Refer to the deficiency cited at Tag A2400 related to Patient 25 on the revisit survey CMS 2567 with Survey Event ID LIQL12 dated 11/16/2018.

Refer to the deficiency cited at Tag A2406 related to Patient 25 on the revisit survey CMS 2567 with Survey Event ID LIQL12 dated 11/16/2018.

Based on observation, interview, review of documentation in 2 of 6 medical records of patients for who the central log reflected a disposition of "Left AMA" (Patients 8 and 9), review of 3 of 9 medical records of patients who were transferred from BAH to another hospital for specialty services not available at BAH (Patients 2, 6 and 14), review of central log documentation, and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure compliance in the following areas: * EMTALA policies and procedures were incomplete and unclear and did not ensure compliance. * Scope of service documents related to BAH's capabilities were incomplete and unclear. * MSEs were not conducted for all patients who presented to the hospital. * Patient specific risks and benefits of transfer were not identified for all patients transferred to other hospitals from the ED for further exam and stabilizing treatment. * The central log did not accurately identify patients' dispositions from the ED. * Required EMTALA signs were not posted in all areas patients waited for exam and treatment. Findings included: 1. a. The p/p titled "EMTALA - Medical Screening Exam" dated as last approved 04/24/2018 was brief. * The "Objective" section in its entirety reflected: "EMTALA requires three distinct legal duties: 1. Hospital must perform a medical screening examination (MSE) to determine whether an emergency medical condition (EMC) exists on any person who comes to the hospital and requests care. 2. If an EMC is present, the hospital must treat and stabilize that condition to the extent of their available resources. 3. If not able to manage or treat the EMC, a transfer will be initiated to a facility with capability/capacity to treat the EMC." * The "Procedure" section of the p/p in its entirety reflected: "1. [MSE] All patients presenting to the [ED] will be screened by the ED provider unless the [PMD] or [PCP] is physically present in the department. See [p/p] Obstetrical Triage for pregnant patients. 2...Triage Process/Documentation, patients will see a triage nurse for evaluation of their initial complaint and a triage exam. If triaged as stable (not equivalent to a MSE), patient will then be registered, as long as there is no delay prior to their MSE by the provider. 3. Transfers originating from another ED shall be coordinated through the Transfer Coordinator's direct line. See [p/p] Transfers - Transfer Coordinator. This type of transfer generally requires ED provider to ED provider contact and continued screening upon arrival. Continued screening shall include the appropriate consultants, and if previously notified, an accepting provider. If a specialty provider accepts an ED to ED transfer, he/she must notify the ED prior to the initiation of the transfer. The ED provider shall perform the initial MSE. The on-call specialty provider will then coordinate care. 4. Providers accepting transfers to the ED from another medical facility should notify the ED provider at BAH. These patients are not under EMTALA regulations until their arrival on the hospital campus. 5. Incoming ambulances, air ambulances, Coast Guard aircraft, and other means of conveyance with patients on board should not be diverted to other facilities unless BAH is on divert or lacks capability or capacity." This p/p was inconsistent with the EMTALA requirements and therefore did not ensure compliance in the following areas: * Contrary to BAH's EMTALA obligation it indicated that "registration" would occur prior to the provision of the MSE. * It was not clear whether the PMDs or PCPs referenced as providing MSEs in lieu of the ED physician would also be credentialed and privileged for the ED, and was inconsistent with language later in the p/p where it stipulated "The ED provider shall perform the initial MSE." * In its reference to BAH's EMTALA obligation to provide further exam and stabilizing treatment, the p/p was not clear where it indicated "to the extent of their available resources." * It lacked reference to BAH's EMTALA obligation to ensure all required elements of an appropriate transfer from BAH ED to another hospital's ED were