The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PROVIDENCE MILWAUKIE HOSPITAL 10150 SE 32ND AVENUE MILWAUKIE, OR 97222 Nov. 21, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observation of video recordings, interviews, review of medical records documentation for 1 of 21 individuals who presented to the hospital seeking emergency services (Person 16), review of the central log, and review of policies and procedures, it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure all individuals who presented to the hospital seeking emergency services received a MSE.

Findings included:

1. Refer to findings identified under Tag A2406, CFR 489.24(a) and (c) which reflects the hospital's failure to fully develop and enforce its EMTALA policies and procedures related to the provision of MSEs for Person 16.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on observation of video recordings, interviews, review of medical records documentation for 1 of 21 individuals who presented to the hospital for emergency services (Person 16), review of the central log, and review of policies and procedures, it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure all individuals who presented to the hospital seeking emergency services received a MSE. Person 16 presented to the hospital for emergency services, did not receive a MSE and was directed by a hospital representative to go to another hospital.

Findings include:

1. Timed video footage, without audio, of the hospital's entrances, ED registration desk, and admitting/information desk for the morning of 11/03/2017 was reviewed on 11/20/2017 at approximately 1300. Video footage of the admitting/information desk located straight down the hall from the ED, timed at 10:15:33, revealed two PMH representatives behind the desk at the time the person later identified as Person 16 entered the video frame from the left of the desk. One representative was observed to be engaging with another person/patient seated at the desk. Person 16 was observed to walk down the hall towards the ED and back towards the admitting/information desk and in the spaces around the front of the desk all the while speaking on a cell phone held in his/her left hand. On the person's right hand was observed to be a white dressing or wrap. On the video footage timed at 10:17:13 Person 16 was observed to approach the desk where the second representative was seated, he/she stopped speaking on the cell phone and placed the phone in his/her left jacket pocket. At 10:17:15 Person 16 was observed to speak to the second representative while raising his/her right hand in front of him/herself, with the dressing in place, as if he/she was showing the representative his/her injured hand. After 12 seconds of interaction with the second representative, at 10:17:27, Person 16 was observed to step away from the desk and exit the video frame to the left of the desk, in the direction from which he/she entered the video frame, and in the opposite direction of the ED.

Video footage of the "West Entrance" of the hospital revealed that Person 16 entered the hospital through that entrance at 10:14:15. Entering through that entrance on the hospital's second floor requires taking the stairs or elevator to the hospital's first floor where one would encounter the admitting/information desk first. The ED is located down the hall and past the admitting/information desk.

Video footage of the ED registration desk for the same time period revealed that Person 16 did not present to the ED, either before or after speaking to the representative at the admitting/information desk.

2. During interview with the CEO, the ED NM, and the QDR on 11/20/2017 at 1015 they stated that PMH had received a report that Person 16 who was examined and treated in KSMC's ED on 11/03/2017 for a hand injury had reported having first presented to PMH for treatment where he/she was directed to go to KSMC for health insurance reasons. They further stated that they had conducted an investigation, including looking at video footage, and had not been able to identify the person who was alleged to have come to PMH.

During interview with Person 16 on 11/27/2017 at 1200 he/she reported that on 11/03/2017 he/she was working in the area around PMH and sustained an injury to his/her hand. He/she stated he/she "walked into emergency" up to the representative at the desk, told the representative that he/she had cut his/her hand, showed the representative his/her hand wrapped in "blood soaked napkins," and asked if PMH took Kaiser insurance. Person 16 stated that the PMH representative responded by saying that PMH didn't take Kaiser insurance and Person 16 would need to go to Kaiser. Person 16 stated he/she drove him/herself to KSMC after leaving PMH.

The first PMH representative observed on the video footage was identified as an "on-call" Patient Access Representative. During interview with him/her on 11/20/2017 at 1535 he/she stated he/she did not remember anyone with a hand injury on 11/03/2017 but he/she did remember a person approached the other PMH representative at the desk that day to ask if the hospital took Kaiser insurance. He/she did not recall the response provided to the person.

The second PMH representative, with whom the person in the video footage was observed to engage, was identified as a PMH Volunteer. During interview with him/her on 11/20/2017 at 1615 he/she stated he/she didn't remember anything about a person with a hand injury or a person inquiring about Kaiser insurance.

3. Review of the ED Central Log revealed that Person 16 who presented to the hospital seeking emergency services was not identified on the log as having been registered for emergency services on 11/03/2017.

4. Review of ED medical records revealed no medical record for Person 16 on 11/03/2017.

5. Review of the policies and procedures of the medical staff or "Professional Staff" dated as last revised 08/26/2017 reflected that "Medical screening examinations within the capability of the Hospital will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition."

Review of the PMH policy and procedure titled "Emergency Treatment and Active Labor Act (EMTALA) Patient Transfers Between Facilities" dated as last revised "08/2016" reflected that "Patients who present to the ED requesting medical services will receive a MSE, regardless of their ability to pay."

Review of the policy and procedure titled "Regional Access Services...Emergency Department Registration" dated as revised "Jan. 2017" reflected its objective was "To identify the procedures for Regional Access Services staff in the Emergency Department...Registrations for ED patients must follow EMTALA guidelines...If nurse not present, Access Services staff will greet patients immediately upon entering the ED and notify clinical staff...Patients presenting to the ED will be asked for identification...Access Service staff will arrive the patient into the computer system...After a patient is assessed by ED nurse triage personnel, Access Services staff will [complete registration...]."

No other related policies and procedures, including for patient access staff in other areas of the hospital or for volunteers, were provided as requested.

The hospital's policies and procedures were not followed for Person 16 who requested emergency services as an MSE was not provided and Person 16 was directed to go to another hospital. Further, whereas the medical staff policies and procedures stipulated broadly a MSE be provided for all individuals who come to the "hospital" as required by this regulation, the hospital's other related policies and procedures only addressed the provision of an MSE for those individuals who presented to the ED specifically. The policies and procedures did not include provisions for identification and management of individuals requesting examination and treatment for an emergency condition in any other location on the hospital premises, or by any representative of the hospital, to ensure compliance with these regulations.