provided by the ambulance including but not limited to O2, monitor, RN/RT accompanying, and time of transfer.

The review of documentation revealed that a "Patient Transfer Acknowledgement or Refusal" form had been signed by Patient #18's parent, documentation in the medical record failed to delineate the specific risks and benefits of a transfer for Patient #18. The review of documentation failed to reflect that an "Authorization/Certification for Transfer" form detailing the risks and benefits of a transfer had been completed by the physician prior to the transfer of Patient #18.

Record #19: The review of documentation revealed that Patient #19 was brought by ambulance to the ED on 5/10/15 with a diagnosis of AMS. Documentation in the record revealed that Patient #19 was transferred to Providence Portland Medical Center. However, documentation in the record failed to reflect that an "Authorization/Certification for Transfer" form, including delineation of the risks and benefits of a transfer" was completed by the physician prior to the transfer of Patient #19.

Patient #37: The review of documentation revealed that Patient #37 was 3 years old. He/she was brought to the ED on 4/30/15 by his/her parents. Documentation revealed the chief complaint was nausea, vomiting, fever, fatigue, chills, and weakness. A "Medical Decision Making" entry made by a physician included, "Patient appeared dehydrated and ill on arrival. [He/she] was tachycardic...........", "There was some question of abdominal pain", and "[He/she] remained markedly tachycardic despite mL's per kilogram of normal saline which was worrisome". Further documentation in this note indicated that Patient #37 had been accepted for transfer to the ICU by a pediatric intensivist at a local hospital which had pediatric services.

The review of documentation failed to reflect that the "Authorization/Certification for Transfer" form had been completed as required prior to the transfer of Patient #37. Documentation in the medical record failed to clearly delineate the risks and benefits of the transfer of Patient #37.

Record #38: The review of documentation in the medical record revealed that Patient #38 was brought to the ED on 3/1/2015 with a diagnosis of neck pain. Documentation revealed that Patient #38 had been seen in the ED the previous evening, 2/28/2015, following a fall. Documentation revealed that the night radiologists determined that Patient #38's radiology examination indicated an old cervical spine fracture. However, documentation reflected that a review of the radiology report by another physician on 3/1/2015 reflected that Patient #38 had a new, acute cervical spine fracture and Patient #38 was contacted for a return visit to the ED.

Documentation in a "Medical Decision Making" note made by a physician on 3/1/2015 indicated, "The patient will be transferred there [local trauma center] for further imaging and possible further workup. I discussed the case with the patient's [family member] who agrees with the plan". This note failed to delineate the risks and benefits of the transfer that were discussed with Patient #38's family member.

The review of documentation on the "Authorization/Certification for Transfer" form completed by a physician on 3/1/2015 also failed to delineate the risks and benefits of the transfer. The review of documentation on the "Patient Transfer Acknowledgement or Refusal" form lacked dates and the time this form had been completed. Documentation on the "Authorization/Certification for Transfer" form indicated that Patient #38 was to be transferred via ALS, however, the "Transfer Check List Acute/Critical Patient" form lacked any documentation to reflect the specific ALS transfer needs for Patient #38, including but not limited to, O2, monitor, and time of transfer.

Record #39: The review of documentation revealed that Patient #39 was 22 months old and brought to the ED 3/1/2015 by his/her parent. The chief complaint was cough, fever, and shortness of breath. Documentation revealed that Patient #39 had been seen in the ED at another hospital the previous evening for similar symptoms. Documentation revealed that due to worsening of these symptoms, the parent brought Patient #39 to this ED for further evaluation.

Documentation revealed a "Medical Decision Making" entry made by the ED physician on 3/1/2015 that reflected, "I spoke with the pediatrician at Emanuel who has agreed to transfer due to [his/her need pf supple [sic] no [sic] oxygen. [Parent] understands and agrees with plan. Documentation in this entry failed to reflect that the specific risks and benefits of the transfer of Patient #39 had been explained to the parent.

The review of documentation on the "Authorization/Certification for Transfer" form failed to identify any risks of transfer, including pertinent medical risks specific to Patient #39.

Record #47: The review of documentation revealed that Patient #47 presented to the ED on 2/25/2015 with a chief complaint of a sore throat.

An entry made by the ED physician in the "Emergency Department Reports" on 2/25/2015 reflected, "I spoke with [receiving physician] (OHSU otolaryngologist) who agrees with patient requiring further evaluation by specialist and requested the patient be transferred to their emergency department. I spoke with [receiving physician] (OHSU emergency physician) who has accepted the patient. Patient understands transfer and has no further precautions [sic] or concerns". This documentation failed to reflect that the risks and benefits, including pertinent medical risks of the transfer were explained to Patient #47.

Record #48: The review of documentation revealed that Patient #48 was brought by ambulance to the ED on 4/27/2014 with a diagnosis of SAH. Documentation made by the ED physician in the "Critical care note" reflected, "Patient emergently transported to OHSU for neurosurgical evaluation". Additional documentation made by the ED physician in the "Medical Decision Making" reflected, "Findings have been explained to the patient and [his/her] family who is present". This documentation failed to reflect that patient specific risks and benefits of the transfer had been explained to the patient and/or his/her family.

The review of documentation revealed a "Transfer Check List Acute/Critical Patient" form. This form included an areas designated for documentation to reflect that the receiving nurse had been given a report from the transferring hospital about Patient #38's condition. This area was blank. In addition, the form included an area for a RN signature. This form had not been signed by the RN. Documentation revealed that Patient #38 was subsequently transferred by ambulance Code 3 to the Neuro ICU at OHSU.

In addition, the review of transfer records for patients who presented to the ED revealed an "Authorization/Certification for Transfer" form. Section 4 of this form included an area designated "Risks of Transfer" with a checkbox and "Pertinent medical risk for this patient". The review of documentation revealed that 21 of 25 transfer records (Records #2, #4, #8, #11, #12, #14, #18, #19, #28, #29, #31, #37, #38, #39, #47, #48, #49, #50, #55, #58, and #61) lacked identification and documentation of pertinent medical risks of transfer for each individual patient.

Documentation presented for review included,"Adventist Health Adventist Medical Center Policy Adm 1887.4 EMTALA: Patient Transfer (Rev: 4)". Documentation on Page 2 included, "IV. Transfer with Physician Certification" which stipulated, "A. An individual with an unstabilized Emergency Medical Condition may be transferred if the transferring physician signs a certification, based on the information available at the time of the Transfer, that the medical benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risks to the individual (or, in the case of a woman in Labor, to the unborn child), from the Transfer. 1. The certification must contain a summary of the risks and benefits upon which it is based" and "3. b. A summary of the risks and benefits upon which the Transfer is based".