met in those cases where BAH lacked capability or capacity. * Contrary to BAH's EMTALA obligation it indicated that patients accepted by BAH as the receiving hospital "are not under EMTALA regulations until their arrival on the hospital campus." * Its reference to ambulances, aircraft, and "other means of conveyance with patients on board" did not clearly ensure that if ambulances, aircraft and other types of vehicles should arrive on BAH property that those would not be turned away regardless of divert status and that those patients would receive a MSE within the capabilities of BAH. * It lacked reference to BAH's EMTALA obligation to ensure the required EMTALA signs were posted. * It lacked reference to BAH's EMTALA obligation to maintain the required Central Log. b. The p/p provided as an EMTALA p/p titled "Transfer of Patient - Ambulance or Self or Secure" dated as last approved 01/16/2018 reflected its objective was "To facilitate the timely efficient transfer of a patient to an appropriate facility where specialized care may be received." There was no specific reference to EMTALA requirements in the document. However, the p/p required "The provider must explain the reasonably expected medical benefits to a patient from the provision of appropriate medical treatment at the stated hospital outweigh the increased risk(s) to the patient and, in the case of a patient in labor, to the unborn child, from affecting a transfer, certifying the transfer is medically appropriate and necessary...The receiving provider/facility must agree to accept the patient before continuing with transport arrangements...The provider indicates one of three options for transfer...Ground ambulance...Air ambulance...Secure transport...The PCS Supervisor or designee will assist in the preparation of the patient for transport by...Obtaining copies of patient's record as indicated on the Interfacility Transfer form...Procuring and having the equipment available with the patient...Complete the Interfacility Transfer form, making sure to fill out ALL spaces." * The p/p did not clearly specify the requirements related to EMTALA identification, communication, and documentation of patient specific risks of patient transfer. * It was additionally unclear where it reflected "Transfer of Patient...Self..." in the title where there was no information in the body of the p/p about when the hospital believed it was appropriate for a patient to transfer from the ED by self to another hospital for further exam and stabilizing treatment. c. The p/p provided as an EMTALA p/p titled "Trauma Patient Transfer into or out of Bay Area Trauma" dated as last approved 12/27/2017 reflected its objective was "To ensure the safe and appropriate transfer of a patient identified as a 'Trauma System' patient both into and out of the BAH system." There was no specific reference to EMTALA requirements in the document. However, the p/p similarly reflected the elements identified in the "Transfer of Patient..." p/p described in the paragraph. 2. BAH's ICU capabilities were unclear and incomplete. a. The undated and untitled document that listed BAH services reflected that "Inpatient Services" included ICU. The "Scope of Service...Intensive Care Unit...2017-2018" document included the following descriptions of the hospital's ICU capabilities and capacity: * The [ICU] provides and (sic) environment where patients can be closely monitored and assessed while receiving continuous and/or special therapy not capable of being delivered in other areas of the hospital. In the ICU every room is equipped for invasive and noninvasive monitoring of: vital signs, cardiac rhythm, ST segment variations and allows interfacing with other equipment throughout the hospital. Patient requiring mechanical ventilation and/or additional complex equipment will be cared for in collaborative approach to minimize the negative effects of disease, limit dysfunction and restore the patient to their optimal level of wellness. The ICU serves population more than 30 days old through the continuum of life and may not be restricted to illness within the following categories: cardiovascular, respiratory, metabolic, psychiatric, gastrointestinal, urologic, neurologic, pain or trauma." * Services provided that are varied and include, but are not limited to: IV Therapy Cardiac/Cardiovascular interventions (Including Balloon Pumps, EKOS, Impella) Wound