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Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the ED staff followed the CAH's policies and ensure that 1 of 1 pregnant women (Patient #1) who presented to the Emergency Department (ED) with an emergency medical condition received an appropriate medical screening examination. Failure to provide an appropriate medical screening exam at the CAH resulted in Patient #1 being transported to Hospital A, which resulted in a delay of Patient #1 receiving an appropriate medical screening exam by more than 30 minutes. The administrative staff identified an average of 244 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the CAH policy "Transfer and Emergency Examination (EMTALA)," approved 11/2020, revealed in part, "Definitions ... Comes to the Emergency Department. ... the individual ... Is in a ground or air nonhospital-owned ambulance on Hospital Property for presentation for examination and treatment for a medical condition at a hospital's [Dedicated Emergency Department]." "Hospital Property. The entire main hospital campus, including the parking lot, sidewalk and driveway ..."

"Entitlement to medical screening examination. Any individual ... shall be provided an appropriate [medical screening examination] within the capabilities of the Emergency Department ..." "A pregnant woman experiencing contractions shall be provided a [medical screening examination]."

2. Review of Patient #1's medical record at the CAH revealed RN E retrieved Patient #1's demographics, allergies, and reported home medications from the CAH's electronic medical record system. RN E documented that Patient #1 arrived at the CAH at 9:42 PM on 4/11/21, with a chief compliant of "OB Complications." The medical record did not contain any evidence that Patient # 1 received a medical screening examination.

3. Review of Patient #1's medical record at Hospital A revealed that Paramedic D documented in Patient #1's medical record that an ambulance was dispatched to Patient #1's home for a female "18 weeks pregnant, in labor." Patient #1's chief complaint was "ruptured placenta" (tearing of the connection between mother and baby in the uterus, a life threatening emergency for the baby).

Paramedic D initiated transport to the CAH, per Patient #1's request. Paramedic D called the CAH's ED and notified them that Paramedic D was transporting Patient #1 to the CAH, Patient #1's chief complaint, and medical condition. During Patient #1's transport to the CAH, Patient #1 experienced "pressure" and "contractions" in the ambulance.

When the ambulance arrived at the CAH, the CAH staff instructed the EMS staff to divert the ambulance to Hospital A, as the CAH staff had closed the Obstetric (OB) unit. Patient #1 experienced contractions lasting less than 1 minute at 10:05 PM (23 minutes after the ambulance presented to the CAH), 10:07 PM (25 minutes after the ambulance presented to the CAH), and 10:10 PM (28 minutes after the ambulance presented to the CAH).

The ambulance containing Patient #1 presented to Hospital A at 10:13 PM on 4/11/21 (31 minutes after presenting to the CAH). ED Physician H examined Patient #1 at 10:13 PM on 4/11/21 and documented that Patient #1's water broke before 37 weeks of Patient #1's pregnancy (placing Patient #1's baby's life in jeopardy). ED Physician H consulted with ED Physician I at Hospital B, who agreed to accept Patient #1 for continued care. The ED staff at Hospital A transferred Patient #1 to Hospital B via a separate ambulance on 4/12/21 at 12:59 AM (137 minutes after the ambulance presented to the CAH).

4. During an interview on 5/13/21 at 9:10 AM, Paramedic D revealed they went to Patient #1's home in response to a 911 call. Upon the arrival of Paramedic D's ambulance at Patient #1's house, Paramedic D assessed Patient #1. During the assessment, Patient #1 revealed they received their normal care at the CAH. Based on Patient #1 receiving their care at the CAH, Paramedic D instructed the other EMS crew members to transport Patient #1 to the CAH.

Approximately 5 minutes prior to the ambulance arriving at the CAH, Paramedic D called the CAH and notified the CAH ED staff that Paramedic D was transporting Patient #1 to the CAH, Patient #1's chief complaint, and current medical status. The CAH ED staff indicated the ED staff would see Patient #1 when the ambulance arrived at the CAH.

Upon the ambulance's arrival at the ED, Paramedic F (who worked at the CAH) informed the EMS crew that the CAH did not offer obstetrical services and the EMS crew should transport Patient #1 to Hospital A, as Patient #1 had an obstetrical chief complaint. Per Paramedic F's instructions, Paramedic D instructed the EMS crew to transport Patient #1 to Hospital A. During the transport from the CAH to Hospital A, Patient #1 began experiencing increasing contractions.

5. During an interview on 5/13/21 at 8:00 AM, Paramedic F (who worked for the CAH) revealed that RN E received a call informing RN E about an ambulance on its way to the CAH with an obstetrical patient. Paramedic F inquired why the ambulance staff chose to bring an obstetrical patient to the CAH, as the CAH lacked obstetrical services. When the ambulance arrived on the CAH's property, Paramedic F went out to meet the ambulance outside the ambulance bay. Paramedic F informed Paramedic D that the CAH did not offer obstetrical services, and Paramedic D should transport Patient #1 to Hospital A (which offered obstetrical services).


Please see C-2406 for additional information.

Based on document review and staff interviews, the administrative staff failed to ensure the critical access hospital's (CAH's) ED staff provided 1 of 1 pregnant women (Patient #1) with an appropriate medical screening examination after presenting to the Emergency Department (ED) by ambulance seeking medical care. Failure to provide an appropriate medical screening exam at the CAH resulted in EMS staff transporting Patient #1 to Hospital A, which resulted in a delay of Patient #1 receiving an appropriate medical screening exam by more than 30 minutes. The CAH's administrative staff identified an average of 244 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #1's medical record at the CAH revealed RN E retrieved Patient #1's demographics, allergies, and reported home medications from the CAH's electronic medical record system. RN E documented that Patient #1 arrived at the CAH at 9:42 PM on 4/11/21, with a chief compliant of "OB Complications." The medical record did not contain evidence that Patient # 1 received a medical screening examination.

