Legacy Meridian Park Medical Center

“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: 40575 ************************************************ Based on interviews, email communications, review of central log and medical record documentation for 7 of 22 encounters of individuals who presented to the hospital for emergency services (Patients 1, 2, 4, 5, 8, 13 and 15 ), review of P&Ps, and review of grievance and other documentation, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured it met its EMTALA obligations in the following areas: * EMTALA signage was not posted in all areas patients wait for exam and treatment. * For Patients 1, 4, 5, 8 and 15, to not dissuade patients from staying at the hospital to receive MSEs, and to obtain or attempt to obtain written and informed refusal of MSEs in accordance with its P&Ps. * For Patient 13, to affect appropriate transfers to other hospitals for further examination and stabilizing treatment that was not within the hospital’s capability at the time, that included physician certification of patient specific risks of transfer. * For Patient 2 who presented to the hospital for emergency services, financial information was discussed prior to an MSE being conducted. Although there was no discernable delay in the provision of the MSE, discussion about financial information was prohibited by hospital policies and procedures. Findings include: 1. Refer to the findings identified under Tag A2402, CFR 489.20(q), that reflects failure to post signs that specify the rights of individuals with EMCs and women in labor. 2. Refer to the findings cited under Tag A-2406 under CFR 489.24(a) & 489.24(c), that reflects failure to 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. 3. Refer to the findings cited under Tag A-2409 under CFR 489.24(e)(1)-(2), that reflects failure to effect appropriate transfer of those individuals as required by the hospital’s policies and procedures. 4.a. Review of the P&P “Emergency Medical Treatment And Labor Act (EMTALA) Compliance For Legacy Health Emergency, Labor And Delivery, Psychiatric Emergency Services And Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements For Non-Compliance” dated reflected: * “Examples of DEDs may include licensed EDs, labor and delivery units, Psychiatric Emergency Services and provider-based urgent care centers.” * “Legacy may not unduly delay or discourage the provision of an appropriate MSE or any necessary stabilizing medical examination and treatment to inquire about the individual’s method of payment or insurance status.” * “The MSE will not be unduly delayed to obtain insurance or payer information or seek prior authorization.” * “If, as a result of the MSE, it is determined that a patient does not have an EMC and is not in labor: Legacy may obtain additional insurance or payer information and may seek authorization from the patient’s payer for follow-up treatment.” 4.b. During interview with CNO and QM on 05/01/2024 at 1440, they confirmed the hospital had an EMTALA violation when a Registration Employee did a presumptive insurance eligibility of OHP prior to an MSE and they provided the following information: * Video footage was obtained and reviewed. Still shots were saved with time stamps. * Patient 2 arrived to the LMPMC ED on 08/14/2023 at 0608. * Registration occurred at 0612 and 0614, prior to an MSE. * The patient was triaged by a RN at 0615. * The triage RN confirmed there was not a delay in getting triaged. * A LMPMC investigation summary document “substantiated the allegation that an employee registered a patient before a medical screening evaluation could be completed, resulting in an EMTALA vioaltion. The investigation determined the employee was trying to be helpful as the patient voiced concerns about [their] ability to pay for [their] visit. Employee Relations determined [Registration Employee] to be a risk based on this and previous behaviors and recommended termination.” 4.c. Review of the ED Central Log revealed Patient 2 presented to the ED on 08/14/2023 at 0608 with a “Chief Complaint” of “Multiple Complaints.” 4.d. The medical record for Patient 2’s 08/14/2023 ED encounter was reviewed and reflected: * At 0608 the ED Timeline reflected “Patient arrived in ED.” * At 0615 the ED Timeline reflected “Triage Started.” * At 0621 an ED Provider Note reflected an MSE was started. * At 0720 an RN documented “Patient discharged.” 4.e. Although the patient was triaged and the MSE was initiated within 13 minutes after arrival to the ED, the registration employee failed to follow the hospital’s policies and procedures.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 40575 Based on observations, interview and review of policies and procedures it was determined the hospital failed to enforce EMTALA policies and procedures that ensured the posting of signage, that specified individuals’ EMTALA rights with respect to examination and treatment for emergency medical conditions and women in labor, in all areas likely to be noticed and where individuals waited for examination and treatment. Findings include: 1. Review of the P&P “Emergency Medical Treatment And Labor Act (EMTALA) Compliance For Legacy Health Emergency, Labor And Delivery, Psychiatric Emergency Services And Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements For Non-Compliance” reflected: * “EMTALA signage provides all patients with the opportunity to receive notice of their right to an MSE and stabilization for an EMC.” * “Signage shall be posted in Legacy’s DEDs and any other place likely to be noticed by all individuals entering these departments and those individuals waiting for examination and treatment in areas of the hospital other than the traditional emergency departments such as the entrance area, admitting areas and waiting rooms located on hospital property. Signage must be posted conspicuously, notify individuals of their right to an MSE and stabilization or treatment for an EMC and required services for patients in labor as specified under EMTALA, as well as incicate whether or not the hospital participates in the Medicaid program.” 2. During tour of the FBC department on 05/01/2024 at 1030 with the CNO, an FBC RN, and other staff members, in the triage room hallway an LDRP room was observed to not have any EMTALA signage. 3. During interview at the time of the tour, the FBC RN stated that all of the LDRP rooms used to have EMTALA signage. They also stated that some patients do not enter the waiting room or the triage room, but go directly to a LDRP room for their exam and treatment. In those cases those patients would not have an opportunity to see the signs that were posted in the waiting room and triage room. The RN stated they were not sure what happened to the missing sign in the LDRP room.”