Care Antibiotic/Medication Therapies Pain Management Nutritional Support Respiratory support and care Induced Hypothermia Infusion of Critical drips only designated for ICU administration Dialysis (Hemodialysis and Peritoneal Dialysis) - Contracted * The ICU is a twelve bed unit...staffed 24hrs a day, 7 days per week with RN's (sic) and support staff..." * The Chair of the Critical Care Committee provides medical direction to the ICU..." The ICU Scope of Service did not include reference to the type and qualifications of medical staff responsible for oversight and patient care in the ICU. Further, the services described were broad in their terms and did not clearly reflect what types of patients could be safely managed. For example: The Scope of Service identified that "Respiratory support and care" could be provided but did not specify what that included or excluded; "Dialysis...Contracted" was identified however it did not specify whether that was routine scheduled dialysis for ESRD patients in the hospital for other reasons or whether acute dialysis could be provided for patients with urgent/emergency needs. b. On 07/13/2018 at 0930 an interview was conducted with the DRM, BAH Medical Director, BAH Head Hospitalist, and a second BAH Hospitalist. During the interview the following information was provided: * BAH had internal medicine physicians on staff who functioned in the role of Hospitalist and covered the ICU. * BAH did not have Intensivists on staff or on-call. * BAH did not have a high level ICU and had limitations to its capabilities in some of the areas that BAH had specialists on staff for. * BAH had specialty physicians on staff, however not all specialty services were provided on an on-call basis. * BAH didn't have capability to provide care for all patients with GI Bleeds, or all orthopedic patients, or all patients who required a ventilator. * BAH had a cardiologist and neurologist on staff but they they didn't have capability to provide care for all patients who required those services for reasons including there was a "limited support structure" for those services. * BAH did not have a pulmonologist or a critical care physician who are generally in the role of Intensivist. * BAH has had a nephrologist for the last year and one/half, however the dialysis services were contracted and in transition. * BAH ICU limitations were not written down. 3. Refer to the findings for Patients 8 and 9 identified under Tag A2406, CFR 489.24(a) that reflects all patients did not receive a MSE. 4. Refer to the findings for Patients 2, 6 and 14 identified under Tag A2409, CFR 489.24(e) that reflects the physician certification lacked identification of patient specific risks and benefits of transfer from the ED. 5. Refer to the findings identified under Tag A2405, CFR 489.20(r)(3) that reflects the central log contained inaccurate information about patient disposition from the ED. 6. Refer to the findings identified under Tag A2402, CFR 489.20(q) that reflects required EMTALA signs were not posted in the ED or FBC.

Based on observation, interview and review of policies and procedures it was determined the hospital failed to develop and enforce EMTALA policies and procedures that ensured the posting of signage that specified patients' EMTALA rights in all areas likely to be noticed and where patients waited for examination and treatment. Findings include: 1. The p/p titled "EMTALA - Medical Screening Exam" dated as last approved 04/24/2018 was brief and lacked reference to BAH's EMTALA obligation to ensure the required EMTALA signs were posted. 2. A tour of the ED was conducted with the ED ANM and the FD on 07/12/2018 beginning at approximately 1530. There was no EMTALA signage observed to be posted in any entrance, registration, waiting, triage, or treatment locations or areas in or near the ED at that time. The findings were confirmed during interviews with the ED ANM and the FD during the tour at 1550. 3. A tour of the FBC was conducted with the FBCM and the FD on 07/12/2018 beginning at 1515. EMTALA signage was observed posted at two nurses' stations/desks. There was no signage posted at the only entrance to the department which was a secured entrance; no signage was posted in the FBC waiting room; and no signage was posted in any triage or treatment rooms. The findings were confirmed during interviews with the FBCM and the FD during the tour.

