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Based on observation, interviews, documentation reviewed in 12 of 26 ED records and documents for patients who presented to the hospital's ED (Patients 3, 4, 5, 7, 9, 16, 18, 19, 20, 21, 22 and 25), review of hospital policies and procedures, and review of other documentation it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures in the areas of physician on-call responsibilities, the maintenance of a central log, MSEs, and appropriate transfers.

Findings include:

1. Physician On-call Responsibilities:

Review of the hospital's ED policy titled, "Scope of Service", effective "4/08" reflected "All patients that present to Southern Coos Hospital's premises for a non-scheduled visit and are seeking care shall receive a medical screening exam by an Emergency Department provider that includes providing all necessary testing and on-call services...An on-call list of specialty physicians is maintained to assist with stabilizing patients."

Review of a document titled "Southern Coos Health District Corporate Compliance Program Standards of Conduct Relating to EMTALA Compliance" dated "March - 1999" reflected on page 2. "A list of physicians who are on call to provide treatment to stabilize an individual with an emergency medical condition will be maintained in the Emergency Department."

A tour of the ED was conducted on 03/31/2014 at 1510 with the DON. No on-call list of physicians was observed during the tour.

During an interview conducted on 04/01/2014 at 1530 the Director of Ancillary Services stated the hospital no longer had any on-call physicians. During the interview he/she indicated that the hospital recently identified that its EMTALA policies and procedures were outdated and needed to be updated including those related to on-call physicians.

2. Central Log: Refer to the findings identified under Tag C2405, CFR 489.20(r)(3), which reflects the hospital's failure to enforce its policies and procedures related to a central ED log.

3. Medical Screening Examination: Refer to findings identified under Tag C2406, CFR 489.24(a) and (c), which reflects the hospital's failure to enforce its policies and procedures related to MSEs.

4. Appropriate Transfer: Refer to the findings identified under Tag C2409, CFR 489.24(e)(1-2), which reflects the hospital's failure to enforce its policies and procedures related to appropriate transfers.

Based on documentation reviewed in 1 of 1 ED document for a patient (Patient 25) who presented to the hospital's ED by ambulance who was intubated and being "bagged" by ambulance personnel, review of hospital policies and procedures, and review of central log documentation, it was determined the hospital failed to enforce its policies and procedures related to maintaining a central log of ED patients. The hospital failed to ensure all individuals who presented to the ED were recorded on the log.

Findings include:

1. A policy titled "Emergency Department Log Maintenance," effective "4/08" was reviewed and reflected "A central log will be maintained on each individual who comes to the Emergency Department seeking assistance, as defined in Sec. 489.24(b), and whether he or she refused treatment, was refused treatment or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. The log will contain the following information (at a minimum):

Patient name
Date
Time of arrival
Age
Sex
Chief complaint
Time of departure
Disposition of patient:
Discharged
Admitted
Transferred
Expired
The names of those dead-on-arrival shall also be entered into the log."

2. A physician "Emergency Room Note" for Patient 25 reflected "Date of Visit: 02/24/2014." The note reflected the patient presented to the ED intubated and "On arrival here, [he/she] was still on the [ambulance gurney]...No chart was generated. The patient was not taken off the [ambulance gurney]...The patient was sent to [another hospital] in critical condition."

3. The hospital's central log was reviewed. There was no documentation reflecting the 02/24/2014 ED visit for Patient 25.

4. On 04/01/2014 at 1140 the DON confirmed that the 02/24/2014 ED visit for Patient 25 was not recorded on the hospital's central log.

Based on documentation reviewed in 1 of 1 ED document for a patient (Patient 25) who presented to the hospital's ED by ambulance and who was intubated and being "bagged" by ambulance personnel, review of hospital policies and procedures, and review of other documentation, it was determined the hospital failed to ensure a MSE was conducted for Patient 25 to determine whether or not the patient had an EMC. The findings reflected that the hospital staff had identified the failure to provide the MSE, had self-reported the failure to the State Agency on 03/24/2014, and had initiated steps to correct the failure, before this investigation was initiated on 03/31/2014.