“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: 40575 Based on observation, interviews, review of medical records or other documentation for 5 of 22 patients who presented to the hospital’s ED or L&D for emergency services (Patients 1, 4, 5, 8 and 15), and review of policies and procedures and other documents, it was determined the hospital failed to enforce its policies and procedures to ensure that each patient who presented for emergency services received a MSE to determine whether or not an EMC existed. * A pregnant patient who presented to the FBC with complaints of ruptured membranes did not receive a MSE and was directed by an FBC RN to go to another hospital. * For other patients who left the hospital without receiving a MSE it was unclear whether hospital staff did or said anything to dissuade them from staying. There was no indication they had been informed of the risks of leaving the hospital without a MSE, nor that attempts to obtain informed written refusal for a MSE had been made. Findings included: 1. Review of the P&P “Emergency Medical Treatment And Labor Act (EMTALA) Compliance For Legacy Health Emergency, Labor And Delivery, Psychiatric Emergency Services And Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements For Non-Compliance” dated last revised “02/23” reflected: * “If an individual comes to one of Legacy’s Dedicated Emergency Departments, Legacy will provide an appropriate Medical Screening Examination within the capability of the department, including ancillary services routinely available, to determine whethere or not an Emergency Medical Condition exists;” * “Examples of DEDs may include licensed EDs, labor and delivery units, Psychiatric Emergency Services and provider-based urgent care centers.” * “Legacy may not unduly delay or discourage the provision of an appropriate MSE or any necessary stabilizing medical examination and treatment to inquire about the individual’s method of payment or insurance status.” * “ All individuals presenting to a DED requesting an examination or treatment, or for whom a prudent layperson observer would conclude from the individual’s appearance or behavior a need for examination or treatment of a medical condition, will receive an MSE within the capability of the applicable DED to determine whether an EMC exists or whether a patient is in labor.” * “The MSE will not be unduly delayed to obtain insurance or payer information or seek prior authorization.” * “If Legacy does not have the capability to provide necessary stabilizing treatment for the patient, Legacy may transfer the patient to another medical facility which has the capability to provide the required treatment and has accepted the patient. All relevant sections of the EMTALA Patient Transfer Form must be completed to ensure that the transfer is an Appropriate Transfer.” * “If, as a result of the MSE, it is determined that a patient does not have an EMC and is not in labor: Legacy may obtain additional insurance or payer information and may seek authorization from the patient’s payer for follow-up treatment.” * “A health record will be opened on all individuals presenting to the emergency department or an obstetrics unit. The health record shall include documentation of triage, the MSE, treatment, and discharge/disposition information.” * “A patient has the right to refuse the MSE, further examination, treatment or transfer to another facility.” * “The DED shall make good faith efforts to encourage the patient to remain for the MSE. If the patient refused the MSE, the reasons for refusing the MSE (if known) and the time of departure shall be recorded in the patient’s health record.” * “If the patient leaves before receiving a MSE without the knowledge of the DED, the time and circumstances (to the extent known) of the patient’s departure shall be recorded in the patient’s health record.” * “If the patient has received an MSE and refuses further examination or treatment, or transfer, the patient shall be informed of the risks and benefits of the examination or treatment, or transfer. If the patient refuses to consent to the examination, treatment, or transfer, then the health record shall reflect ... A description of the examination, treatment or transfer that was refused; The reasons for the refusal; The risks and benefits were explained to the patient; The steps taken to document the patient’s refusal and the time of departure.” * “Legacy