Based on interview, review of documentation in 2 of 6 medical records of patients for who the central log reflected a disposition of "Left AMA" (Patients 8 and 9), review of central log documentation, and review of hospital policies and procedures it was determined that the hospital failed to develop and enforce policies and procedures to ensure the central logs were maintained to accurately reflect patients' dispositions from the ED. 1. The p/p titled "EMTALA - Medical Screening Exam" dated as last approved 04/24/2018 was brief. It lacked reference to BAH's EMTALA obligation to maintain the required Central Log. 2. The p/p titled "Against Medical Advice (AMA)" dated as last approved 06/30/2017 reflected that "BAH and providers will provide information on the risks and alternatives to leaving against medical advice and/or refusal of all or part of treatment...Objective: To describe the actions the staff needs to take when a patient requests to leave when no provider has discharged the patient or when a patient requests to not receive a treatment." The p/p outlined a process for providing information regarding those risks and alternatives to patients, and for obtaining documentation of the patient's understanding of those. 3. The ED log reviewed from 04/01/2018 through the date of the survey contained numerous entries for which the disposition of the patients from the ED were documented as "Left AMA." There were no other dispositions documented to identify those patients who left the ED prior to the completion of care and services, whether it was triage, MSE, or stabilizing treatment; and who had not requested to do so in advance of leaving and for whom therefore the AMA policy and procedure did not apply. 4. The ED log for Patient 8 reflected that the patient (MDS) dated [DATE] at 1350 with a chief complaint of "Personal." The log reflected the patient left the ED on 05/23/2018 at 1515 and the disposition recorded was "Left AMA." However, documentation in Patient 8's ED medical record reflected that the patient was discouraged by staff from remaining in the ED, did not receive an MSE, and did not receive information about the risks of leaving the ED AMA as required in the hospital's policy and procedure. Refer to the findings for Patient 8 identified under Tag A2406, CFR 489.24(a) that reflects the patient did not receive a MSE and did not leave AMA. 5. The ED log for Patient 9 reflected that the patient (MDS) dated [DATE] at 1706 with a chief complaint of "Suicidal ideations Personal." The log reflected the patient left the ED on 05/25/2018 at 1820 and the disposition recorded was "Left AMA." However, documentation in Patient 9's ED medical record reflected that the patient was escorted from the hospital premises by security staff, did not receive an MSE, and did not receive information about the risks of leaving the ED AMA. Refer to the findings for Patient 9 identified under Tag A2406, CFR 489.24(a) that reflects the patient did not receive a MSE and did not leave AMA. 6. These findings were discussed during interview with staff at the time of the record reviews on 07/13/2018 and 07/14/2018, and during the exit conference on 07/14/2018 at 1230. No additional information was provided.

Based on interview, review of documentation in 2 of 6 medical records of patients who presented for emergency services and for who the central log reflected a disposition of "Left AMA" (Patients 8 and 9), and review of policies and procedures it was determined that the hospital failed to fully develop and enforce policies and procedures to ensure the provision of a MSE to all patients who presented and to ensure that its staff did or said nothing to dissuade patients from staying in the hospital to receive a MSE. Findings include: 1. The p/p titled "EMTALA - Medical Screening Exam" dated as last approved 04/24/2018 was brief. * The "Objective" section in its entirety reflected: "EMTALA requires three distinct legal duties: 1. Hospital must perform a medical screening examination (MSE) to determine whether an emergency medical condition (EMC) exists on any person who comes to the hospital and requests care. 2. If an EMC is present, the hospital must treat and stabilize that condition to the extent of their available resources. 3. If not able to manage or treat the EMC, a transfer will be initiated to a facility with capability/capacity to treat the EMC." * The "Procedure" section of the p/p in its entirety reflected: "1. [MSE] All patients presenting to the [ED] will be screened by the ED provider unless the [PMD] or [PCP] is physically present in the department. See [p/p] Obstetrical Triage for pregnant patients. 2...Triage Process/Documentation, patients will see a triage nurse for evaluation of their initial complaint and a triage exam. If triaged as stable (not equivalent to a MSE), patient will then be registered, as long as there is no delay prior to their MSE by the provider. 