Salem Hospital

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 40575 Based on interview, review of documentation in the medical record of 1 of 1 patient at risk for suicide who was transported by secure transport to Brookside Center, a non-hospital secure residential treatment facility (Patient 1), review of hospital policies and procedures and other documentation it was determined that the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure that within the capabilities of the staff and facilities available at the hospital, it provided for further medical examination and treatment as required to stabilize the patient’s medical condition. * Patient 1 was at risk for suicide and was transported by secure transport to Brookside Center despite the fact that the hospital had determined the patient needed inpatient hospital services and had the capability and capacity to provide those services. The documentation implied the patient was transported to Brookside Center because of their insurance coverage. Findings include: 1.a. The medical record for Patient 1 reflected they arrived at the ED on 01/05/2026 at 1322 with a chief complaint of Suicidal. * 01/05/2026 at 1325 an RN documented an ED Triage Note that reflected “Pt reports suicidal thoughts [times] 4 weeks. Here with a friend. Denies having any sort of plan. Has depression. Reports recently holding a knife to [their] wrist and [their] neck and holding a gun to [their] head to see how it felt. States [they] still [have] the gun at [their] house, it is locked up ... Pt also hearing voices for last month.” * 01/05/2026 at 1327 orders were placed by Physician A to “Initiate Suicide Precautions.” * 01/05/2026 at 1355 Physician A’s ED Provider Note reflected “[Patient] endorses SI with a plan, reporting that [they were] very close to shooting [themselves] with [their] fire arm [sic], (had it placed against [their] temple to ‘see how it felt’). [Patient 1] adds that [their] fire arm [sic] is at home with [their family member] who is not fully aware of [their] recent mental health struggle ... The patient reports that [they] began to have auditory hallucinations of a voice saying statements such as ‘you are not worth it’ and ‘the world would be better off without you’ 4 weeks ago. [Patient 1] adds that [they have] been seeing shadows as well ... Mood is depressed. Thought content includes suicidal ideation ... includes suicidal plan ... Differential diagnosis includes was [sic] not limited to depression, suicidal ideation, considered but exam not c/w substance intoxication, or psychosis ...” The note was “filed” on 01/07/2026 at 0805 and additionally included “CLINICAL IMPRESSION: 1. Suicidal thoughts ... 2. Command hallucination ... PLAN: Patient signed out to [another ED Physician’s name] pending secure transport to Kaiser Sunnyside. The patient had a Behavioral Health Consult order during this encounter. The patient will be transferred to [secure residential treatment facility] ... psychiatric consultation was obtained during this ED visit.” * 01/05/2026 at 1736 Physician A’s ED Provider Note reflected “BHC spoke to the patient’s [sic] and states they will attempt voluntary admission to PMC [Salem Hospital’s inpatient psychiatric unit].” * 01/05/2026 at 1921 Physician A’s ED Provider Note reflected “ ... Doc to Doc with [secure residential treatment facility MD]. [They] will admit the pt to [secure residential treatment facility] for further care and management. I informed the pt of the findings and plan, and they are agreeable. Unit clerk is unable to secure transportation to Kaiser Sunnyside tonight, so patient will board in [Salem Hospital’s] ED overnight ...” * BHC B’s Behavioral Health Assessment dated 01/05/2026 at 1737 reflected the following: - “Pt reported that things got ‘really bad’ on New Year’s Eve when [they] had a hallucination that [their] dog was morphing into a ‘human-like monster’ who then told [them] [they were] going to take [their child]. Pt ‘freaked out’ and grabbed a knife to protect [their child]. Pt stated the police were called and arrested [them] for domestic violence ... pt sill admitted to TW that [they want] to end [their] life ... pt said a condition of [their] release is [they] cannot see [their] children which has only ‘made it worse.” - “Pt was arrested on New Year’s Eve after grabbing a knife in an attempt to kill [their] dog, which [they] believed was trying to take [their child] away. Pt had court earlier in the day prior to this assessment and currently has a no-contact order with [their] children as the protected party.” - “C-SSRS Suicide Severity Rating (low, mod, high): Pt is considered a severe risk for suicide.” * “Assessment: The patient meets diagnostic criteria for Major depressive disorder, single episode, severe with psychotic features due to the following factors: Pt endorsed daily depression, decreased interest, low energy, poor sleep, feelings of worthlessness, and active suicidal ideation without a specific plan but with intent. Pt also endorsed auditory and visual hallucinations ...” * “Risk Factors: The patient has the following risk factors: active mental health symptoms, lack of mental health treatment, access to guns/lethal means ... social isolation.” * “Protective Factors: The patient has the following protective factors: access to treatment, willingness to engage in treatment, family/social support, lack of suicidal plans, no access to guns, and stable housing.” - “Recommendation: After consulting with [ED MD], BHC is recommending the following: o IP care with NMI: NO o Voluntary IP care not meeting criteria for NMI: YES o Not needing IP care. Discharge: NO o Continued stay in ED with re-screen follow-up as able: NO” - “Disposition: Pt is seeking voluntary IP admission. As pt has Kaiser insurance, a referral will be made to [secure residential treatment facility]. PMC also notified.” * 01/06/2026 at 0051, an RN documented “Moderate Suicide Risk Reassessment Suicidal Ideation-Behavior Suicide Risk Assessment: 1 - Ideation without a plan Keeps Self Safe: Yes Suicide Precautions/Interventions: Discontinued; Pt contracts for safety Other flowsheet entries Retrigger Reassessment Timer: Completed - Retrigger Reassessment Q12 Environment Check Q Shift Environment Check Complete?: Yes” The suicide risk reassessment reflected the patient had “Ideation without a plan ... Keeps Self Safe ... contracts for safety”. However, there was no documentation that reflected the patient’s risk for suicide was resolved. In addition, just 8 hours earlier on 01/05/2026 at 1737, BHC B documented the patient had active suicidal ideation with intent, auditory and visual hallucinations and was considered a severe risk for suicide. The record reflected the patient was transported by secure transport to a secure residential treatment facility on 01/06/2026 at 1131. * The three-page Salem Health Interfacility Form signed by Physician A and dated 01/06/2026 at 1118 reflected: - “Patient Condition Patient stabilized” - “Reason for Transfer Other (Comment) Inpatient psychiatric hospitalization” - “Transport Mode Other (Comment) secure transport” - “Patient Specific Benefits of Transfer Coordination of Care, Staff of receiving facility are capable of providing the level of care needed” - “Patient Specific Risks of Transfer Worsening condition” - “Accepting Hospital Kaiser Sunnyside” - “Unit/Bed # IP psych” - “Transporting Agency secured tranport [sic]- mountain retreat” Although the Interfacility Form reflected the accepting hospital was “Kaiser Sunnyside,” reason for transfer Inpatient psychiatric hospitalization”, and unit “IP psych”, the patient was not transferred to a hospital inpatient unit. The patient was transported to a secure residential treatment facility and not a hospital. 1.b. During review of Patient 1’s medical record with DED, DRPS, CRS and other hospital staff on 01/08/2026 beginning at 1410, the staff present confirmed the patient was transported to Brookside Center (secure residential treatment facility) and not KSMC (licensed hospital). The surveyor asked if there was documentation in the medical record reflecting that the patient requested to be transferred to Brookside Center (secure residential treatment facility) or had refused admission to Salem Hospital’s inpatient psychiatric unit, PMC. In response, DED pointed out ED Physician A’s Provider Note dated 01/05/2026 at 1921 that reflected “I had a Doc to Doc with [secure residential treatment facility MD]. [They] will admit the pt to Kaiser [secure residential treatment facility] inpatient psychiatry for further care and management. I informed the pt of the findings and plan, and they are agreeable.” Although the medical record reflected the patient was “agreeable” with the plan, it failed to reflect that the patient requested to be transferred to Brookside Center (secure residential treatment facility) or had refused admission to Salem Hospital’s inpatient psychiatric unit, PMC. 1.c. Documentation in an email from CRS dated 01/13/2026 at 1014 was reviewed and included: - “1/5 at 1407 [Physician A] reviewed suicide risk assessment and initiated a [Mental Health Evaluation]. During discussion with [Physician A], patient verbalized ability to maintain immediate personal safety and feels safe in the ED. [Physician A] subsequently placed an order to discontinue suicide precautions and start camera visualization.” - The response to “What, if any, suicide precautions remained in place in the ED until the patient was transported to Brookside Center [secure residential treatment facility] ...?” was ... The following suicide precautions were in place during the patient’s course of treatment in the ED: ... Initial suicide precautions: ... Direct 1:1 continuous visualization ... Ligature resistant ED safe room ... Search of patient belongings to remove potential hazards ... Patient changed into paper scrubs ... Patient environment check performed ... Monitoring of visitors ... Continued protections and preventions after discontinuation of suicide precautions provider order: ... Remained in ligature resistant ED safe room ... Remained in paper scrubs ... Monitoring of visitors ... Camera visualization”. - The response to “Did the patient refuse admission to Salem Hospital’s inpatient psychiatric unit?” was “No, the patient was offered voluntary admission to [Salem Hospital’s inpatient psychiatric unit] PMC or [Brookside Center, secure residential treatment facility]. The patient stated that [they] would like to go to [Brookside Center, secure residential treatment facility] ... This information is supported from a follow-up provider interview on 1/9/2026 with [Physician A], as well as with a follow-up interview on 1/12/2026 with [BHC B]. - The response to “... Describe the secured Transporting Agency: Mountain Retreat. How is it secured? (e.g., Are doors locked so patients cannot get out? Are patients escorted into the destination facility?)” was “Mountain Retreat transportation company arrives at the sending unit/department to transport patients to receiving facility. The staff, security and/or Mountain Retreat staff escort patient to vehicle - the vehicle is locked from the inside. Upon arrival at the receiving facility, Mountain Retreat staff hand off the patient directly to receiving facility staff.” The email documentation further reflected “The stabilized patient was transported to the facility via secure transport to ensure protection and prevention from the risk of suicide.” 1.d. The documentation failed to reflect that Patient 1’s EMC was clearly resolved before Salem Hospital transported the patient to Brookside Center, a secure residential treatment facility after it was determined they needed inpatient hospital care. Examples include: - The patient remained in a ligature resistant ED safe room, under camera monitoring, in paper scrubs and visitors were monitored up until the time they were transported to Brookside Center (secure residential treatment facility). - BHC B documented that the patient was not appropriate for discharge and needed inpatient psychiatric admission. Refer to Salem Hospital’s policy and procedure in finding 3.a. in this tag that reflects “Inpatient: means an individual who is admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services ...” Patient 1 was transported to Brookside Center which is a secure residential treatment facility and not a licensed hospital with inpatient hospital services. - The patient was transported to Brookside Center (secure residential treatment facility) by secure transport, meaning the patient was transported in a locked vehicle “... to ensure protection and prevention from the risk of suicide,” implying the patient’s risk for suicide was not resolved. In addition, the medical record included conflicting information. For example: - BHC B documented the patient did not have access to a gun but had a gun at home. - BHC B documented the patient had stable housing but currently had a no contact order for [their] children. 1.e. The documentation failed to reflect that Patient 1: * Refused admission to Salem Hospital’s inpatient psychiatric unit, PMC. * Requested transport to Brookside Center (secure residential treatment facility) without suggestion from hospital staff or consideration of the patient’s insurance coverage. - Refer to finding 1.c. in this tag that reflects “the patient was offered voluntary admission to [Salem Hospital’s inpatient psychiatric unit] PMC or [Brookside Center, secure residential treatment facility].” - 01/05/2026 at 1921 Physician A documented “Doc to Doc with [secure residential treatment facility MD]. [They] will admit the pt ... I informed the pt of the findings and plan, and they are agreeable.” 1.f. The documentation reflected that Patient 1 was considered a severe risk for suicide and because they had Kaiser insurance, a referral to Brookside Center (secure residential treatment facility) would be made. On 01/05/2026 at 1737 BHC B documented “Pt is considered a severe risk for suicide ... Pt is seeking voluntary IP admission. As pt has Kaiser insurance, a referral will be made to Brookside [Center] ...” 2.a. Review of the hospital’s scope of services document titled “Departments and Services” dated “As of January 2025” included “Psychiatric Medicine Center [Salem Hospital’s inpatient psychiatric unit].” 