1. The hospital's Medical Staff Rules & Regulations, "Last Revision October 10, 2012" was reviewed. Page 36 reflected "All patients who present to the hospital and who request examination and treatment for an emergency medical condition or active labor, shall be evaluated for the existence of an emergency medical condition, or where applicable, active labor by the Emergency Physician or Nurse Practitioner."

2. Review of the hospital's ED policy titled, "EMTALA Guidelines For Emergency Department Services", effective "4/08" reflected the following internal requirements: "All patients shall receive a medical screening exam...Medical Screening Exams should include at a minimum the following:

Emergency Department Log entry including disposition of the patient
Patient's triage record
Vital signs
History
Physical exam of affected systems and potentially affected systems
Exam of known chronic conditions
Necessary testing to rule out emergency medical conditions
Notification and use of oncall [sic] personnel to complete previously mentioned guidelines
Notification and use of oncall [sic] physicians to diagnose and/or stabilize the patient as necessary
Vital signs upon discharge or transfer
Complete documentation of the medical screening exam"

3. An ED document for Patient 25 was reviewed. The document was a one page "Emergency Room Note", generated by Physician A with a "Date of Visit: 02/24/2014". The "Emergency Room Note" was the only document provided by the hospital for the patient's 02/24/2014 ED visit. The "Chief Complaint:" section of the note reflected "The patient is a [adult male/female] who presents to the emergency department intubated...On arrival here, the patient is intubated with a pulse. [Ambulance personnel] states that [he/she] was found collapsed. There was no history of trauma. [He/she] was in ventricular fibrillation, which they defibrillated [him/her] and restored a pulse. [He/she] was also intubated. On arrival here, [he/she] was still on the [ambulance gurney]...I felt that the patient required far more care than we would be able to give [him/her] at Southern Coos. Primarily, we have no ventilators and no ICU. No cardiologist. My feeling was that the patient would be much better served by being transferred to [another hospital], and I felt that any type of workup here would only delay definitive treatment...I also notified the ER physician at [another hospital] regarding the patient's arrival. The patient again was loaded into the ambulance and transported up to [another hospital]. No chart was generated. The patient was not taken off the [ambulance gurney] and placed in a bed for any further exam, as again I felt that the primary place for this patient would be at [another hospital] and that any workup here or further examination would only delay definitive care. As noted, the patient is intubated. The patient was sent to [another hospital] in critical condition." The "Assessment" section of the physician note reflected "Status post cardiac arrest. The patient left in critical condition." The record reflected the note was dictated 02/24/2014 at 1126 by Physician A, and transcribed 02/24/2014 at 1345.

There was no documentation to reflect that a MSE was conducted to determine whether or not an EMC existed. There was no documentation of an ED log entry including disposition of the patient; a patient triage record; vital signs; a physical examination of affected systems and potentially affected systems; an examination of known chronic conditions; testing to rule out emergency medical conditions; vital signs upon discharge or transfer; or other documentation of a MSE in accordance with the hospital's policy.

4. An interview was conducted with Physician A on 04/02/2014 at 1125. The physician stated he/she was on duty in the ED on 02/24/2014 when Patient 25 presented to the hospital. The physician stated the first thing he/she saw was "the squad" with a patient on a gurney. He/she identified "the squad" as two EMS personnel. The physician stated the patient was intubated and being "bagged" when the squad brought the patient into the ED. The physician stated the squad informed him/her that the patient collapsed in the field. The physician stated "I checked the patient. [He/she] was ventilating. [He/she] had a strong pulse. The physician stated he/she checked the patient's ventilation by watching his/her chest rise. He/she stated that to unload and undress the patient would've just delayed treatment and stated "I had frankly nothing more to offer [him/her]." The physician stated he/she told the squad to take the patient up to another hospital (27 miles and 35 minutes driving time away according to mapquest.com). The physician stated if the identical situation occurred again the only thing he/she would do differently would be to fill out the paper work and transfer form and fax it over to the receiving hospital and stated "That was my mistake".