3. Transfers originating from another ED shall be coordinated through the Transfer Coordinator's direct line. See [p/p] Transfers - Transfer Coordinator. This type of transfer generally requires ED provider to ED provider contact and continued screening upon arrival. Continued screening shall include the appropriate consultants, and if previously notified, an accepting provider. If a specialty provider accepts an ED to ED transfer, he/she must notify the ED prior to the initiation of the transfer. The ED provider shall perform the initial MSE. The on-call specialty provider will then coordinate care. 4. Providers accepting transfers to the ED from another medical facility should notify the ED provider at BAH. These patients are not under EMTALA regulations until their arrival on the hospital campus. 5. Incoming ambulances, air ambulances, Coast Guard aircraft, and other means of conveyance with patients on board should not be diverted to other facilities unless BAH is on divert or lacks capability or capacity." This p/p was inconsistent with the Federal EMTALA requirements and therefore did not ensure compliance in the following areas: * Contrary to BAH's EMTALA obligation it indicated that "registration" would occur prior to the provision of the MSE. * It was not clear whether the PMDs or PCPs referenced as providing MSEs in lieu of the ED physician would also be credentialed and privileged for the ED, and was inconsistent with language later in the p/p that stipulated "The ED provider shall perform the initial MSE." * Its reference to BAH's EMTALA obligation to provide further exam and stabilizing treatment the p/p was not clear where it indicated "to the extent of their available resources." * Its reference to ambulances, aircraft, and "other means of conveyance with patients on board" did not clearly ensure that if ambulances, aircraft and other types of vehicles should arrive on BAH property that those would not be turned away regardless of divert status and that those patients would receive a MSE within the capabilities of BAH. 2. The p/p titled "Against Medical Advice (AMA)" dated as last approved 06/30/2017 reflected that "BAH and providers will provide information on the risks and alternatives to leaving against medical advice and/or refusal of all or part of treatment...Objective: To describe the actions the staff needs to take when a patient requests to leave when no provider has discharged the patient or when a patient requests to not receive a treatment." The p/p outlined a process for providing information regading those risks and alternatives to patients, and for obtaining documentation of the patient's understanding of those. 3.. The ED log for Patient 8 reflected that the patient (MDS) dated [DATE] at 1350 with a chief complaint of "Personal." The log reflected the patient left the ED on 05/23/2018 at 1515 and the disposition recorded was "Left AMA." However, documentation in Patient 8's ED medical record reflected that the patient was discouraged by staff from remaining in the ED and left without having received a MSE. The course of the patient's ED visit was reflected in the medical record as follows: * An RN note recorded on 05/23/2018 at 1406 reflected the patient was triaged between 1359 and 1405 with triage findings that included: "'I just want to not hurt'...Suicide Risk? Yes...Depression...Chronic back pain...X3 Back Surgeries..." * An RN note recorded on 05/23/2018 at 1413 reflected the patient had "Past History of Suicide Attempts." * An RN note recorded on 05/23/2018 at 1421 reflected "Patient refused labs at this time." * An RN note recorded on 05/23/2018 at 1510 reflected "Patient reports feeling 'down in the dumps' Not suicidal, would like to talk to someone...Place in room 6, QMHP called. Social work called...[CM RN] from social work bedside." * The next entry in the medical record was written by a CM RN on 05/23/2018 at 1805, approximately three hours after the log indicated the patient left the ED. The note reflected "Discussed patient status with PA. Chart reviewed. Met with patient and introduced services...Discussed appropriate use of ED services, patient appeared upset and left before medical exam." There was no documentation that the patient received a MSE by an ED Provider, or that the patient left AMA as identified on the log and had been informed of the risks of leaving the ED prior to an MSE in accordance with the MSE and AMA policies and procedures. The medical record documentation reflected that the RN's conversation with the patient about the "appropriate use of ED services" was inappropriate and occurred immediately before the patient left the ED and prior to a MSE. That conversation was in contradiction to EMTALA requirements that prohibit the hospital from discouraging patients from remaining in the hospital. 