2.b. Review of the hospital’s current PMC (Salem Hospital’s inpatient psychiatric unit) scope of services document titled “Psychiatric Medicine Center (PMC) - Scope of Services” undated reflected “Salem Hospital is a not-for-profit, acute-care hospital licensed for 644 beds. The Psychiatric Medicine Center (PMC) operates 24 hours a day, 7 days a week, providing specialized inpatient psychiatric services focused on acute crisis stabilization for medically stable adults ... The program is designed to manage both voluntary and involuntary admissions within a licensed holding facility framework. Core services include: ... Acute psychiatric crisis stabilization ... Comprehensive psychiatric and medical assessment ... Expert management of complex psychopharmacology ... Therapeutic patient education and support ... High-reliability nursing care that supports organizational throughput and patient flow ...” 2.c. During interview with the DED, EDNM and other hospital staff on 01/08/2026 at 1410, they stated Salem Hospital had capability and capacity to admit Patient 1 to PMC (Salem Hospital’s inpatient psychiatric unit) when the patient was transported to Brookside Center. 2.d. During interview with DED and DRPS on 01/08/2026 at 1655, they confirmed Salem Hospital had capability and capacity to admit Patient 1 to PMC (Salem Hospital’s inpatient psychiatric unit). DRPS provided an untitled, undated PMC census sheet with handwritten notes on it indicating that PMC’s “census” was 13 patients and the unit was “staffed for up to 18 patients.” 2.e. Review of 2025 State Agency licensing records reflects Brookside Center is located at KSMC and is a non-hospital residential treatment facility that provides addiction and mental health services. 3.a. The policy and procedure titled “Emergency Medical Treatment-Screening, Stabilization, and Transfer (EMTALA)” dated “Final Approval Date 12/2025” was reviewed. It reflected: * “Patients with emergency medical conditions will be cared for without regard to their ability to pay for such services” and “Any individual who comes to the dedicated Emergency Department (ED) or L&D ... for exam or treatment of a medical condition will receive an appropriate medical screening exam (MSE) and stabilization of an Emergency Medical Condition (EMC), if present, or an appropriate transfer without regard to financial considerations.” * “If the patient has an emergency medical condition, the hospital must provide either: Further examination and treatment required to stabilize the condition within the capabilities of the staff and facilities, or an appropriate transfer of the patient to another facility.” * “Emergency Medical Condition: a medical condition manifesting itself by acute symptoms of sufficient severity, (including severe pain, psychiatric disturbances, such as homicidal/suicidal, or assaultive behaviors that indicate danger to self or others, behavioral health complaints ... such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual ... in serious jeopardy ...” * “Inpatient: means an individual who is admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services ... with the expectation that he or she will remain a least overnight and occupy a bed ...” * “Stabilization: a patient is stable when an emergency medical condition exists and care or medical intervention occurs, but there is a reasonable medical probability that no material deterioration in the patient’s condition is likely to result from discharge, or to occur during the transfer of the individual from a facility ...” * “Transfer: the movement, including the discharge, of an individual outside the hospital’s facilities at the direction of any person employed by ... the hospital ...” 3.b. The policy and procedure titled “Management of Patients With Behavioral Health Concerns in the Emergency Department” dated “Final Approval Date 12/2025” was reviewed. It reflected: * “It is the policy of Salem Health that every patient in the Emergency Department (ED) who is seen by an ED Provider receives a Medical Screening Examination (MSE), which includes a Mental Health Evaluation (MHE). The ED Provider is qualified to perform MHEs for patients with behavioral health symptoms.” * “Escalation Pathway during an MSE for Behavioral Health Consults and Psychiatric Evaluations: It is Salem Health’s intent that every patient presenting to the ED ... screen them for homicidal/suicidal, or assaultive behaviors that indicate a danger to self or others. A positive screening for patients with homicidal/suicidal, or assaultive behavior that indicates danger to self or other, will trigger an automated order to a Behavioral Health Clinician (BHC) who will complete a mental health assessment.” * “Mental Health (MH) Evaluation (MHE): a structured evaluation performed by an ED Provider, as part of the MSE. The MHE assesses a person’s emotional, psychological, and behavioral functioning, including, but not limited to, BH and neurocognitive evaluation.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 29708 40575 ************************************************. Based on interviews, review of central log and medical record documentation for 8 of 20 encounters of individuals who presented to the hospital for emergency services (Patients 1.e., 11, 13, 15, 16, 18, 19 and 20), review of incident and internal investigation documentation, review of grievance documentation, review of policies and procedures (P&Ps), and review of other documents, it was determined that the hospital failed to fully develop and enforce its Federal Emergency Medical Treatment and Labor Act (EMTALA) P&Ps to ensure it met its EMTALA obligations. The hospital failed: * To develop P&Ps that clearly describe who is qualified to perform mental health (MH) evaluations for patients with behavioral health (BH) symptoms and which BH patients receive a MH evaluation from a mental health evaluator versus a psychiatrist versus an ED physician or others. * To provide adequate Medical Screening Examinations (MSEs) to all individuals who presented for emergency services to determine whether an Emergency Medical Condition (EMC) existed, including but not limited to patients with BH symptoms at risk of harm/injury to self or others and geriatric patients. * To ensure all individuals who presented to the hospital with a potential EMC were ensured an MSE including individuals presenting elsewhere on hospital property other than the ED, including the hospital’s on-campus Urgent Care Clinic. * To not dissuade individuals from staying at the hospital to receive MSEs, and for those who left prior to an MSE to obtain or attempt to obtain written and informed refusal of MSE in accordance with hospital P&Ps. * For those individuals for whom an EMC had not been resolved or ruled out, to affect appropriate transfers to other hospitals for further examination and stabilizing treatment not within the hospital’s capabilities or capacity at the time, that included physician certification of patient specific benefits and risks of transfer. Findings include: 1. Refer to the findings cited under Tag A-2406, CFR 489.24(a) and (c) Medical Screening Exam. Those findings reflect the hospital’s failure to ensure MSEs were conducted to determine whether an EMC existed for Patients 11, 13, 16 and 18 (Tag A-2406). 2. Refer to the findings cited under Tag A-2409, CFR 489.24(e)(1) and (2) Appropriate Transfer. Those findings reflect the hospital’s failure to ensure all elements an appropriate transfer were conducted for Patients 19 and 20 (Tag A-2409). 3.a. The P&P titled “Emergency Medical Treatment-Screening, Stabilization, and Transfer (EMTALA)” dated “Final Approval 11/2024” was reviewed. It included the following information related to the provision of MSEs for BH patients: * “Medical Screening Examination (MSE) - All individuals presenting to the hospital premises requesting emergency examination or treatment or in active labor shall be offered a medical screening examination to determine if the individual has an emergency medical condition. The screening exam must be sufficient to determine if an emergency medical condition exists ... An appropriate medical screening examination is provided by a physician or qualified medical provider, (as defined in medical staff bylaws), such as nurse practitioner ... with demonstrated competence through training and skills verification.” * “Emergency Medical Condition - a medical condition manifesting itself by acute symptoms of sufficient severity, (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) ...” * “Stabilization - a patient is stable when an emergency medical condition exists and care of medical intervention occurs, but there is a reasonable medical probability that no material deterioration in the in the patient’s condition is likely to result from discharge ...” 3.b. The P&P titled “Psychiatric Consultation Program” dated “Final Approval 01/2023” was reviewed. It reflected: * “Describes the function of the psychiatric consultation service in meeting the psychosocial needs of patients seeking medical care throughout the hospital ...” * “Services provided by the psychiatric consultation team, upon physician request include: Psychiatric evaluations and guidance in treatment recommendations for patients ... outside of the Psychiatric Medicine Center (PMC) experiencing acute psychiatric or behavioral health condition(s).” * “Evaluation for psychiatric medicines where indicated.” * “Assist in crisis intervention, evaluations, and recommendations in management and care.” * “Suicide and safety evaluations.” * “Determine the clinical appropriateness for referral to acute inpatient psychiatric care and assist in the coordination of admission to PMC when indicated.” * “Provides telephone consultation for community physicians and providers.” * “Psychiatric consultation service - comprised of psychiatrist(s), advanced practice providers (i.e. NP, CNS, PA), master’s level prepared therapists (MA, MS, MSW), program therapy associates, nurses, and clinical social workers.” * “Acute psychiatric condition - a patient believed to be at imminent risk of danger to self or others and will likely require acute inpatient psychiatric admission to stabilize and manage.” * “Physician/Provider - Any physician, or his/her physician designee, or licensed practitioner (LP) responsible for the care and treatment of the patient.” * “Requesting a Consult for Monday - Friday, 0800-1630 (refer to ‘Attachment A’)” * “Requesting a Consult Weekday After Hours (1600-0800), Holidays & Weekend (refer to ‘Attachment B’)” * Attachment A - “Psychiatrist/Provider (NP, PA): Services Provided: - Psychiatric diagnostic evaluation and recommendations in care. - Evaluation, recommendation, and guidance for the appropriate use of psychiatric medicines in managing acute or non-acute psychiatric/behavioral health conditions. - Non-acute requests (behavioral management of delirium/dementia, withdrawal management, etc.) - Assist attending team in determining capacity, it is noted any licensed physician can make this determination. - Safety and suicide risk assessments per specific request of attending provider. - Manage all consults placed through SH-ED and patients being recommended for acute inpatient psychiatric care ...” * “Mental Health Evaluator (MHE) Located only in SH-ED to provide the following services; - Diagnostic mental health evaluations for patients presenting with primary psychiatric complaints. - Suicide and safety risk assessments. - Recommendations regarding the course of treatment and to assist in disposition planning once discharged from SH-ED. - Assist in coordinating referral to acute inpatient psychiatric care at SH-PMC or other local area hospitals. - Assist in management of patients with high utilization of emergency services for psychiatric complaints.” * Attachment B - “After hours (1600-0830), Weekends, & Holidays” For emergent requests: - “The MHE team is available in SH-ED from 0800-0030 7 days a week to conduct evaluations and triage requests for SH-ED. - “All other hours, Marion County PCC can be contacted and a QMHP can evaluate the patient ...” For routine requests: - “Place a ‘Consult to Psychiatry’ order within Epic’s order system.” The P&P did not describe who MHEs were. For example, psychiatrists, QMHPs, NPs, PAs, etc. 3.c. The document titled “Medical Staff Rules and Regulations” dated “Amendment approved by Board of Trustees 09/05/24” was reviewed. It reflected: * “Ariticle II”: Treatment of Patients reflected: “Patients may be treated by Credentialed Providers who have submitted proper credentials and have been duly appointed to membership and/or granted privileges.” * “Article III Part B: Consulting Physician and Consultation Requirements” reflected: * “It is the duty of the Staff, through its Sections, Departments, and Medical Executive Committee, to make certain that members of the Staff do not fail in the matter of calling consultants or responding to consultation requests as needed. A consultant must be qualified to give an opinion in the field in which his/her opinion is sought.” - “Once contacted for a consultation, the consulting physician may direct a Physician Assistant or Nurse Practitioner as his or her representative to provide further assessment and stabilizing treatment.” 