Based on policy and record review, the critical access hospital (CAH) did not enforce their policies and procedures and failed to provide two patients (# 1 and 16) that presented to the emergency department (ED) with an appropriate medical screening examination; and failed to obtain physician certification that the expected benefits of transfer outweighed the increased risk of transfer for one patient (# 17) with an unstable emergency medical condition (EMC), out of 25 records selected from the ED log for review from June 2014 - January 2015. The ED treated approximately 296 patients in the six month period August 2014 to January 2015 and transferred approximately 49 patients in the same six months to another healthcare facility. The CAH had an average daily census of one. Findings include: 1. Review of the CAH's "Medical Screening Exams" policy # 2302, last revised 3/2007 reads in part, ... "Medical Screening Exams should include at a minimum the following: Patient's triage record; vital signs; history; physical exam of affected systems and potentially affected systems; exam of known chronic conditions; necessary testing to rule out emergency medical conditions ... " Medical screening exams should include at a minimum...Necessary testing to rule out emergency medical conditions...notification and use of on call physicians to diagnose and/or stabilize the patient as necessary..." A. Review of the medical record revealed patient # 1 presented to the emergency department (ED) on Sunday 1/11/15 at 7:00 AM complaining of severe right upper quadrant abdominal pain. The ED record lacked evidence that any diagnostic imaging or laboratory testing was performed to evaluate the patient's severe pain and determine if an emergency medical condition existed prior to ED physician A's order for discharge. Refer to tag C 2406 for further details. B. Review of the medical record revealed patient # 16, two and a half months pregnant presented on Wednesday 6/18/14 complaining of vaginal bleeding. The ED record lacked evidence that mid-level practitioner D performed a pelvic examination or arranged for an ultrasound to be performed to determine if an emergency medical condition existed prior to discharging patient # 16. Refer to tag C 2406 for further details. 2. Review of a second CAH policy " EMTALA Guidelines for Emergency Department Services " reference # 2302, effective 2/2006 reads in part, ... " A transfer of a potentially unstable patient to another facility may only be for reason of medical necessity. " " If a patient is to be transferred for medical necessity the following guidelines must be followed: A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be documented and the patient ' s medical record must suppose these ... " " In addition to the following: ... " The physician will order appropriate medical personnel to attend the patient, maintain and/or initiate treatment or medications and manage known potential adverse affects. " The policy did not address the EMTALA requirements qualified medical personnel (QMP) / mid-level practitioners must follow in the event a physician is not physically present in the ED when transferring a patient with an unstabilized EMC. The policy did not direct the QMP / mid-level practitioner to sign the certification that must contain a summary of the risks and benefits upon which it is based only after consultation with a CAH physician who agrees with the transfer. The policy did not direct the CAH physician to countersign the certification, or establish the timeframe in which the physician must countersign the certification. A. Review of the medical record revealed patient # 17 presented on Saturday 6/14/14 at 9:14 AM complaining of abdominal pain. Mid-level practitioner E determined the patient had an unstable emergency medical condition and arranged transfer to hospital X. The medical record did not contain evidence that mid-level practitioner E consulted a CAH physician prior to transfer, or that a CAH physician certified in the medical record, the benefits expected from appropriate care at hospital X and the risks associated with the transfer, including the time away from the CAH to reach hospital X. Refer to tag C 2409 for details.

Based on medical record review and staff interviews, the Critical Access Hospital (CAH) failed to perform a medical screening examination (MSE) sufficient to determine if an emergency medical condition (EMC) existed prior to discharging two patients (# 1 and 16) that presented to the hospital emergency department (ED) requesting care out of 25 ED records reviewed from August 2014 to January 2015. Findings include: 1. Review of Patient #1's medical record on 2/2/15 revealed patient #1 presented to the emergency department (ED) on Sunday 1/11/15 at 7:00 AM complaining of right upper quadrant abdominal pain. Registered Nurse B's notes at admission indicated patient #1 complained of right upper quadrant pain that started the day before at 7:00 AM, the patient's prescribed Norco (an oral pain medication) didn't help. Registered Nurse B documented that Patient #1 was not eating and had vomited four times in the night. Further documentation showed patient # 1 had a gall bladder scan last Sunday (1/4/15) which showed gallstones, and that it was the third time this week the patient had been in the ED. Registered Nurse B documented that Patient #1 rated her pain a 10 (most severe) on a 1-10 scale and described the pain as sharp, acute, radiating into her back. Physician A's notes indicated patient #1 complained of abdominal pain, nausea, vomiting which started 2 weeks ago and had been evaluated for gallstones at another hospital. Further documentation showed patient # 1 had exquisite right upper quadrant abdominal pain and a positive Murphy ' s sign (pain elicited when the clinician applies deep pressure over the gallbladder when the patient is taking a deep breath). Physician A ordered patient # 1 to receive an intramuscular injection (shot) of Dilaudid (narcotic pain medication), a shot of Toradol (non-narcotic pain medication) and a shot of Rocephin (antibiotic). Physician A diagnosed patient # 1 with [DIAGNOSES REDACTED] (inflammation of the gallbladder due to obstruction) and Cholelithiasis (stones in the gallbladder), and discharged the patient to home at 8:39 AM with instructions to continue taking Norco (previously prescribed pain pills), Cephalexin (previously prescribed antibiotic), increase fluid intake and to contact her surgeon. The ED record lacked evidence that any diagnostic imaging or laboratory testing was performed to evaluate the patient ' s severe pain and determine if an emergency medical condition existed prior to ED physician A ' s order for discharge. A. Review of Hospital Z ' s medical