4. The ED log for Patient 9 reflected that the patient (MDS) dated [DATE] at 1706 with a chief complaint of "Suicidal ideations Personal." The log reflected the patient left the ED on 05/25/2018 at 1820 and the disposition recorded was "Left AMA." However, documentation in Patient 9's ED medical record reflected that the patient was escorted from the hospital premises by security staff. The course of the patient's ED visit was reflected in the medical record as follows: * An RN note recorded on 05/25/2018 at 1752 reflected the patient was triaged with findings that included: "discharged from APU today. pt reports continues to be suicidal and anxious...Blood Pressure 148/103...Suicide Risk? Yes...Suicide Precautions Implemented Yes." * An RN note recorded on 05/25/2018 at 1755 reflected the patient had "Suicide Ideation with Concrete Plan - Cutting [Yes]...Past History of Suicide Attempts [Yes]." * On 05/25/2018 at 1824 a "Discharge Instructions" form was dated as "electronically signed" by a PA. The patient "Signature Acknowledgement Page" of the form was blank and contained no signatures of any persons and no other information. * A QMHP "Final" note recorded on 05/25/2018 at 1848 reflected the following: "Pt has returned to the ED after being discharged several hours ago at [his/her] own request...Pt returned to BAH saying [he/she] will commit suicide by overdosing on [his/her] Ambien unless [he/she] is readmitted to the APU. This is the same threat made when [he/she] was admitted on Wednesday...This is not a full evaluation. For more information about pt, see evaluation from admission on 05/23/2018 or the progress notes from [Physician]...QMHP discussed situation with [ED Physician on duty], who agreed that pt did not appear to be in need of acute care at this time...QMHP advised pt that [he/she] would not be admitted to the APU at this time. Pt became agitated and said [he/she] would continue to call crisis services tonight then because [he/she] is 'highly suicidal.' QMHP advised that we all hope [he/she] will make good choices and continue to keep [him/herself] safe. Pt escorted out by security." There was no documentation that the patient received a MSE by an ED Provider, or that the patient left AMA as identified on the log and had been informed of the risks of leaving the ED prior to an MSE. The medical record documentation reflected that the QMHPs conversation with the patient was inappropriate and contradictory to EMTALA requirements that prohibit the hospital from discouraging patients from remaining in the hospital. The documentation reflected the hospital refused to provide an MSE and had the patient escorted from the facility when he/she objected. 5. These findings were discussed during interviews with staff at the time of the record reviews on 07/13/2018 and 07/14/2018, and during the exit conference on 07/14/2018 at 1230. No additional information was provided.

Based on interview, review of documentation in 3 of 9 medical records of patients who were transferred from BAH to another hospital for specialty services not available at BAH (Patients 2, 6 and 14), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved as individualized, patient specific medical benefits vs risks of transfer were not documented. Findings include: 1. The p/p provided as an EMTALA p/p titled "Transfer of Patient - Ambulance or Self or Secure" dated as last approved 01/16/2018 reflected its objective was "To facilitate the timely efficient transfer of a patient to an appropriate facility where specialized care may be received." There was no specific reference to EMTALA requirements in the document. However, the p/p required "The provider must explain the reasonably expected medical benefits to a patient from the provision of appropriate medical treatment at the stated hospital outweigh the increased risk(s) to the patient and, in the case of a patient in labor, to the unborn child, from affecting a transfer, certifying the transfer is medically appropriate and necessary...The receiving provider/facility must agree to accept the patient before continuing with transport arrangements...The provider indicates one of three options for transfer...Ground ambulance...Air ambulance...Secure transport...The PCS Supervisor or designee will assist in the preparation of the patient for transport by...Obtaining copies of patient's record as indicated on the Interfacility Transfer form...Procuring and having the equipment available with the patient...Complete the Interfacility Transfer form, making sure to fill out ALL spaces." * The p/p did not clearly specify the requirements related to EMTALA identification, communication, and documentation of patient specific risks of patient transfer. * The p/p was unclear where it reflected "Transfer of Patient...Self..." in the title where there was no information in the body of the p/p about when the hospital believed it was appropriate for a patient to transfer from the ED by self to another hospital for further examination and stabilizing treatment. 