must maintain a Central Log of individuals who come to any Legacy DED ... The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE.” 2.a. During interview with the CNO on 05/01/2024 at 1425 they confirmed the following: * Patient 1, who was 34 weeks gestation with twins, called their OB MD from home with concerns that they were in labor. The OB MD told the patient to go to PSVMC or OHSU because they have a level three NICU, if needed. * The patient arrived to the FBC unit at LMPMC a short time later. The CN told the patient they needed to go to PSVMC. * The patient left our facility. The CN realized the patient should have had an MSE. The CN called the patient, the patient did not answer. The patient called back when they got to OHSU. * OSHU did not have any NICU beds. OSHU triaged the patient and transferred them to LEMC FBC, where they delivered twins without any complications. 2.b. An incident report reflected the following: * “Received/Reported date: 06/21/2023.” * “Alleged incident date: 06/21/2023.” * “Primary issue: Emergency Medical Treatment and Labor Act (EMTALA) Matters.” * “Summary: An allegation of an EMTALA violation when a patient presented for care and was advised to go to another facility.” * “Details: On 6/21/2023 [RN name] reported that [Patient 1 MRN number] came to Legacy Meridian Park in [redacted] labor, and was advised that [Patient 1] needed to go to another facility with a level three nursery.” * “Synopsis notes: Substantiated the allegation of an EMTALA violation when an employee suggested a patient go to another facility for care before a medical screening evaluation could be completed. The investigation determined the employee realized the error but was unable to catch the patient to return for a medical screening evaluation. The employee and team received education and training related to this event.” 2.c. Review of the ED central logs revealed no log entries to reflect that Patient 1 had presented to the hospital for obstetric/emergency services on 06/21/2023. 2.d. There was no evidence of a medical record or any other documentation to reflect that Patient 1 had presented to the hospital for emergency services on 06/21/2023. 3.a. The central log for Patient 4 reflected that they presented to the ED on 12/05/2023 at 1437 with a “Chief Complaint” of “Head Injury, Fall.” The “ED Disposition” on the log was “LWBS after Triage” on 12/05/2023 at 1613. 3.b. The medical record for 13 year-old Patient 4’s 12/05/2023 ED encounter was reviewed and included the following information: * At 1437 the ED Timeline reflected, “Patient arrived in ED.” * At 1504 the ED Timeline reflected, “Triage Started.” * At 1515 an RN documented an ED Note, “Pt presents with [parent] for c/o tailbone and head injury. Today at 1230 pt was playing basketball when another player came and checked [them] in the side/back causing [them] to fall. [Positive for] pain to coccyx, struck head on metal frame for [sic] bad mitten [sic] net. Unknown LOC. [Positive for] nausea initially then resolved. Pt initially dazed as well. Injury not witnessed by staff. [Postive for] abrasion to posterior head, bleeding controlled. Steady gait. Advised to wait in the lobby. Notify triage of any change in sx.” * At 1613 the ED Timeline reflected, “Disposition Selected, ED Dispostition set to LWBS after Triage.” 3.c. The medical record lacked any documentation to reflect the time or circumstances of the patient’s departure and that attempts were made to inform Patient 4 or their parent of the risks of leaving the hospital without an MSE or that any attempts to obtain informed written refusal of an MSE had been made, as required by the hospital’s P&Ps. 3.d. During interview with the CNO at the time of the ED record review on 05/01/2024, they confirmed that the record reflected Patient 4 or their parent had not been informed of the risks of leaving without an MSE and that informed written refusal of an MSE had not been obtained. 4.a. The central log for Patient 5 reflected that they presented to the ED on 12/07/2023 at 1840 with a “Chief Complaint” of “Chest Tightness, Rash.” The “ED Dispostion” on the log was “LWBS sfter Triage” on 12/07/2023 at 2123. 