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Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to ensure a medical screening evaluation was performed for 1 of 1 ED patient (Patient #9) who presented to the ED for a wellness check, and whose record was reviewed. This resulted in unclear documentation as to the course of the patient's ED medical care and unclear determination if the patient was stable at the time of departure from the ED. Findings include:

A facility policy, "TRIAGE AND ADMISSION OF PATIENTS TO THE EMERGENCY DEPARTMENT," reviewed/revised 8/21/19, stated, "The Health Care Provider shall be notified of the arrival of a new patient, the presenting complaint, initial vital signs and any other immediate need within 10 minutes of the patient's admission to a treatment area. This notification shall be performed by the triaging staff member." This policy was not followed.

A facility policy, "TIMELINESS OF EMERGENCY DEPARTMENT PROVIDER NOTIFICATION OF A NEW PATIENT ARRIVAL," reviewed/revised 8/21/19, stated, "Emergency Department providers, Physician Assistants (PA-C), Medical Doctors (MD), Doctors of Osteopathic Medicine (DO) or Nurse Practitioners (NP) shall be notified within 10 minutes of the arrival, check-in, and initial assessment of a new patient." This policy was not followed.

A facility policy, "EMTALA," reviewed/revised 8/21/19, stated, "Medical Screening Examination...conduct and document an appropriate medical screening examination reasonable [sic] calculated to identify an emergency medical condition...Emergency Medical Condition is a condition manifesting itself by acute and severe symptoms of sufficient severity (including...psychiatric disturbances...)." This policy was not followed.

A facility policy, "Leaving Against Medical Advice/Refusal of Medical Treatment," reviewed/revised 8/21/19, stated, "Provider shall explain the possible consequences or complications which may result from refusing treatment...Obtain the patient's refusal for treatment, after explanation of possible consequences...Obtain patient's signature on form. If responsible party refuses to sign, said refusal will be documented in the electronic medical record...Document refusal on Emergency Department nursing notes as well as document patient's understanding of possible consequences." This policy was not followed.

Patient #9 was a 38 year old male who was seen in the ED on 6/02/20 at 9:01 PM, with presenting psychiatric symptoms. He was brought to the ED via LEA for a "wellness check." It was documented the patient signed an AMA form and departed the ED at 9:33 PM.

Patient #9's medical record includes an "ED Note -Nurse," dated 6/02/20, which stated:

- "2101: [PA name], PA-C (Outside facility at time of patient arrival)...38 YOM arrived via law enforcement who reports that he was found near a local convenience store presenting with disorientation and erratic behavior. The patient and accompanying officers were greeted by ED registration staff who initiated the registration process as well as screening procedures for potential COVID-19 signs which were noted as absent."

- "2110: Initially upon presentation the patient demonstrated general affability with staff with stated confidence that he is in either [California town] or somewhere near [Oregon town]...however the patient maintains that it is currently 2012...During the assessment process the patient presented an articulate and communicative demeanor although he continued to demonstrate an inability to identify or recognize his current environs nor circumstances...Prior to direct focused assessment, the patient expressed concern about why he is being detained. When he was reassured that he is not presently under arrest, detainment or a psychiatric hold the patient stated he would like to leave and directly stated that he does not consent to medical examination nor treatment."

- "2125: [ED RN name], RN out of the room consulting with law enforcement regarding whether or not a law enforcement hold or protective custody was being asserted as the patient requests to leave."

- "2127: [ED RN name], RN and Officer [name] back in the room conversing with the patient who is growing increasingly anxious and beginning to demonstrate agitation via more rapid speech and physical restlessness. Law Enforcement officers assured the patient that he is presently neither under arrest nor officially detained. The patient requested to go for a walk outside the ED entrance and Officer [name] agreed to accompany the patient and amicably escorted the patient through the exterior ED entrance. While the patient was being escorted during his stable ambulation, PA-C staff was apprised of the patient presentation and current statements."