During the interview, the physician stated that the 02/24/2014 "Emergency Room Note" identified in finding 3. above reflected his/her MSE and history of the patient.

5. An interview was conducted with an ED RN on 04/01/2014 at 1445. The RN stated he/she was on duty in the ED when Patient 25 presented to the ED on 02/24/2014.

During the interview, the RN stated he/she was in a treatment room with another patient when Patient 25 was brought into the ED. The RN stated when he/she came out of the treatment room, he/she looked at the ED camera screen and saw a patient being wheeled out the hospital door on a gurney. He/she stated it looked like the patient was being "bagged" by EMS staff. The RN stated he/she asked Physician A where the patient was going and the physician stated "Oh, don't worry about it. I took care of it. I sent them to [another hospital]", and "EMS came in with a patient who collapsed at home. They shocked [him/her] and [he/she] barely had a pulse." The RN stated he/she told the physician, "You can't do that" and "That's EMTALA." The RN stated the physician told him/her "I'm the doctor" and stated that he/she had done a proper assessment of the patient. The RN stated he/she then called his/her manager and reported the incident.

6. An interview was conducted with a second RN on 04/01/2014 at 1400. The RN stated he/she was in the ED when Patient 25 presented to the hospital on 02/24/2014.

During the interview the RN stated that he/she observed the patient wheeled into the ED just inside the ED doors. He/she stated Physician A started getting a verbal report from EMS and visually looked over the patient, but the RN stated he/she never saw the physician touch the patient. The RN stated the physician told EMS staff "just keep going. Go up to [another hospital]." The RN stated the EMS staff turned right around and put the patient back into the ambulance and left the ED. The RN stated that he/she had no knowledge of EMTALA "laws" and never received any EMTALA training from the hospital before the 02/24/2014 incident involving Patient 25.

Based on documentation reviewed in 11 of 12 ED records of patients (Patients 3, 4, 5, 7, 9, 16, 18, 19, 20, 21 and 22), who presented to the hospital's ED with an EMC and who were transferred to other facilities for stabilizing treatment, and review of hospital policies and procedures, it was determined that the hospital failed to effect appropriate transfers of those individuals as required by the hospital's policies and procedures. The hospital failed to ensure the required physician certification that the benefits of the transfer outweighed the risks of transfer; and the hospital failed to ensure that all medical records available at the time of transfer related to the individual's EMC were sent to the receiving hospital.

Findings include:

1. Review of the hospital's policy titled "EMTALA Guidelines for Emergency Department Services", effective "4/08" reflected "If a patient is to be transferred for medical necessity the following guidelines must be followed...A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these..."

2. Review of the hospital's policy titled "Transfer of Patient to Another Facility," effective "4/08" reflected "If the provider determines through the hospital policy that a patient should be transferred to another facility for further care, EMTALA standards must be followed...Transfer papers will be completed:..Copy of medical records, lab and x-rays will accompany the patient."

3. The ED record for Patient 9 was reviewed. Documentation by the RN on the "Southern Coos Hospital Emergency Room Record" reflected the patient presented to the ED by ambulance on 10/24/2013 at 0528 with a chief complaint of chest pain.

The 10/24/2013 physician "Emergency Room Note" reflected a MSE was conducted and the "Assessment" section of the note reflected "ST elevation inferolateral myocardial infarction with bradycardia and junctional rhythm. The note reflected "The patient is sent to [another hospital] for evaluation by Cardiology..."

A form titled "EMTALA Transfer Request Form" was signed and dated by the physician on 10/24/2013, but was not timed. The following "Physician" sections of the form were unmarked and/or blank: "Diagnostic Impression", "Condition", "Stable", "Unstable", "Benefit(s) of transfer", and "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)".