4. The ED medical record for Patient 1.e.’s 06/14/2023 ED encounter was reviewed and included: * At 1510 “Patient arrived in ED.” * At 1510 “Arrival Complaint” reflected “Suicidal Gesture.” * At 1535 an RN ED note reflected “Pt BIB Dallas Police ... from pt’s home. Pt called 911 saying [they] wanted to kill [themselves]. Was threatening to cut [their] throat with a razor. Pt came out of the house without a weapon cooperatively per police. Pt was seen in ED recently for self inflicted wrist lacerations. * At 1552 “ED Provider Note” reflected “Patient with borderline personality disorder and multiple visits here to the ED and psychiatric unit for suicidal ideation. [They return] today with history that [they] held a razor blade to [their] neck and was threatening to cut [themselves] but did not. I evaluated this patient in the emergency department 2 days ago for self-inflicted volar wrist wounds that were full-thickness and required staple repair. [They were] admitted to the psychiatric Medical Center ... was diagnosed with personality disorder unspecified ... historically inpatient psychiatric hospitalization has not been recommended as it only fosters further dependency and regression, utilizing this setting as a forearm for attention seeking behaviors ...” * At 1556 “ED Provider Note” reflected “I discussed the case with [psychiatrist name] psychiatrist on-call. [MD] actually admitted and discharged this patient from the psychiatric Medical Center just 24 hours ago ... does not think admission to PMC is warranted given [their] personality disorder and attention seeking behaviors. I spoke with patient at length regarding potential medications. [They are] agreeable to a trial of Seroquel ... pt will continue [their] medications as prescribed and is forward-looking to a counseling appointment ... agreeable to a safety plan.” * At 1745 an ED RN note reflected “Pt provided a day bus pass and a 40X bus pass to get from the transit center to the Dallas Walmart. Pt states [they] can walk home from the Walmart. Pt provided step by step instructions, bus passes and a printed map.” 5. The ED medical record for Patient 13’s 02/07/2024 ED encounter was reviewed and included: * At 1227 “Patient arrived in ED.” * At 1244 an ED RN note reflected “Pt threatened [family member] verbally and attempted to strike them and to ‘shoot them’ took steering wheel and attempted to crash car.” * At 1257 “Chief Complaints Updated” reflected “Evaluation.” * At 1307 an ED MD ordered “Consult-Services - ED Consult to Care Management.” * At 1314 an MSW note reflected “Pt from Grand Ronde. Per chart, has dementia at baseline, allegedly having auditory hallucinations. Tribal police detained [them] due to concern for ... safety due to pt’s aggressive behavior ... must be evaluated in ED prior to discharge ...” * At 1522 an ED RN note reflected “Patient reviewed and given discharge instructions. Questions or concerns with discharge instructions addressed, no further questions noted. Verbalized understanding ... ambulated out of the department with a steady gait, with the police officers that brought [them] here.” * At 1541 “Patient discharged” 5.a. Refer to findings 10-18 under Tag A-2406, CFR 489.24(a) and (c) Medical Screening Exam. Those findings reflect that Patient 13 presented to the hospital with MH symptoms including hallucinations and risk for harm/injury to self and others. The patient received an exam by an ED MD to rule out an “organic cause” for their symptoms but were not provided a mental health evaluation because they were geriatric and had dementia (Tag A-2406). 6. The ED medical record for Patient 15’s 12/09/2024 ED encounter was reviewed and included: * At 2332 “Patient arrived in ED.” * At 2344 “Chief Complaints Updated” reflected “Anxiety.” * At 0035 on 12/10/2024 “ED Provider Notes” reflected “The patient ... history of OCD and depression who presents ... with concerns for worsening anxiety ... reports that [they have] had frequent panic attacks in the last week with episodes where [they feel] paralyzed ... additional concerns that [they have] schizophrenia and is experiencing psychosis. Medical decision making ... will obtain labs and consult MHE.” * At 1714 “Mental Health Assessment” reflected “SHED staff requested an evaluation for assessment and management of mental illness ... severe anxiety ... wanting psychiatric IP admission ... not currently in counseling and just started taking medications yesterday ... denied being suicidal or homicidal. A referral to IOP program was offered ... MHE will make the referral to IOP and will sign off.” * At 2052 “MHE Note” reflected “MD shared with this writer that the pt is now endorsing SI after [they] found out [they were] scheduled to be dc’d ... pt will remain in the ED until [their] crisis passes ... IP is still not recommended at this time.” * At 1011 on 12/11/2025 “ED Notes” reflected “Belongings returned to pt by security. Pt changed into [their] clothing. AVS provided, pt did not verbalize understanding of d/c instructions. [They] grabbed [their] AVS and stormed towards the lobby door. Pt stopped at the door and looked back and said [expletive]. Pt then walked out.” * At 1014 “Patient Discharged.” 7. The ED medical record for Patient 19’s 02/10/2025 ED encounter was reviewed and included: * At 0110 “Patient arrived in ED.” * At 0123 an RN ED Note reflected “Brief History: EMS Pt Overview. Approx 0000, pt took approx 15 hydroxyzine 25mg tablets, and 25 sertraline 100mg. SI attempt. Denies other drugs/alcohol. EMS contacted poison control ...” * At 0123 “Chief Complaints Updated” reflected “Overdose, Intentional Suicide Attempt.” * At 0133 an ED MD note reflected “15 y.o. [patient] with a history of anxiety and depression here after an intentional ... overdose. The patient is hyperreflexic in the bilateral lower extremities ... consistent with serotonin syndrome. I have paged the OHSU transfer center.” * At 0219 an ED MD re-evaluation reflected “Case was discussed with [OHSU Intensivist]. [They] have accepted the patient for direct admit to the PICU at Doernbecher Children’s Hospital” and at 0309 “PANDA has arrived in the ED. They will transport the patient ...” 8. During interview with Physician N on 05/06/2025 starting at 1001, the following information was received: * Every patient seen in the ED will get an MSE by a licensed provider. * Patient 1.e. was challenging with frequent ED visits for SI and self harm. Had several inpatient visits. * The patient was in the ED on 06/12/2025 with wrist lacerations that were repaired. Became an inpatient and then discharged home. * The patient came back to the ED on 06/14/2025 for SI and a thorough evaluation was done. Consulted with the psychiatrist that managed inpatient care two days prior. They recommended discharging the patient home after current crisis was over and that is what was done. * The patient has a long history of personality disorder that is not treatable with medication like schizophrenia. IP admissions are counter productive. * Mental health patients are seen face-to-face by a board certified physician and it is up to the ED physician to decide if a consult to a Psychiatrist or a mental health evaluator is necessary and if the patient needs to be seen in person or a telephone consult is sufficient. The P&Ps do not clearly describe who is qualified to perform MH evaluations for patients experiencing MH symptoms presenting to the ED. Some of the patients only see an ED physician while others are examined by an MHE. There are times when the MHE sees the patient in person in the ED and other times when the ED physician consults a psychiatrist over the phone. For example: * Patient 13 had auditory and visual hallucinations and risk for harm/injury to self and others. The patient received an exam by an ED MD to rule out an “organic cause” for their symptoms but were not provided a MH evaluation because they were geriatric and had dementia. * Patient 15 had severe anxiety and received a mental MH evaluation by an MHE. * Patient 19 had SI attempt and received a MH evaluation by an ED MD.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 29708 Based on observation, interviews, review of documentation in the medical records of 4 of 12 individuals (Patients 11, 13, 16 and 18) who presented to the hospital for emergency services, review of incident and investigation documentation, review of grievance documentation, review of policies and procedures, review of medical staff rules and regulations and manuals, and review of other documentation, it was determined the hospital failed to develop and enforce its EMTALA policies and procedures to ensure patients who presented for emergency services, including individuals presenting to areas elsewhere on hospital property other than the ED, were provided a MSE to determine if an EMC existed as follows: * Patient 18 presented to the hospital’s on campus Urgent Care Clinic without a prescheduled appointment. The patient was hunched over with shortness of breath and was not provided assistance, monitoring and/or transported to the ED to ensure a MSE would be conducted to determine whether or not an EMC existed. The patient took themselves from the Urgent Care Clinic to the ED which entailed crossing a pedestrian foot bridge over water, past a building and parking area to the ED where they were determined to have a pulmonary embolism, an EMC. * Patient 13 presented to the hospital’s ED with police officers with auditory and visual hallucinations and risk of danger to self and others and was not provided a MSE within the capabilities of the hospital which included a MH evaluation available to other patients because the patient was geriatric and had dementia; and suicide risk screening was not conducted and documented in accordance with hospital policies and procedures, to determine whether an EMC existed. The patient was discharged with POs and presented to another hospital’s ED an hour later with suicidal ideation, homicidal ideation, and hallucinations and was admitted to the other hospital’s inpatient psychiatric unit. * Patient 11 and Patient 16 both presented to the hospital’s ED with a chief complaint of SOB. Both patients left the ED without being seen. There was no physician notes and no documentation that these patients received an MSE. There was no documentation to reflect the time or circumstances of the patients departure and that attempts were made to discourage them from leaving prior to an MSE, as required by the hospital’s P&Ps. Findings include: 1.a. During interview with UCD, MSCM, MDUC and other hospital staff on 03/17/2025 at 1550, the following information was provided: * MSCM stated they were aware of an incident where Patient 18 walked into the Urgent Care Clinic with shortness of breath. MSCM stated they believed the incident was in January 2025 and occurred around 1510 or 1515. * UCD stated the incident “came in as a grievance” through patient advocacy. * MSCM stated that the hospital conducted an investigation of the incident. * MSCM stated three MOAs were working at the Urgent Care Center reception desk when the patient came in. A provider was in the Urgent Care Clinic when the patient came in but was not seeing patients that day. The patient was offered the next available appointment at 1600. The patient did not take the appointment and walked from the Urgent Care Clinic to the ED and was later admitted with a pulmonary embolism. * The UCD stated they did not know if the patient was offered ambulance transport from the Urgent Care Clinic to the ED. * MSCM stated “we recognize potential gaps where providers were not at their station and available.” MSCM stated the hospital had taken no “formal” corrective actions to address the gaps. MSCM stated the hospital had done some staff coaching and “We tweaked the lunch hour so there’s always a provider available.” MSCM stated the hospital was working on additional corrective actions but those were not completed yet. * Regarding the check in process for Urgent Care Clinic patients without a prescheduled appointment, MSCM stated MOAs ask the patient what they are there for and if that aligns with what they can do at the clinic, they will schedule an appointment for the patient “now or later that day.” If the reason the patient needs to be seen is not clear, the MOA will get an MA who will talk to the patient and get more information. The MA will give the information to a provider who may or may not go and see the patient, and the provider will make a decision about whether the patient can be seen in the clinic. If a patient comes in with a “serious condition,” for example, a laceration with lots of blood, difficulty breathing, chest pain or collapse in the lobby, the MOA will get a provider to come and see the patient. The provider will make a decision about whether they will see the patient in the clinic or if they need to go to the ED. Regarding Patient 18, MSCM stated the MOA did not get a provider to see the patient in accordance with this stated process. * If a patient needs to go to the ED, the provider will decide if the patient can go on their own or if they need an ambulance. The MSCM stated “We don’t provide transportation [to the ED] and don’t escort them over to the ED.” Regarding Patient 18, MSCM did not know if the MOA offered to arrange ambulance transport to the ED for the patient. * Regarding documentation for Patient 18’s January 2025 Urgent Care Clinic encounter, MSCM stated that if a patient did not have an appointment “we would not have a record of them coming in.” MSCN confirmed the patient had no prescheduled appointment and no appointment was made for them during the Urgent Care Clinic encounter on 01/16/2025. 1.b. During interview with UCD, MSCM, MDUC and other hospital staff on 03/19/2025 beginning at 1030, MDUC stated MOAs at the Urgent Care Clinic had no formalized training for how to manage patients arriving at the Urgent Care Clinic with a serious condition as described in finding 1.a. in this tag. MSCM stated “I don’t believe we have any training for MOAs.” 2. During tour of the Urgent Care Clinic with DCMSD on 03/17/2025 at 1445, the following observations were made: * The Urgent Care Clinic was located on the hospital campus in a separate building from the ED and on the other side of a pedestrian foot bridge. A river was observed below the pedestrian foot bridge. The foot bridge was cement with solid cement sides such that an individual crouching, sitting or laying on the foot bridge was not easily visible from either side of the foot bridge. * In order to reach the ED, located in Building A from the Urgent Care Clinic building, an individual had to walk over the pedestrian foot bridge, through or near a parking area, and past hospital Building D. 3.a. A document titled “Salem Health Hospital & Clinics Departments and Services” dated “As of January 2025” was reviewed. The document reflected that the Urgent Care Clinic was a department of the hospital. 3.b. During interview on 03/17/2025 at 1700 MRPS confirmed the Urgent Care Clinic was part of the licensed hospital. 4. Grievance documentation regarding Patient 18 included: * “Patient Initiated Concern ... Brief Factual Description ... Main concerns: 1. Patient with severe SOB and difficulty walking on 1/16/25 told by Urgent Care staff at 3 pm [they] would need to wait until 4 pm before they could assist [them] with wheelchair to ED. 2. Patient started walking to ED and pushed button on Emergency Call post near Building D and no help arrived after waiting 2 minutes. 