Based on document review and interview, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to ensure a medical screening exam was performed by a qualified medical professional as appointed in the Bylaws for one (#1) of twenty four patients reviewed, from a total sample of twenty four, see A 2406.

Based on document review and interview the facility failed to ensure a medical screening exam (MSE) was conducted for 1 of 24 patients (pt.#1) by an individual determined qualified by hospital bylaws or rules and regulations resulting in the potential for failure to identify an emergent medical condition for patients seeking emergency care. Findings include: On 3/7/2018 at 0900 a review of the Emergency Medical Services (EMS) record of patient #1, the patient of concern listed in the complaint, was conducted. The EMS record revealed that the patient was a [AGE]-year-old Caucasian female with a medical history of a heart attack, abdominal bleeding, and dementia. The patient's chief complaint was noted as nausea/vomiting and secondary complaint as chest pain/discomfort. The record states that a call was placed to EMS at 1617, arrived at scene at 1635, assessed patient at 1639, and departed to the receiving hospital at 1700. The patient was documented as having nausea for several hours. The patient denied chest pain, radiating pain, and denied numbness. Also noted was the patient had exposure to a family member whom had tested positive for the flu within the past week. The patient's vital signs were documented as blood pressure 162/72, pulse 68, respirations 16, oxygen saturation 93%, and was recorded as alert and oriented with equilateral hand grasps. Two 12-lead electrocardiograms (EKG) were present in the record. The first EKG was interpreted as normal sinus rhythm. The second (repeat) EKG was interpreted as normal sinus rhythm. The record stated the patient was then taken to hospital B (receiving hospital) upon the request of the daughter (the patient's durable power of attorney) and the patient. On 3/7/2018 at 1050 an interview was conducted with staff R, one of two paramedics sent to patient #1 ambulance run on duty on 2/8/2018. Staff R was asked what the chief complaint of pt. #1 at the time she arrived on scene. Staff R explained the patient (#1) was extremely weak and had been vomiting for several hours. Staff R was asked to confirm that the secondary complaint was cardiac pain. Staff R responded, "although we were initially sent with the call stating cardiac pain when we got there the patient had weakness and nausea and vomiting ...the patient denied chest pain." Staff R was then asked to confirm her documentation "(patient) denies chest pain, discomfort, radiation of pain anywhere." Staff R confirmed this was her documentation. Staff R was then asked if the patient's only complaint was epigastric pain and nausea. Staff R confirmed this was the patient's only complaint. Staff R was then asked if the patient's 12-lead-EKG showed any abnormalities that indicated an active infarct (active heart attack). Staff R stated the patient's 12-lead-EKG was not indicating an STEMI (ST elevation myocardial infarction which requires immediate intervention). Staff R was then asked if she received communication to transfer the patient to the hospital located north and 41 miles from the patient's home. Staff R confirmed she had received a text on her personal phone stating "No beds available. Send north." Staff R was asked whom she received the text from and she stated staff Q, another paramedic from home base. Staff R was then asked if she had been in touch with the medical control at which time staff R became tearful and stated, "No. I did not contact medical control." Staff R was then asked if she was required to contact medical control. Staff R stated "yes." Staff R stated, "I did share (with the patient and her daughter) that we had received a text from the facility that no beds were available, and we had been advised to head north." Staff R was asked if she was the only person to receive the text and she stated, "No ...we both received a text." Staff R stated the option provided to the patient was a transfer to hospital B or to remain home. Staff R stated the patient and patient's daughter agreed to the transfer. On 3/7/2018 at 1130 an interview was conducted with the emergency department (ED) physician, Staff J, on duty the afternoon of 2/8/2018. Staff J was asked if he was aware of a transfer of a patient on 2/8/2018 to hospital B. Staff J responded "well, yes. I remember an ambulance being dispatched for a chest pain patient in the Bear Lake area. I also know I have been asked about this transfer as the hospital has been looking into this incident for a complaint investigation." Staff J was then asked if he had given a directive for the EMS team to take the patient to hospital B. Staff J responded "I know that I had asked more than twice what had happened with the run with the patient with chest pain ...I specifically said 'what happened to the patient with chest pain ...we never heard from that call' and then I had been told that the run went north but I had not been included on that decision." On 3/7/2018 at 1300 review of the requested census of the hospital and ED on the date in question revealed on 2/08/2018 the hospital in-patient census was 29 and the total number of patients seen in ED was 41. On 3/7/18 at approximately 1345 Staff A, director of nursing was queried if the facility was on diversionary status for the date of 2/08/18. Staff A stated "We (the facility) would not have been able to admit additional patients to upstairs, but we were not on diversion and did not divert any patients." On 3/7/2018 at 1400 a review of the medical staff bylaws was conducted. Review of the document failed to contain an appointment of those individuals who were authorized to conduct a medical screening exam. Staff A was asked to provide proof of documentation that existed in the medical staff bylaws of individuals that were privileged to conduct a medical screening exam. Staff A was unable to provide documentation of who was privileged to conduct medical screening exams as specified by the medical staff bylaws. Staff A presented a policy titled "Medical Screening Examinations" dated 7/2014 with a expiration date of 6/2017. The policy was noted as being expired. The policy states "a medical screening examination (MSE) by the ED physician on duty."