Documentation on the "Nursing" section of the form reflected that "Accompanying Documentation" was sent via "Transporter" and "Faxed" to another hospital. However, it was not clear what documentation was sent as the following sections of the form were unmarked and/or blank: "Records available to receiving hospital through shared electronic record." "Treatment notes", "Lab/ECG Results", "Imaging Studies", "Transfer Form", and "Court Order".

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks; and there was no documentation to reflect that all available medical records were sent to the receiving facility at the time of the patient's transfer.

4. The ED record for Patient 7 was reviewed. Documentation by the RN on the "Southern Coos Hospital Emergency Room Record" reflected the patient presented to the ED on 12/05/2013 at 1703. The chief complaint was recorded as tremors, chest pain, and "...woozy and dizzy."

The 12/05/2013 physician "Emergency Room Note" reflected a MSE was conducted and the "Emergency Department Course" section of the note reflected the patient was transferred by ambulance to another hospital. The "Diagnoses" section of the note reflected "Severe bradycardia" and "Third-degree heart block."

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician was 12/05/2013 at 1752. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" section of the form was blank and included no specific risks.

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

5. The ED record for Patient 20 was reviewed. Documentation by the RN on the "Southern Coos Hospital Emergency Room Record" reflected the patient presented to the ED on 08/27/2013 at 1954. The chief complaint was recorded as low blood pressure, nausea, vomiting and weakness.

The 08/27/2013 physician "Emergency Room Note" reflected a MSE was conducted and the "Diagnosis" section of the note reflected "Gastrointestinal bleed." The 08/27/2013 physician "Emergency Room Note" addendum reflected the patient was transferred to another hospital.

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician was 08/27/2013 at 2300. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" was recorded as "MVA" and included no patient specific risks.

Documentation on the "Nursing" section of the form reflected "Accompanying Documentation" was sent via "Patient". However, it was not clear what documentation was sent as the following sections of the form were unmarked and/or blank: "Records available to receiving hospital through shared electronic record", "Treatment notes", "Lab/ECG Results", "Imaging Studies", "Transfer Form" and "Court Order".

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks; and there was no documentation to reflect that all available medical records were sent to the receiving facility at the time of the patient's transfer.

6. The ED record for Patient 21 was reviewed. RN documentation on the "ER Flow Sheet" dated 03/10/2014 at 2350 reflected "[Patient] brought to the ED by family for c/o ongoing dizziness, stating 'I think [he/she] is having a heart attack'."

The 03/10/2014 physician "Emergency Room Note" reflected a MSE was conducted and the "Assessment" section of the note reflected the patient had a diagnosis of 3rd degree heart block. The "Emergency Department Course" section of the note reflected "EMS was called and the patient left the department by ambulance."

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician were written over and illegible. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" was recorded as "MVA" and included no patient specific risks.

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

7. The ED record for Patient 5 was reviewed. Documentation by the RN on the "Daily Focus Assessment Report" reflected the patient presented to the ED on 02/05/2014 at 0706. The chief complaint was recorded as "Chest pain 6/10".

The 02/05/2014 physician "Emergency Room Note" reflected a MSE was conducted and the "Assessment" section of the note reflected "Acute myocardial infarction." The note reflected the patient was transferred by ambulance in serious condition.

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician was 02/05/2014 at 0720. The form reflected the patient was transferred to another hospital. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" was recorded as "MVA" and included no patient specific risks.

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

8. The ED record for Patient 16 was reviewed. Documentation by the RN on the "Southern Coos Hospital Emergency Room Record" reflected the patient presented to the ED on 03/18/2014 at 1729 by ambulance. The chief complaint was recorded as "[ground level fall] from w/c onto porch. Pt. doesn't remember falling..." The record reflected the patient complained of right leg and neck pain.

The 03/18/2014 physician "Emergency Room Note" reflected a MSE was conducted. The "Laboratory and X-Ray Data" section of the note reflected "A CT of the neck shows a fracture..." The note reflected the patient was transferred by ambulance to another hospital, which is in a city 143 miles; and 2 hours 45 minutes driving time away (mapquest.com).