3. Patient had great difficulty walking to ED and was diagnosed with pulmonary embolism in ED 1/16/25.” * “FOLLOW-UP NOTES ... After reviewing the CCTV footage, it is evident that the patient walked from urgent care to the emergency room. I can observe [them] pressing the call box alarm and then sitting down ... the alarm was pressed at 15:16:32, and [they] walked towards the emergency room at 15:17:32 ... Security followed all procedures and made efforts to assist ...” * “FOLLOW-UP NOTES ... Patient was not scheduled to be seen in Urgent Care, if [they were] a walk in at 3 pm that is the lunch hour for urgent care. Our next available time slot is 4 pm. If the patient is not in distress and the patient does not want to wait, we offer them a list of other urgent care clinics or the ED. If the patient appears to be in distress, we immediately contact a provider and call 911 per the Code Blue policy. It is out of scope of practice for staff to physically transfer patients from the urgent care to the ED.” 5. Incident documentation regarding Patient 18 included the following: * “Specific Event Type: Delay/Lack of Response to Patient Condition” * “Type of Person Affected: Outpatient/ED” * “Injury or Harm Incurred? Yes” * “Severity Level (Reported) E. Harm - Temporary” * “Location of injury on body/system Respiratory” * “What was the injury? SOB, rib pain - ED admit PE w/infarction” * “Equipment involved/Malfunctioned? No” * “Brief Factual Description ... Main concerns: 1. Patient with severe SOB and difficulty walking on 1/16/25 told by Urgent Care staff at 3 pm [they] would need to wait until 4 pm before they could assist [them] with wheelchair to ED. 2. Patient started walking to ED and pushed button on Emergency Call post near Building D and no help arrived after waiting 2 minutes. 3. Patient had great difficulty walking to ED and was diagnosed with pulmonary embolism in ED 1/16/25.” * “FOLLOW-UP NOTES ... While I am unable to comment on what occurred in Urgent Care, I can provide details from the CCTV footage reviewed. [Patient 18] was seen leaving Urgent Care at 3:12 pm and struggling to walk. [They] reached the area in front of Building D, knelt down, and pressed the Call Box at 3:15 pm. Our dispatch office responded and assured [them] that an officer would be sent to assist. At 3:16:32, [Patient 18 was] seen walking around to the side of Building D and kneeling down. At 3:17:30, Officer [name] arrived and was seen on CCTV looking for a patient in distress outside the main entrance to Building D. Unaware that the patient had moved to the side of Delta, Officer [name] asked a bystander if they needed help or had seen anyone in distress. At 3:17:42, the patient was seen standing and walking toward the emergency room. Officer [name] cleared the call at 3:19 pm after not locating the patient. A dispatcher later informed [that] patient walked through the emergency lobby and was provided with a wheelchair by the screener ...” 6.a. During an interview with Security Staff D on 03/19/2025 at 1225, they provided the following information regarding Patient 18: * Security Staff D stated they had watched recorded video (CCTV) of the incident involving Patient 18 and remembered what they saw on the video. Security Staff D stated “I watched the video many times.” * Security Staff D stated the video was no longer available. * Security Staff D stated they would provide the survey team a written summary of what they saw on the video. 6.b. On 03/19/2025 at the time of the interview in finding 6.a. in this tag, Security Staff D wrote and provided the survey team a summary regarding the incident involving Patient 18. It reflected “After Reviewing CCTV: Upon reaching urgent care parking lot the patient is seen entering through the lower level door. [They] opened the door and walked through the Evolv machine. I could see the patient was walking hunched over holding [their] left side and stomach area. The contracted [screener] appeared to offer a wheelchair. Patient appeared to decline this offer and walked up the two flights of stairs into the urgent care lobby. There was no wait and [they] immediately walked to the third window from right. A [gender] Salem Health registrar is seen assisting [the patient]. After about one minute, I can see the patient still in front of the window appear to squat down holding [their] side. [Patient] stays in this position for 20-30 seconds. [They] then [stand] up and is seen walking (no longer holding [their] side) and walks down the two flights of stairs. [Patient] exited back through the Evolv and has no interaction with the screener. [Patient] is seen turning to the right and walking to the pedestrian foot bridge that separates Urgent Care and Building D. Half way over the bridge, [patient] is seen squatting down and holding [their] side. [Patient] stays in this position for about 20 seconds. [Patient] then stands up and proceeds to walk to Building D. [Patient] then squats down again. A Salem Health Dispatcher is seen walking past [the patient]. [Patient] remains hunched over for 15-20 seconds. [Patient] stands up and makes it to the call box in front of Building D.” The summary was signed by Security Staff D. 7. Regarding Patient 18, there was no Urgent Care Clinic documentation of the patient’s Urgent Care Clinic encounter including but not limited to: * The date and time the patient arrived at the Urgent Care Clinic and their condition at that time. * MOA or MA communication or interactions with the patient. * An evaluation of the patient by a physician or any other LIP. * Whether the patient was offered or provided assistance to the ED. * Whether the patient was informed of the risks of not going to the ED. * The date and time the patient left the Urgent Care Clinic and their condition at that time. * Communication with the ED of the patient’s potential arrival there. 8. The ED medical record for Patient 18 was reviewed with MRPS, DCMSD, ED NM and other hospital staff on 03/18/2025 at 1520. The record reflected the patient presented to the ED on 01/16/2025 at 1521 with a chief complaint of rib pain. The “Means of Arrival:” reflected “Self.” The patient was provided an MSE by an ED provider, diagnosed with a pulmonary embolism and pneumonia, and admitted to an inpatient medical telemetry unit on 01/16/2025 at 2150. Although the record reflected the patient received a MSE, there was no documentation that reflected Patient 18 had initially presented to the Urgent Care Clinic or that they were provided assistance, monitoring or transport to the ED to ensure a MSE would be conducted. 9.a. The P&P titled “Emergency Medical Treatment-Screening, Stabilization, and Transfer (EMTALA)” dated “Final Approval 11/2024” was reviewed. It reflected: * “It is the policy of Salem Health to comply with the federal regulatory requirements of the Emergency Medical Transfer and Active Labor Act ... Patients with emergency medical conditions will be cared for without regard to their ability to pay for such services ... A. Any individual who comes to the dedicated Emergency Department, (ED, L&D), for exam or treatment of a medical condition will receive an appropriate medical screening exam (MSE) and stabilization of an Emergency Medical Condition (EMC), if present, or an appropriate transfer without regard to financial considerations. B. EMTALA applies to all hospitals providing emergency services participating in Medicare; to all patients, and to physicians affiliated with the facility ...” * “Individuals who present elsewhere on hospital property and request examination or treatment for an EMC should be screened and stabilized to the best of the staff’s ability and transferred to the ED or L&D, whichever location is most appropriate for the patient ...” * “If an individual, who has been registered as an outpatient and has begun to receive a scheduled course of outpatient care, develops an EMC while receiving treatment, or presents anywhere on the Hospital Property for examination or treatment of an EMC, EMTALA does not apply.” * “Medical Screening Examination (MSE) - All individuals presenting to the hospital premises requesting emergency examination or treatment or in active labor shall be offered a medical screening examination to determine if the individual has an emergency medical condition. The medical screening examination shall be offered regardless of the individual’s ability to pay and shall not be denied or delayed pending inquiry as to the individual’s method of payment or insurance status. The screening exam must be sufficient to determine if an emergency medical condition exists, including whether a woman is in active labor. A triage exam is not inclusive enough to meet criteria for an appropriate medical screening exam. An appropriate medical screening examination is provided by a physician or qualified medical provider, (as defined in medical staff bylaws), such as nurse practitioner, certified nurse midwife (CNM), physician’s assistant or L&D RN with demonstrated competence through training and skills verification. The medical screen is performed to determine whether the individual has an emergency medical condition.” * “If the patient has an emergency medical condition, the hospital must provide either: 1. Further examination and treatment required to stabilize the condition within the capabilities of the staff and facilities, or 2. An appropriate transfer of the patient to another facility.” * “Definitions” - “Emergency Medical Condition: a medical condition manifesting itself by acute symptoms of sufficient severity, (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse), such that the absence of immediate medical attention could reasonably be expected to result in ... Placing the health of the individual, (or, with respect to a pregnant woman, the health of the woman or her unborn child), in serious jeopardy ... Serious impairment to bodily functions ... Serious dysfunction of any bodily organ or part ...” - “Medical Screening Exam (MSE): the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an individual has an emergency medical condition or not; the MSE is not an isolated event--it is an on-going process that begins, but typically does not end, with triage.” - “Stabilization: a patient is stable when an emergency medical condition exists and care or medical intervention occurs, but there is a reasonable medical probability that no material deterioration in the patient’s condition is likely to result from discharge, or to occur during the transfer of the individual from a facility ...” Although this P&P included that “Individuals who present elsewhere on hospital property and request examination or treatment for an EMC should be screened and stabilized to the best of the staff’s ability and transferred to the ED,” it failed to include how that should occur. For example, whether patients were expected to transport themselves, family/significant others were expected to transport patients, staff were expected to escort patients, or staff were otherwise expected to arrange appropriate transport. 9.b. The P&P titled “Medical Screening Exam in the Emergency Department” dated “Final Approval 01/2021” was reviewed. It reflected * “The purpose of this policy is to define the Medical Screening process for patients presenting to the Emergency Department. It is the policy of Salem Hospital to ensure that patients are treated in a timely manner, based upon the acuity of their illness or injury, and ensure that patients are treated for their illness by the most appropriate provider.” - “1. All patients who present to the ED for services will be triaged ... prior to the completion of patient registration.” - “a. Triaging of a patient always precedes inquiry into source of payment.” - “b. Patients requiring immediate medical attention or treatment will receive this either in triage or by placement in a room in the department, prior to registration.” - “c. At no time will necessary medical treatment be delayed for patient registration.” - “2. If, at any time, the patient decides, for any reason, to leave and discontinue treatment in the ED, inform him/her of the risks and if they have not yet seen an MD they shall be designated as left without being seen. If they have already had a medical screening by an MD ask him/her to sign an AMA form; document this information in the medical record. Refer to Non-Compliant/Disruptive Patients, Patients Refusing Care, Leaving Without Treatment or Leaving Against Medical Advice Administrative House Wide Policy and Procedure.” - “3. The patient has the right to be seen in the ED at his/her request, regardless of the results of the medical screening exam and the alternative care options provided.” * “Definitions ... Medical Screening Exam (MSE) - the portion of the Emergency Department visit that either determines or excludes an “Emergency Medical Condition”- all MSEs in the Emergency Department are performed by a physician.” 9.c. The P&P titled “Non-Compliant/Disruptive Patients, Patients Refusing Care, Leaving Without Treatment or Leaving Against Medical Advice” dated “Final Approval 11/29/2023” was reviewed. It reflected: * “Patients Leaving Without Treatment - 1. Attempt to locate patient and document attempts to locate in patient’s record. 2. Notify the physician of the patient’s unplanned departure. 3. Nursing staff and/or the physician should make an attempt to document in the medical record the patient’s departure and inability to provide information to discourage the patient and/or family from leaving and inform them of the risks and possible complications that may occur with leaving due to their unplanned departure without treatment.” 