2. The p/p provided as an EMTALA p/p titled "Trauma Patient Transfer into or out of Bay Area Trauma" dated as last approved 12/27/2017 reflected its objective was "To ensure the safe and appropriate transfer of a patient identified as a 'Trauma System' patient both into and out of the BAH system." There was no specific reference to EMTALA requirements in the document. However, the p/p similarly reflected the elements identified in the "Transfer of Patient..." p/p described in the paragraph above. 3. The ED medical record of Patient 2 reflected he/she (MDS) dated [DATE] at 1545 with a chief complaint of "Disorientation, unspecified Personal." An MSE was conducted by the ED Physician. * A "Transfer Summary" dated as dictated by the ED Physician on 04/15/2018 at 2117 reflected "This is a child with somnolence of undetermined etiology. Ingestion comes high on the list, however, we do not have any evidence about what ingestion that might be if [he/she] did have ingestion...I am discussing transfer with [Doernbecher Children's Hospital ICU Physician]...we agree that [he/she] should be shipped. There was a recommendation of lumbar puncture be done; however, it took three people to place an IV in [him/her]. I do not think I would be able to get an LP in [him/her] without sedation and I do not feel that our facility is equipped to do a sedation in a pediatric patient with altered mental status...Discussed the risks and benefits of deferring LP until getting to OHSU. [Parent] agrees with waiting to do LP until reaching the center." There was no documentation in the transfer summary or elsewhere in the record to reflect what the patient specific risks and benefits of the transfer were. * An "Interfacility Transfer Form" signed by the ED Provider on 04/15/2018 at 2235 included a section for the ED provider to document "determined risks (include risks of transport and alternatives)." The only documentation recorded in that section was "Risks of transport also Randall Children Hospital." There was no documentation on the form to reflect what the patient specific risks of the transfer were. 4. The ED medical record of Patient 6 reflected he/she (MDS) dated [DATE] at 1022 with a chief complaint of "Disruption of wound...Back pain." An MSE was conducted by the ED PA. * A "Transfer Summary" dated as dictated by the ED PA on 05/12/2018 at 1435 reflected "Patient has a surgical incision that is approximately 6 cm long on the lumbar spine. There is dehiscence to 2/3 of this wound. Sutures in place. Copious amount of drainage...I did call Sacred Heart and spoke to spinal surgeon...who stated [he/she] had already agreed to accept the patient...This is a surgical wound from surgery approximately two weeks done...in Eugene...will be transferred to Sacred Heart..." There was no documentation in the transfer summary or elsewhere in the record to reflect that patient specific risks and benefits of transfer were identified and discussed with the patient. * An "Interfacility Transfer Form" signed by the ED PA on 05/12/2018 at 1109 included a section for the ED provider to document "determined risks (include risks of transport and alternatives)." That section was blank. There was no documentation recorded in that section. 5. The ED medical record of Patient 14 reflected he/she (MDS) dated [DATE] at 0640 with a chief complaint of "Gun shot wound." An MSE was conducted by the ED DO and on-call Orthopedic MD. * An "Emergency Department Note" dated 06/28/2018 as dictated by the ED DO on 06/28/2018 at 0919 reflected "...shot [him/herself]...entered kind of [his/her] left pectoral area and went up towards the left shoulder...The surgeon here is involved. Orthopedics here are involved. I have discussed the case with Eugene for transfer. They do not feel that there is anything emergent to do with this brachial plexus injury and they have no beds." * A "Consultation Note" dated as dictated by the Orthopedic MD on 06/28/2018 at 0921 reflected "The emergency room staff has discussed the patient with the trauma service in Eugene. They say at this point they are unable to take the patient. From an orthopedic point of view with a brachial plexus injury, observation is appropriate at this time. There is not a need for urgent medical or surgical management. The patient can be serially observed, and if there is a change in status, we could arrange for a transfer up to [OHSU] as necessary...at this point [he/she] is stable and safe for observation here." * An "Interfacility Transfer Form" signed by the ED Provider on 06/28/2018 at 1102 reflected that OHSU had accepted Patient 14 for transfer on 06/28/2018 at 1037. The form included a section for the ED provider to document the "determined benefits" of transfer and "determined risks (include risks of transport and alternatives)." Those spaces were blank. There was no documentation recorded to reflect the patient specific risks and benefits of the transfer. 6. These findings were discussed during interviews with staff at the time of the record reviews on 07/13/2018 and 07/14/2018, and during the exit conference on 07/14/2018 at 1230. No additional information was provided.