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician was 03/18/2014 at 1920. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" was recorded as "MVA" and included no patient specific risks.

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

9. The ED record for Patient 18 was reviewed. Documentation by the RN on the "Southern Coos Hospital Emergency Room Record" reflected the patient presented to the ED on 01/25/2014 at 1329 by ambulance.

The 01/25/2014 physician "Emergency Room Note" reflected the patient presented to the ED with a chief complaint of right hip pain after a fall. The note reflected a MSE was conducted and reflected "X-ray examination shows a subcapital fracture of [his/her] right femur."

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician was 01/25/2014 at 1430. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" was recorded as "MVA" and included no patient specific risks.

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

10. The ED record for Patient 19 was reviewed. Documentation by the RN on the "Southern Coos Hospital Emergency Room Record" reflected the patient presented to the ED on 08/25/2013 at 2210 by ambulance. The chief complaint was recorded as nausea, vomiting and black colored emesis.

The 08/25/2013 physician "Emergency Room Note" reflected a MSE was conducted and the "Diagnosis" was "Upper gastrointestinal bleed." The "Course in the Department" section of the note reflected "...the patient...will be transported...by ground ambulance."

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician was 08/26/2013 at 0030. The form reflected the patient was transferred to another hospital. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" was recorded as "MVA" and included no patient specific risks.

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

11. The ED record for Patient 22 was reviewed. RN documentation on the "Southern Coos Hospital Emergency Room Record" reflected the patient presented to the ED on 03/10/2014 at 1617 by ambulance. The chief complaint was recorded as nausea, vomiting, weakness for three days, and a history of diabetes mellitus and chronic renal failure.

The 03/10/2014 physician "Emergency Room Note" reflected a MSE was conducted and the "Assessment" section of the note reflected the patient had a diagnosis of acute renal failure and reflected "Patient was transferred by ambulance to [another hospital] with diagnosis of acute renal failure."

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician was 03/10/2014 at 1730. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" was recorded as "MVA" and included no patient specific risks.

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

12. The ED record for Patient 3 was reviewed. RN documentation on the "Southern Coos Hospital Emergency Room Record" reflected the patient presented to the ED on 02/27/2014 at 0908 with a chief complaint of pain and nausea.

The 02/27/2014 physician "Emergency Room Note" reflected the patient presented to the ED with a chief complaint of chest pain. The note reflected a MSE was conducted, the patient signed out AMA, and reflected "One hour later, [he/she] was still out in the waiting room waiting for [his/her] ride when [he/she] had a recurrence of [his/her] chest pain and readmitted [himself/herself] to the emergency department. At this point, [he/she] again looked quite uncomfortable complaining of chest pressure and shortness of breath. The record reflected "I spoke with...the ER physician at [another hospital], who accepted the patient. The patient was then transferred by ambulance...The patient was discharged from the hospital in serious condition." The "Assessment" section of the note reflected "Acute myocardial infarction."

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician was 02/27/2014 at 1120. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" was recorded as "MVA" and included no patient specific risks.

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

13. The ED record for Patient 4 was reviewed. RN documentation on the "Southern Coos Hospital Emergency Room Record" reflected the patient presented to the ED on 02/14/2014 at 0700 by ambulance with a chief complaint of "Chest pain/upper gastric".

The 02/14/2014 physician "Emergency Room Note" reflected a MSE was conducted. The "Assessment/Plan" section of the note reflected the patient was transferred to another hospital with a diagnosis of chest pain.

A form titled "EMTALA Transfer Request Form" was signed, dated and timed by a physician. The date and time recorded by the physician was 02/14/2014 at 0730. The "Risk(s) of transfer (in addition to deterioration of patient's condition/clinically specific)" was recorded as "MVA" and included no patient specific risks.

There was no documentation to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks.

14. These findings were reviewed and verified on 04/02/2014 at 1645 with the Director of Nursing and the "Administration" RN.