- "2133: The patient ambulated cooperatively back to ED#4 with law enforcement escort whereupon he reiterated to nursing staff his desire to leave. Following counseling provided by [ED RN name], RN regarding the potential need for further care and staff eagerness to provide assistance in determining the etiology of his current disorientation the patient again stated his intent to egress the facility and requested the appropriate documentation to sign. Officer [name] offered the patient transportation to the Crisis Center if he was willing to accept it and after several minutes of discussion and reassurance, the patient agreed to being provided somewhere to stay overnight rather than 'walk around town until my dad finds me' which was his previously stated intent. Following the provision and review of the documentation pertaining to the patient's decision to discharge against medical advice, the patient signed the documents and ambulated with Officer [name] to his patrol vehicle without incident."

Patient #9's medical record did not include an AMA form. Patient #9's medical record did not include documentation by a medical provider. Patient #9's medical record did not include a medical screening examination to determine if an emergency medical condition existed.

It was unclear why 26 minutes elapsed before the ED RN notified the ED PA of Patient #9's arrival and presentation. It could not be determined if the ED PA, who was offsite at the time of Patient #9's ED arrival, entered the facility and performed a medical screening examination to determine if there was an emergency medical condition. Additionally, even though he had been triaged by an RN and registered, it was unclear why Patient #9 signed out AMA if he had not been examined by a medical provider; as well as having been counseled for leaving against medical advice by an RN without a medical provider's involvement. Without a medical provider's examination, it could not be determined if Patient #9 was stable when he left the ED.

The ED Supervising PA, who was on shift during Patient #9's ED presentation and documented as his medical provider, was interviewed on 7/22/20, beginning at 2:10 PM, and Patient #9's medical record was reviewed in his presence. He stated he "vaguely remembered" Patient #9. The ED Supervising PA stated it usually took approximately 3 minutes for him to arrive to the facility ED if he was offsite. He stated he thought he had entered an ED note, but confirmed he did not. The ED Supervising PA confirmed Patient #9's medical record did not include a medical screening examination and stated, "that's my fault for no note."

The ED Supervising PA failed to perform a medical screening examination to determine if Patient #9 had an emergency medical condition.

Based on medical record review, facility policy review, facility document review, and staff interview, it was determined the facility failed to ensure patient transfer certifications were reviewed and countersigned by a physician for 9 of 9 ED patients (#4, #8, #12, #21, #33, #34, #36, #37, and #38) who were transferred from the ED to another facility by a midlevel practitioner, and whose records were reviewed. This resulted in midlevel practitioners transferring ED patients without physician oversight. Findings include:

A facility policy, "EMTALA," reviewed/revised 8/21/19, stated, "...(3) if a provider is not physically present, a qualified medical person consults with a physician and certifies in writing that the benefits of discharge or transfer outweigh the risks. The physician must subsequently countersign the certification..." This policy was not followed. Examples include:

Nine medical records of patients who transferred to another facility for higher level of care were requested, and Patient #'s 4, 8, 12, 21, 33, 34, 36, 37, and 38 medical records were reviewed. Each of the 9 records included an "AUTHORIZATION FOR TRANSFER FORM" which were signed by an ED PA. Each of the forms included a section for a "Physician's Signature." There were no physician signatures on 9 of 9 transfer forms. It could not be determined if a physician had reviewed or audited the forms for completion to ensure the patient transfers performed by ED PAs were appropriate.

The CCO was interviewed on 7/22/20, beginning at 10:40 AM. She stated the ED Medical Director provided administrative oversight for the ED PAs to include chart and peer review.

The CCO was interviewed again on 7/22/20, beginning at 12:50 PM, and the facility's transfer form was reviewed in her presence. She confirmed the forms were not being countersigned by a physician and stated, the "transfer forms are a broken process."

The ED Medical Director, was interviewed on 7/22/20, beginning at 1:02 PM. He stated he was responsible for all ED PA oversight at the facility. The ED Medical Director stated he would review transfer cases, however, he stated he, "hasn't seen any transfer forms in a long time." He stated he was unsure why he stopped receiving transfer forms to review. The ED Medical Director stated that he did not work shifts in the facility's ED and that the ED was entirely run by PAs.

The facility failed to ensure patient transfer certifications were reviewed and countersigned by a physician.