9.d. The P&P titled “Code Blue/Medical Emergency Plan-EOP (Off Campus Salem Health Medical Clinics and Locations)” dated “Final Approval 11/2024” was reviewed and reflected “... New policy for Off-campus Salem Health Medical Clinics (SHMG) and locations not interconnected to the emergency department via sky bridges ...” * “Policy Content ... To provide guidelines, both general and specific, in response to Adult or Pediatric Code Blue situations defined as: an unresponsive person that is unconscious, and/or has an absence of breathing and/or absence of detectable pulse. It is the policy of Salem Health that outpatient facilities operated by Salem Health, will activate 9-1-1 services and provide basic life support (BLS) until Emergency Medical System (EMS) Responders arrive and hand-off is complete ...” * “I. Initial Actions A. First Responder - 1st staff member on the scene 1. First responder remains with patient until hand-off to EMS Responders is complete 2. Uses PPE as indicated 3. Immediately begin BLS care ... a. call out ‘CODE BLUE’, and the location help is required ...” *II. Documentation Requirements A. If the patient is checked-in for appointment: a. Document event in patient’s medical record. b. Clinic leadership will report the event to directors. c. Provide written EMS handoff, if applicable B. If person is not checked in as a patient, visitor, employee or community member, no documentation is required for these situations, other than EMS hand-off form ...” 9.e. The hospital’s medical staff “Organization and Functions Manual Salem Health” dated “Approved by Board of Trustees 10/7/04 for implementation beginning January 1, 2005” was reviewed and included under 1.2.2.: “The Medical Staff Officers, Department Chairs, Hospital, Committee Chairs and Medical Staff Committee Chairs, are responsible to work collaboratively to promote adherence to regulatory/accreditation compliance and appropriate standards of medical care.” 9.f. The “Salem Hospital Medical Staff Rules and Regulations” dated last approved 09/05/2024 was reviewed and included: * “Emergency” means a condition which could result in serious or permanent harm to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that harm or danger ...” * “ARTICLE IX - PART D: EMERGENCY MEDICAL SERVICES (1) Emergency services and care shall be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care. Such emergency services and care shall be provided without regard to the patient’s race, ethnicity, religion, national origin, citizenship, age, gender, gender identity, sexual orientation, pre-existing medical condition, physical or mental handicap, insurance status, economic status or ability to pay for medical services ... (2) 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 emergent medical condition. Qualified medical personnel who can perform Medical Screening Examinations within applicable Hospital policies and procedures are defined as: (a) Emergency Section: (1) Physician members of the Medical Staff with clinical privileges in Emergency Medicine. (2) Advanced Practice Clinicians with clinical privileges in Emergency Medicine.(3) Registered Nurses who have completed Sexual Assault Nurse Examiner (SANE) certification and maintain competency may perform medical screening examinations on adolescent and adult alleged sexual assault victims in accordance with Emergency Department policies and procedures.” 9.g. Documentation in an email from DCMSD dated 05/12/2025 at 1143, reflected: The response to “Regarding medical staff rules and regulations, Article IX - Part D: Emergency Medical Services states ‘Medical Screening Examinations ... will be performed on all individuals who come to the hospital ... Qualified medical personnel who can perform Medical Screening Examination within applicable Hospital policies and procedures are defined ...’ Please provide the “applicable Hospital policies and procedures” regarding patients (including but not limited to geriatric patients) presenting to the ED at risk for harm to self or others (psychiatric patients)” was “We do not have any additional polices to submit ...” 9.h. The P&Ps and medical staff rules and regulations and manual in findings 9.a., 9.b., 9.c., 9.d., 9.e. and 9.f. in this tag failed to include a process that described how all individuals that presented to the Urgent Care Clinic or elsewhere on hospital property other than the ED with a potential EMC should be managed and ensured a MSE, including how they would be transported to the ED and whether they would be expected to walk there, unassisted and without monitoring. These failures resulted in an IJ situation. Refer to Tag 000 Initial Comments for the details regarding this IJ situation, the hospital’s IJ Removal Plan submissions, and the IJ Removal Plan Verification Visit. ********** 10. The ED medical record for Patient 13 was reviewed with MRPS, DCMSD, ED NM, RN O and other hospital staff on 03/18/2025 at 1555. The medical record reflected the patient presented to the ED on 02/07/2024 at 1227 by “Police Car” with a chief complaint of “Evaluation” and included: * A “Report of Peace Officer Custody of an Allegedly Mentally Ill Person” that reflected: - “TO THE TREATING PHYSICIAN OF AN APPROVED HOSPITAL OR NONHOSPITAL FACILITY:” - “Re: [Patient 13] DOB [date] a person alleged to be mentally ill.” - “I, [TPO L], a peace officer of Grand Ronde Tribal P.D., Oregon, Badge No. [number] took the above-named person ... into custody at 1132 a.m. on the 7th day of February, 2024 in Polk County, Oregon for the following specific reasons: Dementia - walked off into woods, auditory and visual hallucinations - has no caretaker or live in family - Grabs steering wheel to at [sic] to crash - believes others intend to shoot [them]. Vietnam Vet - found last 3x contacts outside alone believing someone who does not exist told [them] to stay there. Serious concern that [they] will wander off [and] die of exposure ... Onset has been rapid ...” * “[They] may ask to use bathroom - if [they do, they are] likely to run off. Needs escort.” - “Pursuant to ORS 426.288(1) because the above factors establish probable cause to believe the above named person is a mentally ill person who is dangerous to self or other [sic] and in need of immediate care, custody or treatment for mental illness.” - The report included a signature line with an illegible signature and TPO L’s badge number next to the signature. * An RN note dated 02/07/2024 at 1234 reflected “Pt attempted to assault [family member], then attempted to crash personal vehicle. Pt requested to ‘use bathroom’ when allowed to do so, the [patient] wandered off to the forest, had to be searched for, nearly had to involve search and rescue Pt reports hearing commands to go to certain locations alone and wait Rapid onset dementia Needs referral to VA for hold and treatment Visual and auditory hallucinations Has no caretaker or live in family Vietnam vet +PTSD Concern they will walk out and die of exposure, no regard for own safety Will use excuse to use bathroom to take off High elopement risk” * An RN note dated 02/07/2024 at 1244 reflected “Pt threatened [family member] verbally and attempted to strike them and to ‘shoot them’ took [sic] steering wheel and attempted to crash car.” * An RN noted dated 02/07/2024 at 1257 reflected: “Pt asked to go to the bathroom Urinal provided Pt on camera visualization Tribal officers here with pt, [informed] this nurse they will be with pt until able to speak with ED provider about referral to VA CM [CM J’s name] asked for assistance Officer finding out who chief spoke to to try to arrange pt admission to VA.” * An “ED Provider Note” with “Date of Service:” 02/07/2024 at 1300 and electronically signed by ED Physician K on 02/09/2024 at 0249 reflected “History of Present Illness: The patient is a 74 y.o. [sex] with a [history] of cognitive impairment, dementia, and alcohol use [brought in by] police to the Salem Health Emergency Department with altered mental status. Per nurse, the patient has sudden-onset dementia. [Patient] lives with [family]. [Patient] was driving with [family member] earlier today and [patient] threatened to assault [family member] and struck at [family member]. [Patient] told [family member they] had to go pee so [patient] stopped the car and ran out. This is the third time [patient] has done this. However, this time it was harder to find [patient] and they almost had to get search and rescue involved. However, they found [patient]. They are concerned that [patient] has no worry about [their] self-preservation. The patient is a Vietnam veteran and has PTSD. [Patient] has auditory and visual hallucinations and [their] voices are telling [them] to go out to the forest and wait. [Patient] does not have a caregiver. The Tribal police chief spoke with the VA and they would like the patient to be transferred there. The patient states [they are] here to see a judge. [Patient] denies being in any pain. [Patient] confirms [they were] driving with [family member] today. [Patient] says the guy next door is a ‘clown and junkie’ ... states [guy next door’s parent] stabbed [patient] ... [Patient] was also trying to get rid of [family member] ... [Patient] reports taking some medications today ...” - “CHRONIC MEDICAL CONDITIONS SIGNIFICANTLY AFFECTING CARE: Cognitive impairment and dementia.” - “Physical Exam Vitals and nursing note reviewed. Constitutional: General: [Patient] is not in acute distress. Appearance: Normal appearance. [Patient] is not ill-appearing or toxic-appearing. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Mouth/Throat: Mouth: Mucous membranes are moist. Mucous membranes are not dry. Pharynx: Oropharynx is clear. No oropharyngeal exudate. Eyes: General: No scleral icterus. Extraocular Movements: Extraocular movements intact. Pupils: Pupils are equal, round, and reactive to light. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulses: Normal pulses. Heart sounds: Normal heart sounds. Comments: Heart sounds regular. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Abdominal: General: There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. There is no guarding or rebound. Musculoskeletal: General: No swelling or tenderness. Normal range of motion. Cervical back: Normal range of motion and neck supple. Skin: General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds. Findings: No rash. Neurological: General: No focal deficit present. Mental Status: [Patient] is alert. Mental status is at baseline. Comments: A&O x2 Psychiatric: Mood and Affect: Mood normal.” - “MEDICAL DECISION MAKING/ED COURSE” reflected “DIFFERENTIAL DIAGNOSIS: The patient is a 74 y.o. [sex] evaluated for altered mental status. [Differential diagnosis] includes, but is not limited to: [their] dementia at baseline. Will see if I can find an organic cause to [their] agitation today. Will order a UA, CBC, CMP, TSH, and UDS and give [them] a dose of risperidone.” - “TEST INTERPRETATION: CBC: No indication of leukocytosis. No indication of anemia. Normal platelet count. CMP: Normal renal function. Hypernatremia at 146. Hyperchloremia at 108. Elevated AST at 46. TSH: 0.66 UDS: Unconfirmed positive for cannabinoids. Alcohol: Negative UA: Ketones: 1+” - “CONSIDERATION OF TESTING OR TREATMENT: None” - “MANAGEMENT OF THE PATIENT’S CARE WAS DISCUSSED WITH: Care Management Team Member: [CM J]” - “RE-EVALUATION & FINAL ASSESSMENT: 2:19 PM: Patient has been calm the whole time [they have] been here. I have not been able to identify an organic cause of the patient’s increased agitation today. I suspect this is [their] baseline dementia. Will discharge [them] home. Will see if police will coordinate [their] transportation. CM member [CM J] evaluated the patient and we [coordinated their] safe plan for discharge. Findings were discussed with the patient and they verbalized understanding. Upon reassessment, the patient feels improved. They have no other complaints or concerns at this time. Patient is comfortable with this plan to go home. They have been provided prescriptions for Risperidone 0.5 BID. Patient has also been advised to follow up with their PCP for further evaluation. Home care instructions and return precautions were discussed prior to discharge.” - “CONSIDERED ESCALATION TO ADMISSION/OBSERVATION: Discharge: After ED evaluation, workup and/or treatment, patient is appropriate for outpatient management with return instructions provided.” - “CLINICAL IMPRESSION:” reflected “Dementia.” - “PLAN:The patient will be discharged.” - “DISCHARGE INSTRUCTIONS: I discussed my findings with the patient or representative and all questions were answered. The patient or representative was instructed to follow-up [with] their primary care physician or referred physician per EPIC Discharge Instructions. The patient or representative was instructed to return to the Emergency Department if symptoms worsen or if new symptoms develop. Additional discharge instructions were provided to the patient or representative by the nurse.” * A “Care Management Progress Note” dated 02/07/2024 at 1314 written by CM J reflected “Objective: Care coordination, Discharge planning Assessment: Pt from Grand Ronde. Per chart, has dementia at baseline, allegedly having auditory hallucinations. Tribal police detained [patient] due to concern for [patient’s] and family’s safety due to Pt’s aggressive behavior. RN requested help determining if Pt can go to Portland VA from ED in custody of police. S/w Grand Ronde Tribal detective [name] who was told by Police Chief [name] that Pt was accepted at VA, but needs ‘doctor approval.’ Therefore they stopped at Salem ED. Intervention: [Telephone call] to VA access line, [spoke with] staff who verified Pt is enrolled in the VA and has full VA benefits. They have no notes that indicate Pt was approved for transfer. Pt can show up at VA ED for workup, but no guarantee of admission. Alternately, if Pt requiring admission at [Salem Hospital], we can request transfer. Engaged in discussion of EMTALA rules with [ED Physician K], RN [name], and police officers. Determined Pt must be evaluated in ED prior to discharge, but police may choose to take [patient] to VA in Portland afterwards if Pt is medically cleared for [discharge] and they feel [patient] is still a danger. Plan: Pending workup. MSW to remain involved for potential geropsych assessment.” * An RN note dated 02/07/2024 at 1522 reflected “Patient reviewed and given discharge instructions. Questions or concerns with discharge instructions addressed, no further questions noted. Verbalized understanding of instructions. Patient remains alert and oriented. Respirations even unlabored. No acute distress noted. All patient belongings given to patient upon discharge. Pt ambulated out of the department with a steady gait, with the police officers that brought [them] here.” * The record reflected the patient discharged on 02/07/2024 at 1541. 