record revealed patient # 1 presented on Sunday 1/11/15 at 4:30 PM. Documentation in the medical record confirmed patient # 1 was emergently taken to surgery at 8:50 PM. B. Registered Nurse (RN) staff B interviewed on 2/3/15 at 8:40 AM acknowledged they were the nurse in the ED when patient #1 came to the ED on 1/11/15. Staff B indicated patient #1 came in excruciating pain and the patient had already had a sonogram showing stones in the gallbladder. Physician staff A sent the patient home and instructed to follow-up at hospital Z if needed. Staff B indicated they knew the patient would probably end up at hospital Z since the patient was eating Norco like crazy. C. Physician A interviewed on 2/5/15 at 10:40 AM confirmed he did not order any lab tests or imaging studies on patient #1 on 1/11/15. Physician A stated that patient # 1 had lab tests performed four days prior on 1/7/15. Physician A acknowledged that the labs test results could have changed. Physician A stated he felt lab tests would be performed at hospital Z. 2. Patient #16's medical record reviewed on 2/4/15 revealed the patient (MDS) dated [DATE] at 11:17 PM complaining of vaginal bleeding and mild abdominal cramping. Nurses' notes revealed patient # 16 was two and a half months pregnant; bleeding started at 3:00 PM and had increased through the evening. Mid-level practitioner, physician assistant (PA) D noted patient # 16 was ten weeks pregnant and had vaginal bleeding that began around 3:00 PM that had increased as the day progressed. Further documentation showed patient # 16 indicated her OB (Obstetrician) physician (located approximately 140 miles away) had instructed her to go to the local ED if her bleeding increased. Mid-level practitioner D ordered routine lab testing including a complete blood count (CBC), a comprehensive metabolic panel (CMP), a human chorionic gonadotropin level (hCG), to check the level of the pregnancy hormone hCG, type Rh (blood test to determine the fetus ' blood type) and a urine specimen to determine the presence of a urinary tract infection. Mid-level practitioner D documented she contacted physician A who confirmed the patient did not require antibiotics. Mid-level practitioner D discharged patient # 16 back to her home. At 1:19 AM the ED nurse documented on the discharge instruction form that patient # 16 should drink plenty of fluids, " if bleeding gets worse go to (another town) or somewhere where they have a bigger ER " , and " Follow up with provider/OB Doctor in AM. " The ED record lacked evidence that mid-level practitioner D performed a pelvic examination or arranged for an ultrasound to be performed to determine the presence of an emergency medical condition prior to discharging patient # 16.

Based on medical record review, the critical access hospital (CAH) failed to consult with and obtain the physician's certification that the expected benefits of transfer outweighed the increased risk of transfer for one patient (# 17) with an unstable emergency medical condition (EMC), out of 25 records selected from the ED log for review from June 2014 - January 2015. The ED treated approximately 296 patients in the six month period August 2014 to January 2015 and transferred approximately 49 patients in the same six months to another healthcare facility. The CAH had an average daily census of one. Failure to consult with the physician regarding the transfer of a patient with an unstabilized emergency medical condition placed the patient at risk for a delay in transfer and subsequent stabilizing treatment which could potentially lead to further complications or death. Findings include: Review of the medical record revealed patient # 17 presented on Saturday 6/14/14 at 9:14 AM complaining of abdominal pain. Registered Nurse (RN) B's Nurses' notes indicated that the patient ' s pain began last night and worsened after supper. Further documentation showed the patient had tenderness throughout his abdomen, especially in the right upper and lower quadrant. Patient # 17 rated his pain intensity 8 on a pain scale of 1-10 with 10 being the worst pain and demonstrated facial grimacing, moaning, perspiration, and vital sign changes.. At 9:56 AM the nurse administered 1 mg of Morphine (narcotic pain medication) through the intravenous catheter. At 10:07 patient # 17 received a second dose of Morphine 1 mg for continued pain rated at 8, a third dose of Morphine 2mg at 11:50 AM and a fourth dose of Morphine 2mg at 1:33 PM for a pain level of 8. At 9:50 AM physician assistant (PA) mid-level practitioner E examined patient # 17 and ordered blood for lab testing and a CT scan (special type of x-ray) of the patient ' s abdomen and pelvis. At 12:05 PM the radiologist contacted mid-level practitioner E and reported the CT scan results showed an abnormal appearing appendix felt to represent appendicitis. At 12:55 PM, mid-level practitioner E diagnosed patient # 17 with acute appendicitis (an emergency medical condition) and documented that the patient would be transferred to Hospital X for surgery. Further documentation showed that patient # 17 refused to be transported to Hospital X by an ambulance. Mid-level practitioner E documented " I discussed the risks of using POV (personal own vehicle) and benefits of a trained EMS crew." "Pt (patient) again refused and has signed a waiver releasing us from liability." "Pt's spouse will drive him to (Hospital X) for surgery today. " " (Hospital X) knows that they will be in personal vehicle. " Mid-level practitioner E documented on the "Physician Assessment and Certification for Patient Transfer" form that patient # 17's condition had not been stabilized, that Hospital X had agreed to accept the transfer, the name and phone number of the accepting physician and that the patient's condition exceeded the capabilities of the CAH and needs surgery. The certification form was signed by mid-level practitioner E at 12:28 PM on 6/14/14. Just prior to the patient's departure at 1:35 PM, the ED nurse documented that the patient "still refuses" to go by ambulance, stated he will go by private vehicle. "Spouse states that she can do just as well as EMS and pt has been in the back of the ambulance before and it was too rough and he won't be able to tolerate the ride." On 6/25/14 at 3:12 PM, eleven days after patient # 17's transfer, physician A electronically signed the medical record on page 2 of the "Provider Form" where mid-level practitioner E documented his exam. The medical record did not contain evidence that mid-level practitioner E consulted with a CAH physician just prior to patient # 17's transfer to obtain the physician's risks and benefits certification, or that the physician subsequently countersigned the certification as required by EMTALA.