4.b. The medical record for Patient 5’s 12/07/2023 ED encounter was reviewed and included the following information: * At 1840 the ED Timeline reflected, “Patient arrived in ED.” * At 1841 the ED Timeline reflected, “Triage Started.” * At 1842 an RN documented an ED Note, “Pt was driving with [their child] approx 15 min ago - [they] began to feel chest tightness and tingling in [their] left arm, which [they have] never had before. Yesterday [they were] seen at [PSVMC] for sulfa/drug rash with benadryl and doxepin.” * At 1859 an EKG was obtained. * At 2123 the ED Timeline reflected, “Dispostion Selected, ED Dispostion set to LWBS after Triage.” 4.c. The medical record lacked any documentation to reflect the time or circumstances of the patient’s departure and that attempts were made to inform Patient 5 of the risks of leaving the hospital without an MSE or that any attempts to obtain informed written refusal of an MSE had been made, as required by the hospital’s P&Ps. 4.d. During interview with the CNO at the time of the ED record review on 05/01/2024, they confirmed that the record reflected Patient 5 had not been informed of the risks of leaving without an MSE and that informed written refusal of an MSE had not been obtained. 5.a. The central log for Patient 8 reflected that they presented to the ED on 01/19/2024 at 2306 with a “Chief Complaint” of “Abdominal Pain.” The “ED Disposition” on the log was “Eloped” on 01/20/2024 at 0134. 5.b. The medical record for Patient 8’s 01/19/2024 ED encounter was reviewed and included the following information: * At 2306 the ED Timeline reflected, “Patient arrived in ED.” * At 2308 an RN documented a Triage Note that reflected “Pt presents to ED for eval of RLQ pain. Increase with palpation. [Postive for] diarrhea. Denies n/v or gu complaints. Pt aox4, resp even and unlabored, skin pwd, mae, conversation appropriate. States [they haven’t] had [their] period in almost 4 months.” * At 2345 Labs and Pelvic Ultrasound ordered. * At 0017 on 01/20/2024 the ED Timeline reflected, “Imaging Exam Ended.” * At 0044 on 01/20/2024 the ED Timeline reflected, “Ct Abdomen/Pelvis with Contrast” was ordered. * At 0119 on 01/20/2024 the ED Timeline reflected, “ED Disposition set to LWBS after Triage.” * At 0134 on 01/20/2024 an RN documented “Patient eloped. No reason given.” 5.c. The medical record lacked any documentation to reflect the time or circumstances of the patient’s departure and that attempts were made to inform Patient 8 of the risks of leaving the hospital without an MSE or that any attempts to obtain informed written refusal of an MSE had been made, as required by the hospital’s P&Ps. 5.d. During interview with the CNO at the time of the ED record review on 05/01/2024, they confirmed that the record reflected Patient 8 had not been informed of the risks of leaving without an MSE and informed written refusal of an MSE had not been obtained. 6.a. The central log for Patient 15 reflected that they presented to the ED on 03/04/2024 at 1620 with a “Chief Complaint” of “Head Injury.” The “ED Disposition” on the log was “LWBS after Triage” on 03/04/2024 at 1929. 6.b. The medical record for Patient 15’s 03/04/2024 ED encounter was reviewed and included the following information: * At 1620 the ED Timeline reflected, “Patient arrived in ED.” * At 1627 the ED Timeline reflected, “Triage Started.” * At 1632 an RN documented an ED Note, “Pt presents with c/o head injury while trying to do a trick snowboarding on Saturday. C/o dizziness. Noted neck pain worse with movement. [Negative for] LOC, [Negative for] nausea. Self reports some abdominal pain last night, now resolved. Pt able to snowboard Sunday. Steady gait. Advised of expected wait time. Notify triage of a change in sx.” * At 1928 an RN documented “Pt left per registration.” * At 1929 the ED Timeline reflected, “Disposition Selected, ED Disposition set to LWBS after Triage.” 6.c. The medical record lacked any documentation to reflect the time or circumstances of the patient’s departure and that attempts were made to inform Patient 15 of the risks of leaving the hospital without an MSE or that any attempts to obtain informed written refusal of an MSE had been made, as required by the hospital’s P&Ps. Further, it was unclear whether the RN’s advisement to the patient “of expected wait time” was unsolicited and may have contributed to the patient leaving without an MSE. 6.d. During interview with the CNO at the time of the ED record review on 05/01/2024, they confirmed that the record reflected Patient 15 had not been informed of the risks of leaving without an MSE and that informed written refusal of an MSE had not been obtained.”