11. The ED medical records in findings 10 and 20 and interviews in findings 13, 15, 16 and 17 in this tag reflected the patient experienced psychiatric symptoms including hallucinations, and danger to self and others prior to ED presentation, throughout their ED encounter, and after discharge. 12. The documentation in the ED medical record in finding 10 in this tag was unclear, inconsistent and failed to reflect a MSE that included a MH evaluation and suicide risk screening was conducted within the hospital’s capability and P&Ps similarly conducted for other patients. Examples included: * The “Report of Peace Officer Custody of an Allegedly Mentally Ill Person” reflected the patient “walked into the woods and was having auditory and visual hallucinations,” was “a mentally ill person ... dangerous to self or others ... in need of immediate care, custody or treatment for mental illness,” and was taken into custody on 02/07/2024 at 1132, less than one hour before the patient presented to the ED. * An RN note reflected “Pt attempted to assault [family member], then attempted to crash personal vehicle ... Concern they will walk out and die of exposure, no regard for own safety.” * An ED provider note reflected the patient was experiencing auditory and visual hallucinations during or just prior to arriving at the ED and the physician would see if they could find an organic cause of the patient’s agitation. However, no organic cause was found as the notes reflected “I have not been able to identify an organic cause of the patient’s increased agitation today.” Although the record reflected no organic cause was found, there was no documentation of further evaluation of the patient’s symptoms that included a mental health evaluation within the capability of the hospital as reflected in the P&P titled “Psychiatric Consultation Program” in finding 18.a. in this tag. * An ED provider note reflected the patient’s mental status was alert, at baseline, psychiatric mood normal, and “suspect this was the patient’s baseline dementia.” However, those same notes also reflected the patient was experiencing sudden onset dementia, auditory and visual hallucinations, voices telling them to go out to the forest, striking out at family, and other indications of harm to self and others. Although the ED provider notes reflected no organic cause was found for the patient’s MH symptoms, there was no documentation that explained the reason no MH evaluation was conducted by a psychiatrist, MHE, or QMHP conducted for other patients with MH symptoms. * ED provider notes reflected the patient was calm the whole time they were in the ED. However, refer to findings 16 and 17 in this tag that reflects TPO L and TPO M remained with the patient the entire time they were in the ED and the patient was experiencing hallucinations, was “only lucid for very short periods of time,” and “would go off on tangents.” * ED provider notes reflected the patient was not agitated in the ED. However, they also documented the patient was administered Risperidone to keep them calm while in the ED. * Care management notes reflected “concern for [patient’s] and family’s safety due to Pt’s aggressive behavior ... Pt must be evaluated in ED prior to discharge, but police may choose to take [patient] to VA in Portland afterwards if Pt is medically cleared for [discharge] and they feel [patient] is still a danger ... potential geropsych assessment.” There was no further documentation about a potential geropsych evaluation for the patient including why that was or was not indicated. The documentation was also unclear regarding what was meant by “police may choose to take [patient] to VA in Portland if ... they feel [patient] is still a danger” as this inferred the patient may still be a danger to self or others. * There was no documentation regarding a psychiatric evaluation or collaboration with a MHE as described during interview with CM J in finding 14 in this tag. * There was no documentation that reflected a suicide risk screening was conducted and documented in accordance with the hospital P&Ps as reflected in findings 18.b. and 19 in this tag. 13. During an interview regarding Patient 13 on 03/18/2025 at 1550 with the ED NM and RN O, the following information was provided: * They confirmed the patient did not receive a psychiatric evaluation. * The ED NM stated the patient did not have a psychiatric evaluation “Because our geriatric patients are typically seen by case management.” * Regarding the patient’s auditory and visual hallucinations and other presenting symptoms, RN O stated “Those aren’t psych issues. Those are issues that go along with dementia.” 14. During interview regarding Patient 13 with CM J on 05/06/2025 at 1430, the following information was provided: * CM J stated they remembered the patient. * CM J stated they were a case manager and not a MHE. * The patient arrived at the ED in the custody of Grand Ronde POs. Case management was asked to get involved because the patient had dementia. * The POs asked ED staff about taking the patient to the VA and “the ER folks didn’t know what to do.” CM J stated they let the POs know that “we had to evaluate the patient and we cannot transfer them [to the VA] unless it is something we cannot do in our ER.” * CM J stated “I left it up to the ED provider to do the evaluation and any mental health evaluation the patient might need. I did lay eyes on [the patient]. [The patient] was in a room chatting with people.” * CM J stated that when they saw the patient, the patient had signs and symptoms of dementia and no aggressive behaviors. CM J stated they reported this to the ED physician and was not asked to return to the patient’s room after that. * CM J stated the POs indicated that prior to ED arrival, the patient had been agitated, was aggressive toward others, and exit seeking from their home and vehicle. * Regarding whether the patient was suicidal or homicidal, CM J stated “[Patient 13] didn’t say that to me ... The concerns were more about inadvertent self-harm.” CM J stated they were not with the patient very long, “Maybe 5 minutes.” * CM J stated they did not know if the patient was experiencing hallucinations or delusions while in the ED. * CM J stated the POs wanted to know if they could take the patient to the VA after the patient was discharged because they were worried about the patient. * CM J stated the POs thought they should stop at Salem Hospital ED before going to the VA and that is how they ended up in the Salem Hospital ED. * CM J stated they did not know what the patient’s condition was upon discharge from the ED. * CM J stated the patient was discharged with POs and they were not sure where the POs took the patient after discharge. * Regarding patients with psychiatric symptoms including risk for harm to self or others, CM J stated “They do a workup for medical causes that might cause a mental health concern ... Once the patient is medically cleared, the [ED] doctor determines if they need additional input from a Case Manager or [MHE] ... The ER physician does the initial evaluation for mental health and then they decide if the patient needs additional help from a [MHE] ... [MHEs] are licensed professional counselors. Some are social workers and some are QMHPs.” * CM J stated it was a judgement call regarding which patients get a MHE and which patients get case management. The MHEs don’t evaluate patients with dementia. As soon as they are determined to have dementia, they go to case management. CM J stated “The split is if they have dementia. The ER physician determines if the patient needs further psychiatry involvement.” * CM J stated that “If someone is very with it and in their 70s and still getting around, but seems like they have depression, they could be seen by a MHE ... if there is any suspected or diagnosed dementia and they are very debilitated and not a good fit for inpatient, we discuss this gray area and collaborate with the ER doctor, MHE and Case Manager.” * CM J stated they did not know if the hospital had any P&Ps that described who conducted psychiatric evaluations of ED patients. 15. During an interview regarding Patient 13 with ED Physician K on 05/06/2025 at 1530, ED Physician K provided the following information: * ED Physician K stated they remembered the patient. * The patient was brought in by POs, was elderly, and had cognitive impairment. The POs were concerned because the patient was acting out more, threatening family members, and ran out of a car. The SOs came to the ED for an evaluation of these concerns. The patient arrived not oriented to time or place and was confused. * ED Physician K stated they tried to decide if there was an organic issue that was causing the patient’s agitation so they checked basic labs and a UA. They gave the patient Risperidone to make sure they remained calm in the ED. * ED Physician K stated “There was a question about going to the VA per [PO] so I talked to case management about [patient] going to the VA.” * ED Physician K stated the patient was not known to the VA and was not experiencing SI or HI at this point so it was decided the patient could be discharged home. * ED Physician K stated they prescribed the patient Risperidone and had the POs coordinate getting the patient home. * Regarding “Care Management Progress Note” dated 02/07/2024 at 1314 that reflected “Engaged in discussion of EMTALA rules with [ED Physician K name], RN [name], and police officers. Determined Pt must be evaluated in ED prior to discharge, but police may choose to take [patient] to VA in Portland afterwards if Pt is medically cleared for [discharge] and they feel [patient] is still a danger. Plan: Pending workup. MSW to remain involved for potential geropsych assessment,” ED Physician K stated the reason behind that note was that the POs thought the patient needed to be evaluated in the ED before going to the VA. ED Physician K stated “I asked case management to call the VA and VA didn’t know the patient. I discharged the patient home. If I thought the patient needed to go to the VA I would have transferred the pt to the VA.” * ED Physician K stated “I had care management see the patient to see if the patient had any association with the VA. The question was if the patient needed to be transferred up to the VA, but the patient didn’t need to be transferred so we discharged [them].” * ED Physician K stated “I evaluated the patient fairly quickly when [the patient] arrived.” ED Physician K stated the patient was calm while in the ED. Physician K stated they did not think they placed the patient on a hold. * ED Physician K stated the patient was not evaluated by a psychiatrist or MHE. * ED Physician K stated that when the patient was discharged from the ED, the POs did not express any concerns about the patient being a danger to self or others. * Regarding MSEs for patients at risk for harm to self or others, ED Physician K stated a psychiatrist will see the patient in the ED if they are being admitted to the hospital’s inpatient psychiatric unit or another inpatient unit. ED Physician K stated “If I’m worried a patient needs to be admitted to the hospital, I consult the MHEs.” * ED Physician K stated that the normal process for conducting MSEs for patients at risk for harm to self or others was “I do an [MSE] on everyone I see. I do a [MSE] on psychiatric patients and a medical exam.” * ED Physician K stated that patients were not automatically evaluated by psychiatrists if they were experiencing SI or HI. ED Physician K stated they would evaluate the patient and then decide if the patient needed to be seen by a psychiatrist or MHE. * ED Physician K stated psychiatrists evaluate ED patients if patients are being admitted to the psychiatric unit or other inpatient unit. Whether the patient is evaluated by a psychiatrist is based on whether they need admission to an inpatient bed or psychiatric inpatient bed, and for mental health outpatient resources. * ED Physician K stated they did not know if the hospital had P&Ps regarding who conducted MSEs for psychiatric patients. 16. During an interview with TPO L regarding Patient 13 on 03/28/2025 at 2215 the following information was provided: * TPO L remembered Patient 13 and stated they were a Grand Ronde police officer. TPO L stated they and another Grand Ronde police officer, TPO M transported the patient in a police vehicle to Salem Hospital ED. * TPO L stated, “We saw a rapid onset of deterioration.” [Patient 13] was on a [police officer hold] because [they were] a danger to self or others. [They were] going to die out here in the winter.” The patient jumped out of a vehicle and ran into the woods. “We got lucky and found [them] ... There are bears and cougars in the woods and [the patient] was not properly dressed and it was night and cold.” The patient was screaming profanities and a family member called 9-1-1. * TPO L stated when they arrived at Salem Hospital ED, they told the staff that they brought the patient in for a “psych eval.” * TPO L stated “I handed [ED staff] the police officer hold form that spelled out what was going on.” * TPO L stated they stayed with the patient the entire time the patient was in the ED. TPO L stated the patient was not in a safe room or seclusion room. TPO L stated the patient was in a “regular emergency department room.” * TPO L stated it seemed like the ED did “a standard check ... like check vitals, give an aspirin and discharge.” * TPO L stated, “No psych eval was completed.” [The patient] had a urine drug screen and a CBC. “We told [ED staff] that [the patient] needed to be held ...” * TPO L stated “[They] just sort of discharged [the patient] and said [the patient] no longer had a problem.” The ED staff said the patient did not meet criteria for admission. TPO L stated, “I thought the [police officer hold] meant they would evaluate [the patient] psychologically.” * TPO L stated that while in the ED the patient did odd things like they did not believe they had eaten anything right after we bought them food to eat. “The patient was only lucid for very short periods of time. [They] would go off on tangents.” Just before discharge, the patient was talking to themselves, and appeared to have auditory and visual hallucinations. They were talking about leaving the hospital and plotting with a person who was not there, “plotting [their] grand escape, grabbing at the door to get out ... [they were] not alert to self.” * TPO L stated they coaxed and encouraged the patient to get in the police vehicle. The patient continued to hallucinate as they were leaving the ED and their behaviors continued during transport from Salem Hospital to Providence Milwaukie Hospital. * TPO L stated they took the patient directly from Salem Hospital to Providence Milwaukie. TPO L stated “... once they booted [the patient],” they contacted the VA. The VA directed them to take the patient to Providence Milwaukie [Hospital] for geri psych.” When they presented to Providence Milwaukie Hospital, Providence Milwaukie Hospital said they knew they had to take care of [the patient] because that is a regulation. * TPO L stated, “I feel like [the patient] had nowhere else to go and if [the patient] discharges [they will] wander off and not be safe.” 17. During an interview with TPO M regarding Patient 13 on 04/09/2025 at 0930, TPO M provided similar information to that of TPO L in finding 16 in this tag. Examples included: * TPO M remembered the patient. * TPO M stated they took the patient to Salem Hospital ED. “We specifically told [ED staff] what [the patient] was doing, that [they were] talking to people who weren’t there.” * The ED staff were busy so TPO M and TPO L had to “basically take care of [the patient]. [ED staff] would come and go but it was brief.” * The hospital told TPO L and TPO M the patient didn’t meet their requirements to hold the patient at the hospital. TPO M stated “I told the hospital I’m not leaving [Patient 13] alone. We’re going to keep [them] in custody and they said, ‘We are releasing [the patient]’.” * TPO M stated the patient was still hallucinating when they left Salem Hospital. The patient was “still unstable ... talking about people who weren’t there. I was trying to calm [the patient] down.” 18.a. The P&P titled “Psychiatric Consultation Program” with “Final Approval” “01/2023” was reviewed and reflected the hospital had capability for mental health evaluations for patients presenting to the ED with psychiatric complaints as follows: * “Describes the function of the psychiatric consultation service in meeting the psychosocial needs of patients seeking medical care throughout the hospital.” * “Services provided by the psychiatric consultation team, upon physician request include ... Evaluation for psychiatric medicines where indicated ... Assist in crisis intervention, evaluations, and recommendations in management and care ... Suicide and safety evaluations ... Determine the clinical appropriateness for referral to acute inpatient psychiatric care and assist in the coordination of admission to [Psychiatric Medicine Center] when indicated.” * “Provides telephone consultation for community physicians and providers.” * “Psychiatric Consultation Flowcharts: 1. Requesting a Consult for Monday Friday, 0800-1600 (refer to ‘Attachment A’) 2. Requesting a Consult Weekday After Hours (1630-0800), Holidays & Weekend (refer to ‘Attachment B’).” * “Definitions ... Psychiatric consultation service - comprised of psychiatrist(s), advanced practice providers (i.e. NP, CNS, PA), master’s level prepared therapists (MA, MS, MSW), program therapy associates, nurses, and clinical social workers ... Acute psychiatric condition - a patient believed to be at imminent risk of danger to self or others and will likely require acute inpatient psychiatric admission to stabilize and manage ... Physician/Provider - Any physician, or his/her physician designee, or licensed practitioner (LP) responsible for the care and treatment of the patient. LP - Licensed Practitioner PMC - Psychiatric Medicine Center.” * Attachment A, a flow chart included: - “Requesting a Psychiatric Consult: Monday - Friday 0800-1630.” - A box with the following information: “Types of Consult Requests: Psychiatric evaluation of patients presenting with acute psychiatric/behavioral conditions. Consultation regarding management of delirium, dementia, and alcohol/drug withdrawal. Safety and suicide evaluations. Referral to acute inpatient psychiatric care. Evaluation for psychiatric medicines.” An arrow pointed from this box to another box that reflected “How to Request a Consult: Phone messages are reviewed daily on the Psychiatric Consult Service Line (4-9235). If you have an urgent or emergent request, contact the psychiatrist through the hospital’s paging service, WebXchange or contact the consultant-liaison ...” An arrow pointed from this box to two boxes. One reflected “Psychiatric Consultant-Liaison Triages consult requests for the psychiatrist/Provider (NP, PA) and assists in prioritizing case load Tie-line: 4-9235” and the other reflected “Psychiatrist/Provider (NP, PA): Services Provided: Psychiatric diagnostic evaluation and recommendations in care. Evaluation, recommendation, and guidance for the appropriate use of psychiatric medicines in managing acute or non-acute psychiatric/behavioral health conditions. Non-acute requests (behavioral management of delirium/dementia, withdrawal management, etc.). Assist attending team in determining capacity; it is noted any licensed physician can make this determination. Safety and suicide risk assessments per specific request of attending provider. Manage all consults placed through [Salem Hospital - Emergency Department] and patients being recommended for acute inpatient psychiatric care who approach 24 hours in [Salem Hospital - Emergency Department] (and every 24 hours thereafter).” - A box with no arrow pointing to it reflected “Mental Health Evaluator (MHE) Located only in [Salem Hospital-Emergency Department] to provide the following services: ... Diagnostic mental health evaluations for patients presenting with primary psychiatric complaints ... Suicide and safety risk assessments ... Recommendations regarding the course of treatment and to assist in disposition planning once discharged from [Salem Hospital-Emergency Department] ... Assists in coordinating referral to acute inpatient psychiatric care at [Salem Hospital - Psychiatric Medicine Center] or other local area hospitals ... Assists in management of patients with high utilization of emergency services for psychiatric complaints.” - Another box with no arrow pointing to it reflected “Care Management/Social Work ... Provides screening to patients with psychiatric/mental health complaints focusing on psychosocial needs (i.e. Insurance, temp housing, etc.) and assistance in accessing appropriate care (i.e. Follow-up with community provider) ... In collaboration with consultant-liaison, assists in determining appropriate disposition and aftercare ... Makes referrals to community mental health resources as appropriate. [Salem Hospital - Psychiatric Medical Center] social worker team and discharge coordinator are available as resources for challenging/complex disposition needs of psychiatric patients.” - Another box with no arrow pointing to it reflected “Marion County Psychiatric Crisis Center (PCC) ... Provides back-up/on-call services to [Salem Hospital - Emergency Department] and MHE team during periods of high census.” * “Attachment B, a flow chart reflected: - “Requesting a Psychiatric Consult: After hours (1630-0800), Weekends, & Holidays.” - A box with the following information: “An after-hours psychiatric consultation is needed.” An arrow pointed from this box to another box that reflected “Is the request emergent?:” A line went from this box went to “Yes” and then to two arrows. One arrow went to a box that reflected “In [Salem Hospital - Emergency Department] ... The MHE team is available in [Salem Hospital Emergency Department] from 0800-0030 7 days a week to conduct evaluations and triage requests for [Salem Hospital - Emergency Department] ... All other hours, Marion County [Psychiatric Crisis Center] can be contacted and a QMHP can evaluate the patient, [phone number].” The other arrow went to a box that reflected “All other locations ... A call can be made to the on-call psychiatrist/provider (NP, PA) 1630-0800 by way of the hospital’s paging system ... Place a ‘Consult to Psychiatry’ order within Epic’s order system ... Under ‘Comments,’ please provide a brief description of the issue(s) you are requesting to be addressed and note request as ‘emergent’.” The P&P did not reflect that the hospital lacked capability to conduct MH evaluations for geriatric patients or patients with symptoms of dementia. 18.b. The P&P titled “Suicide Assessment and Prevention Guidelines” dated last reviewed “01/2024” was reviewed and reflected: * “The purpose of this document is to define the clinical management of any patient assessed to be at risk for suicide and placed on Suicide Precautions. It is the policy of Salem Health Hospitals to provide safe, prompt and appropriate assessment and treatment to patients experiencing suicidal ideations or those who have attempted suicide. The health care team should accept and act upon any credible source of information that indicates that a patient has suicidal ideation, or intent/actions to harm him/herself. Treatment strategies emphasize assessment, observation, increased interpersonal support and communication to the LP while maintaining the least restrictive environment possible.” * “Suicide Risk Screening Adults (18 years and older)” * “ a. Suicide Risk Screening is completed & documented in the EHR using the C-SSRS Suicidal Ideation Severity tool (Columbia-Suicide Severity Rating Scale) (Attachment D) i. Risk Screening Identification Levels: No Risk Identified (no to question 1 & 2), Low risk (yes to questions 1 or 2) Moderate Risk Identified (yes to questions 3), High Risk Identified (yes to question 4, 5 or 6) ii. Suicide Precautions ... are implemented for patients at high Risk for suicide only. 1. Patients seeking care in the ED for suicide attempt or self-harm attempts will be immediately placed in suicide precautions (considered high risk), RN to notify LP.” * “b. Suicide Risk Assessment is completed and documented using the C-SSRS Suicidal Ideation Severity Tool and risk level. i. Patients at Moderate Risk for suicide will receive a suicide assessment SAFE-T Protocol with CSSRS Assessment tool that directly asks about suicidal ideation, severity, behavior, activating events, clinical status, treatment history, access to lethal means, and internal and external protective factors. ii. Patients at High risk for suicide will receive the Moderate Risk assessment items as listed in I.b.i. above and additionally be assessed for suicidal ideation intensity, precautions/interventions and risk factor treatment plan. 1. This is completed by interviewing the individual, individual’s family or significant other as appropriate, or observations of the individual.” * “c. Suicide Reassessment: Patients that score as moderate or high on the C-SSRS Suicidal Ideation Severity Tool will have their suicidal ideation-behavior assessed every shift assessing ideation, plan, behavior, ability to keep self safe, and precautions/interventions i. RN to notify LP with any changes in patient condition. ii. LP determines treatment plan ...” * “... Emergency Department: i. Complete and document a C-SSRS Suicidal Ideation Severity Tool for adult patients ... For all patients with a primary diagnosis or primary complaint of a behavioral health condition 2. During visit, if it is noted that suicidal intentions become present. 3. C-SSRS Suicidal Ideation Severity Tool may be completed on any adult patient in the Emergency Department ... When C-SSRS ... completed, the level of risk for suicide will be documented and a plan is formed to mitigate the risk for suicide.” * “Suicide Reassessment: a. Patients that score as moderate or high on the C-SSRS ... Ideation Severity Tool will have their suicidal ideation-behavior assessed every shift assessing ideation, plan, behavior, ability to keep self safe, and precautions/interventions 1. RN to notify LP with any changes in patient condition. 2. LP determines treatment plan changes from reassessment results.” 18.c. The P&Ps and medical staff rules and regulations and manual in findings 9.a., 9.b., 9.c., 9.d., 9.e., 9.f., 18.a. and 18.b. did not include a clear process that ensured all individuals that presented to the ED expressing suicidal or homicidal thoughts or gestures, or danger to self or others, including geriatric patients and patients with dementia symptoms would be ensured a MSE within the capability of the hospital that included a mental health evaluation and a suicide risk screening that was provided to other patients. Examples included: * Refer to finding 13 in this tag regarding Patient 13 that reflected the patient who had expressed auditory and visual hallucinations did not receive a psychiatric evaluation because “geriatric patients are typically seen by case management” and “Those aren’t psych issues. Those are issues that go along with dementia.” * Refer to finding 14 in this tag that reflected “... it was a judgement call regarding which patients get a MHE and which patients get case management. The MHEs don’t evaluate patients with dementia. As soon as they are determined to have dementia, they go to case management ...” * Refer to finding 15 in this tag that reflected “psychiatrists evaluate ED patients if patients are being admitted to the psychiatric unit or other inpatient unit. Whether the patient is evaluated by a psychiatrist is based on whether they need admission to an inpatient bed, and for mental health outpatient resources.” * Refer to finding 19 in this tag that reflected patients with suicidal or homicidal thoughts or gestures, danger to self or others have a suicide risk screening completed and documented. There was no documentation in the P&Ps and medical staff rules and regulations and manual that explained these stated practices related to lack of MH evaluations for geriatric patients and patients with symptoms of dementia. 19. Documentation in an email from MRPS dated 03/27/2025 at 1121 regarding MSEs reflected: * “Information about psychiatric evaluations in the ED:” * “When are those conducted: Patients arriving to the ED with a psychiatric condition are assessed by a Licensed Practitioner.” - “If the Licensed Practitioner (LP) in the ED determines they need further psychiatric evaluation they can initiate a consult.” * “Who is conducting them (e.g., psychiatrist and/or others):” - “ED licensed providers” - “Salem Hospital mental health evaluators” - “Marion County [Psychiatric Crisis Center] Qualified Mental Health Professionals (QMHP)” - “Psychiatrists” * “For individuals expressing suicidal or homicidal thoughts or gestures, danger to self or others, etc.: (see Suicide Assessment and Prevention Guidelines policy) ... Patients who arrive with suicidal or homicidal thoughts or gestures, danger to self or others, etc. have a Suicide Risk Screening completed & documented in the EHR using the C-SSRS Suicidal Ideation Severity tool (Columbia-Suicide Severity Rating Scale).” Refer to findings 10, 15 and 16 in this tag that reflects Patient 13 presented to the ED on a police officer hold with auditory and visual hallucinations, and danger to self and others and no suicide risk screening was completed and documented. 20. Review of the PMH ED medical record reflected that on 02/07/2024 at 1647, approximately one hour after Patient 13 was discharged from Salem Hospital ED, the patient presented to PMH ED with Grand Ronde police officers. The patient’s chief complaints upon presentation to PMH ED were “Mental Health Evaluation” and “Altered Mental Status.” The patient was provided a MSE that included a behavioral health evaluation related to the patient’s presenting psychiatric symptoms as follows: * A PMH “ED Provider Note” dated 02/07/2024 at 1717 reflected: - “In summary, this is a 74 y.o. [sex] with a history of ... dementia, who presents for evaluation with concerns of the patient may hurt [themselves] or others ... The patient’s physical exam was remarkable for hypertensive blood pressure, as well as tachycardic heart rate ... appeared to be mildly agitated, with a flat affect, did appear to be attending to auditory hallucinations ... [they] did exhibit some thought disorder when I had a conversation with [them] ...” - “Impression: 1. Agitation 2. Dementia, unspecified dementia severity, unspecified dementia type, unspecified whether behavioral, psychotic, or mood disturbance or anxiety ... 3. Auditory hallucinations 4. Paranoia ...” - “HISTORY OF PRESENT ILLNESS ... [Patient] has exhibited worsening paranoid behavior, and has apparently been speaking with people that are not present. The patient apparently has weapons in [their] home, and multiple members of the community are very concerned for both [the patient’s] safety, as well as theirs [sic] given [the patient’s] erratic behavior. Patient arrives here in the custody of Grand Ronde tribal police. According to the police, [patient] was initially seen at Salem Hospital and was told that since there was a long wait for psychiatric beds, that the patient could instead be ‘discharged’ and [they] could be taken to Portland at the VAMC where [they] could be evaluated. On the way to the Portland VA the police contacted the VA hospital and was told to come here because we have a geriatric psych unit.” - “PHYSICAL EXAM ... Psychologic: Flat affect. The patient appears to be attending to auditory hallucination ... patient has obvious thought disorder.” * A “Behavioral Health Emergent Assessment” note dated 02/07/2024 at 1753 reflected: - The patient “... was brought in by Grand Ronde Tribal Police on a [police officer hold] with a chief complaint of SI, HI, psychosis, and agitation ... After SW eval pt is witnessed leaving [their] room to use the bathroom multiple times and stating [they are] going to leave the ED. Pt ultimately attempts to elope and requires security intervention/Code Grey and seclusion. Pt is placed on [a physician hold] ... Per Tribal Police, there was discussion in Salem ED of pt needing inpatient psych treatment and they thought the VA had accepted [the patient], but Salem ED staff called and were told [patient] would need to be evaluated in the ED and a transfer request submitted to the VA if appropriate. Tribal Police state ED staff told them they would discharge pt to police so they could drive [patient] directly to Portland for eval at the VA. Later Tribal Police were told that because of pt’s age/cognitive impairment, [patient] would likely not be a candidate for VA admission and that [patient] would be better served coming to PMH for geri-psych inpatient ... Risk Factors: Impulsive self-harm/suicidal gestures recently; command AH to engage in risky behavior; threats to harm others; psychosis and paranoia; minimal family support; no outpatient providers; lives alone; hx of trauma; owns firearms ... History of aggression: Notes from Salem ED indicate pt assaulted a family member, but unclear if this happened or was a verbal threat. Has tried to crash car while others are driving. Attempted to elope from Tribal PD and PMH ED multiple times. Access to weapons: ... Tribal Police found one firearm and secured it but also found ammo for multiple other weapons they were unable to find/secure ...” - “-Formulation of plan: Due to risk of harm to self/others and grave disability [due to] severity of symptoms, I believe the patient meets criteria for Psychiatric Hospitalization at this time.” The PMH ED medical record reflected a MSE was conducted that included a MH evaluation and the patient was admitted to PMH’s inpatient psychiatric unit. ********** 21. Review of the ED medical record for pediatric patient, Patient 11’s 07/23/2023 ED encounter included the following: * The patient arrived to the ED at 0513 with a chief complaint of “SOB.” * At 0514 an RN recorded “Pt c/o SOB starting yesterday was seen here and given breathing tx. Hx of asthma. Denies any recent fevers.” * At 0515 triage was started and at 0521 the RN recorded “No wheezing noted at this time. [Parent] states pt was seen for croup recently. No stridor noted.” * At 0614 an RN recorded “Pt’s mom up to triage window stating pt is feeling better and that they are leaving. Pt ambulated out with mom with strong steady gait. No acute distress.” * At 0615 the ED Care Timeline reflected “ED Disposition set to WBS.” There was no physician notes and no documentation that the patient received an MSE. There was no documentation that reflected staff attempts were made to inform Patient 11 or their parent of the risks of leaving the hospital without an MSE or that any attempts to discourage them from leaving prior to an MSE had been made, as required by the hospital’s P&Ps in findings 9.b. and 9.c. in this tag. ********* 22. Review of the ED medical record for Patient 16’s 12/18/2024 ED encounter included the following: * The patient arrived to the ED at 1107 with a chief complaint of “sob.” * At 1117 an RN recorded “Pt states [they are] here for SOB, wheezing, tightness in [their] chest. States [their] rescue inhalers have not been working for [them] at home. Hx of asthma.” * At 1126 an EKG was ordered. * At 1310 a Registration staff recorded “Not Available in Lobby x3.” * At 1334 the ED Care Timeline reflected “ED Disposition set to WBS.” There was no physician notes and no documentation that the patient received an MSE. There was no documentation to reflect the time or circumstances of the patient’s departure and that attempts were made to discourage them from leaving prior to an MSE, as required by the hospital’s P&P in finding 9.c. in this tag. 40575”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, 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 or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 29708 40575 Based on interview, review of documentation in 2 of 2 medical records of pediatric patients who were transferred to other hospitals for services not available at Salem Hospital (Patients 19 and 20), review of central log documentation, and review of policies and procedures, it was determined that the hospital failed to develop and enforce its EMTALA policies and procedures to ensure that it effected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved: *Patient specific, individualized risks of transfer had not been identified for Patients 19 and 20. Findings include: 1. The P&P titled “Emergency Medical Treatment-Screening, Stabilization, and Transfer (EMTALA) Clinical House Wide Policy and Procedure” dated “Final Approval 11/2024” was reviewed. It reflected: * “If the patient has an emergency medical condition, the hospital must provide either: 1. Further examination and treatment required to stabilize the condition within the capabilities of the staff and facilities, or 2. An appropriate transfer of the patient to another facility.” * “Certification of Transfer A. The attending physician must provide written certification of the reasons for transfer and that the benefits of transfer outweigh the risks on the interfacility transfer form. B. The documentation of risks and benefits of transfer must be specific to the patient’s condition.” * “Transfer: the movement, including the discharge, of an individual outside the hospital’s facilities at the direction of any person employed by ... the hospital ...” 2.a. The central log for Patient 19 reflected that they presented to the ED on 02/10/2025 at 0110 with a chief complaint of “Suicide Attempt, Overdose.” The ED Disposition on the log was “COBRA” on 02/10/2025 at 0343. 2.b. The medical record for Patient 19’s 02/10/2025 ED encounter was reviewed and included the following information: * At 0110 the ED Timeline reflected, “Patient arrived in ED.” * The “ED Provider Note” dated 02/10/2025 at 0133 reflected a MSE was conducted. The “Clinical Impression: 1. Serotonin syndrome; 2. SSRI overdose, intentional self-harm ... 3. Suicide attempt.” * The “ED Provider Note” dated 02/10/2025 at 0219 reflected “Case was discussed with [Pediatric Intensivist]. [They have] accepted the patient for direct admit to the PICU at Doernbecher Children’s Hospital. The patient will go via ambulance. The patient and [parent] are comfortable with this plan.” * The “ED Provider Note” dated 02/10/2025 at 0309 reflected “PANDA has arrived in the ED. They will transport the patient to Doernbecher Children’s Hospital. Further care of the patient has been transferred to [Pediatric Intensivist] and [their] team.” 2.c. The one-page Interfacility Transfer form in Patient 19’s record contained physician transfer certification and other required documentation and included the following: - In the space for “Summary of Patient Diagnosis:” was written “Serotonin Syndrome, Intentional OD.” - In the space for “Risk of Transfer:” was pre-printed language with the boxes checked for “Accident” and “Worsening of medical condition.” - In the space for “Benefit of Transfer:” was pre-printed language with the box checked for “Access to specialized care/tertiary.” - In the space for “Transportation:” was pre-printed language with the box checked for “Ambulance.” - In the space for “Level of Care:” was “Kids Team” written in for “Agency Name:” - The bottom of the page reflected: the Provider Certification with the ED MD’s signature dated and timed as 02/10/2025 at 0330. 2.d. There was no documentation on the transfer form or elsewhere in the medical record to reflect what individualized and specific risks of transfer for Patient 19 had been discussed, if any. 2.e. During interview with MRPS, DCMSD, ED NM and other hospital staff on 03/18/2025 at 1604, they confirmed the lack of clear and patient specific transfer risks in the medical record for Patient 19. 3.a. The central log for Patient 20 reflected that they presented to the ED on 03/05/2025 at 1017 with a chief complaint of “Respiratory Distress.” The ED Disposition on the log was “COBRA” on 03/05/2025 at 1432. 3.b. The medical record for Patient 20’s 03/05/2025 ED encounter was reviewed and included the following information: * At 1017 the ED Timeline reflected “Patient arrived in ED.” * At 1018 the ED Timeline reflected “Arrival Documentation Brief History: EMS Pt. Overview: Called when pt was unconscious and unresponsive at school, in and out of consciousness. On arrival, pt was sitting in a chair, moving aggressively with staff and not cooperative. Refusing all tx, unable to start neb initially. [Parent] arrived shortly after, neb tx brought RA sats from 77% to 98%. Coarse wheezing and rhonchi bilaterally. No recent illness. Takes daily BID inhaler. Has rescue inhaler ...” * The “ED Provider Note” dated 03/05/2025 at 1018 reflected “Differential Diagnosis: The patient is a 8 y.o. [sex] evaluated for respiratory distress. [Differential Diagnosis] includes, but is not limited to: asthma exacerbation, acute respiratory failure with hypoxia, viral illness, pneumonia ... I will initiate high-flow NC O2 ...” and at 1109 ‘Case was discussed with [MD name] Pediatrics at the Doernbecher Children’s Hospital. Pertinent history, physical exam findings, and diagnostics were discussed. [MD] accepts patient for transfer for further care and management. I have informed the patient’s [parent] of the findings and plan ... The Doernbecher Children’s Hospital is sending a PANDA.” * The “ED Provider Note” dated 03/05/2025 at 1432 reflected “The KIDS team has now arrived and will take the patient up to Portland.” 3.c. The one-page Interfacility Transfer form in Patient 20’s record contained physician transfer certification and other required documentation and included the following: - In the space for “Summary of Patient Diagnosis:” was written “Respiratory Failure.” - In the space for “Risk of Transfer:” was pre-printed language with the boxes checked for “Accident” and “Worsening of medical condition.” - In the space for “Benefit of Transfer:” was pre-printed language with the box checked for “Access to specialized care/tertiary.” - In the space for “Transportation:” was pre-printed language with the box checked for “Ambulance.” - In the space for “Level of Care:” was pre-printed language with the box checked for “Advanced Life Support” and line for “Agency Name:” was blank. - The bottom of the page reflected: the Provider Certification with the ED MD’s signature dated and timed as 03/05/2025 at 1422. 3.d. There was no documentation on the transfer form or elsewhere in the medical record to reflect what individualized and specific risks of transfer for Patient 20 had been discussed, if any. 3.e. During interview with MRPS, DCMSD, ED NM and other hospital staff on 03/18/2025 at the time of the medical record review, they confirmed the lack of clear and patient specific transfer risks in the medical record for Patient 20.”