“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: 40575 Based on interview, documentation reviewed in 1 of 6 medical records of patients who presented to the hospital’s ED and who were transferred to other facilities (Patient 13), and review of hospital policies and procedures, it was determined that the hospital failed to effect all aspects of an appropriate transfer of those individuals as required by the hospital’s policies and procedures. * The hospital failed to ensure that the required physician certification, that the benefits of the transfer outweighed the increased risks of transfer, identified the patient specific and individualized risks of transfer. * The hospital failed to ensure that all medical records available at the time of the transfer were sent to the receiving facility. Findings include: 1. Review of the P&P “Emergency Medical Treatment And Labor Act (EMTALA) Compliance For Legacy Health Emergency, Labor And Delivery, Psychiatric Emergency Services And Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements For Non-Compliance” dated last revised “02/23” reflected: * “If an individual comes to one of Legacy’s Dedicated Emergency Departments Legacy will: 1. Provide to an individual who is determined to have an Emergency Medical Condition such further medical examination and treatment as is required to stabilize the Emergency Medical Condition, or 2. Arrange for transfer of the individual to another medical facility in accordance with the procedures set forth ...” * “If Legacy does not have the capability to provide necessary stabilizing treatment for the patient, Legacy may transfer the patient to another medical facility which has the capability to provide the required treatment and has accepted the patient. All relevant sections of the EMTALA Patient Transfer Form must be completed to ensure that the transfer is an Appropriate Transfer.” * “A patient has the right to refuse the MSE, further examination, treatment or transfer to another facility.” * “Legacy must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2) records related to the individual’s EMC; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; (8) the written patient consent or LIP certification to transfer; and (9) the name and address of any on-call LIP who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment.” * “Legacy must forward relevant records, pending lab work and test results to the receiving facility that was not available at the time of transfer as soon as possible.” 2.a. The cental log for Patient 13 reflected that they presented to the ED on 02/27/2024 at 1649 with a “Chief Complaint” of “Shoulder Injury, Hip Injury.” The ED Disposition on the log was “Transfer to Another Facility” on 02/27/2024 at 2038. 2.b. The medical record for Patient 13’s ED encounter was reviewed and included the following information: * At 1649 the ED Timeline reflected, “Patient arrived in ED.” * At 1703 the ED Timeline reflected, “Triage Started.” * At 1703 an RN documented a ED Note, “Pt BIBA from LA fitness for fall onto left shoulder and hip. States was playing basketball, player ran into [them] and landed on floor. Cant [sic] bare [sic] weight or stand, no obvious hip deformity and [positive for] shoulder pain. Pt AOx4, resp even and unlabored, skin pwd, mae, conversation appropriate, sling in place, no obvious deformity noted, cms intact.” * At 1723 the ED Timeline reflected, “Imaging Exam Started.” * The ED Provider Note reflected the following: At 1805, “XR Left Shoulder shows anterior left humeral dislocation - plan for reduction under sedation. XR Left Hip shows bilateral superior pubic ramus fractures - ordered CT pelvis to further evaluate.” At 1822, “Left shoulder reduction performed under propofol sedation.” At 1900, “XR Left Shoulder (post-reduction) shows improved alignment.” At 1937, “Case discussed with [MD Name] from Trauma Surgery (at [LEMC]), who agrees to accept, but would like to get input from trauma ortho prior to transfer to confirm that this is a [sic] either surgical injury or patient would benefit from trauma center care.” At 2018, “Case discussed with [PA name for Ortho MD], who reviewed the images and discussed with staff, who agreed that this can be treated surgically. They would be willing to operate upon transfer. Will transfer under trauma, [Trauma Surgeon Name] accepting.” * At 2038, the ED Timeline reflected, “ED Disposition set to Transfer to Another Facility.” 2.c. The electronic two-page “Patient Transfer form in Patient 13’s record contained EMTALA physician transfer certification and other required documentation and included the following: * Beginning on Page 1 the form reflected: - In the space for “Emergency Medical Condition (EMC):” was written “Bilateral Pelvic and Sacral Fx’s.” - In the space for “Reason for Tranfer:” was “Medically Indicated due to: Lack of capability.” - In the space for “Benefits” was written “Trauma/Ortho eval and management, surgery.” - In the space for “Risks (List specific & individualized symptoms & outcomes the patient might experience)” was blank. - Pre-printed language on the form: “The receiving facility will be provided with all medical records related to the EMC:” with 2 boxes to choose from. The first box had “Printed copy sent with patient” and the second box reflected “Records available to receiving organization in Epic Care Everywhere.” Neither box was checked. The form continued on Page 2 and reflected: the Provider Certification with the ED MD’s signature dated and timed as 02/27/2024 at 2020. 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 13 had discussed. There was no documentation that medical records had been sent with the patient or that the receiving facility would have access to Epic Care Everywhere. 2.e. During interview with the CNO on 05/01/2024 at the time of the ED record review, they confirmed the lack of clear transfer risks in the record for Patient 13.”