2. Review of Patient #1's medical record at Hospital A revealed that Paramedic D documented in Patient #1's medical record that the ambulance was dispatched to Patient #1's home for a female "18 weeks pregnant, in labor." Patient #1's chief complaint was "ruptured placenta" (tearing of the connection between mother and baby in the uterus, a life threatening emergency for the baby).

Paramedic D initiated transport to the CAH, per Patient #1's request. Paramedic D called the CAH's ED and notified them that Paramedic D was transporting Patient #1 to the CAH, Patient #1's chief complaint, and medical condition. During Patient #1's transport to the CAH, Patient #1 experienced "pressure" and "contractions" in the ambulance.

When the ambulance arrived at the CAH, the CAH staff instructed the EMS staff to divert the ambulance to Hospital A, as the CAH staff had closed the Obstetric (OB) unit. Patient #1 experienced contractions lasting less than 1 minute at 10:05 PM (23 minutes after the ambulance presented to the CAH), 10:07 PM (25 minutes after the ambulance presented to the CAH), and 10:10 PM (28 minutes after the ambulance presented to the CAH).

The ambulance containing Patient #1 presented to Hospital A at 10:13 PM on 4/11/21 (31 minutes after presenting to the CAH). ED Physician H examined Patient #1 at 10:13 PM on 4/11/21 and documented that Patient #1's water broke before 37 weeks of Patient #1's pregnancy (placing Patient #1's baby's life in jeopardy). ED Physician H consulted with ED Physician I at Hospital B, who agreed to accept Patient #1 for continued care. The ED staff at Hospital A transferred Patient #1 to Hospital B via a separate ambulance on 4/12/21 at 12:59 AM (137 minutes after the ambulance presented to the CAH).


3. During an interview on 5/13/21 at 9:10 AM, Paramedic D revealed they went to Patient #1's home in response to a 911 call. Upon the arrival of Paramedic D's ambulance at Patient #1's house, Paramedic D assessed Patient #1. During the assessment, Patient #1 revealed they received their normal care at the CAH. Based on Patient #1 receiving their care at the CAH, Paramedic D instructed the other EMS crew members to transport Patient #1 to the CAH.

Approximately 5 minutes prior to the ambulance arriving at the CAH, Paramedic D called the CAH and notified the CAH ED staff that Paramedic D was transporting Patient #1 to the CAH, Patient #1's chief complaint, and current medical status. The CAH ED staff indicated the ED staff would see Patient #1 when the ambulance arrived at the CAH.

Upon the ambulance's arrival at the ED, Paramedic F (who worked at the CAH) informed the EMS crew that the CAH did not offer obstetrical services and the EMS crew should transport Patient #1 to Hospital A, as Patient #1 had an obstetrical chief complaint. Per Paramedic F's instructions, Paramedic D instructed the EMS crew to transport Patient #1 to Hospital A. During the transport from the CAH to Hospital A, Patient #1 began experiencing increasing contractions.

4. During an interview on 5/12/21 at 1:35 PM, Ambulance Driver A revealed that they picked Patient #1 up at Patient #1's home. Paramedic D informed Ambulance Driver A to transport Patient #1 to the CAH. Upon arrival at the CAH, Paramedic F approached Ambulance Driver A and asked why the ambulance was at the CAH. Paramedic F (who worked for the CAH) informed Ambulance Driver A that the CAH did not have obstetrical services. Ambulance Driver A instructed Paramedic F to speak to Paramedic D about Patient #1. After Paramedic F spoke with Paramedic D, Paramedic D instructed Ambulance Driver A to transport Patient #1 to Hospital A.

5. During an interview on 5/12/21 at 3:00 PM, RN E revealed they received a call from the county sheriff's department that the ambulance was bringing a patient to the CAH who was 18 weeks pregnant and complaining of cramping (an early sign of labor). RN E took down the information for Patient #1 from the sheriff's department staff and registered Patient #1 in the CAH's electronic medical record. RN E informed ED Physician G and Paramedic F that an ambulance was bringing Patient #1 to the CAH and Patient #1 was complaining about cramping while also 18 weeks pregnant.

During RN E's conversation with Paramedic F, Paramedic F informed RN E that the ambulance staff should not bring Patient #1 to the CAH, as the CAH lacked obstetrical services. RN E informed Paramedic F that the CAH ED staff needed to evaluate Patient #1, as failing to evaluate Patient #1 was possibly an EMTALA violation.

While RN E prepared the CAH's ED for Patient #1's arrival, Paramedic F informed RN E that Paramedic F went out to the ambulance after it arrived on the CAH's property, informed the ambulance crew that the CAH lacked obstetrical services, and that the ambulance crew needed to transport Patient #1 to Hospital A.

6. During an interview on 5/13/21 at 8:00 AM, Paramedic F (who worked for the CAH) revealed that RN E received a call informing RN E about an ambulance on its way to the CAH with an obstetrical patient. Paramedic F inquired why the ambulance staff chose to bring an obstetrical patient to the CAH, as the CAH lacked obstetrical services. When the ambulance arrived on the CAH's property, Paramedic F went out to meet the ambulance outside the ambulance bay. Paramedic F informed Paramedic D that the CAH did not offer obstetrical services, and Paramedic D should transport Patient #1 to Hospital A (which offered obstetrical services).

7. During an interview on 5/12/21 at 3:30 PM, CAH ED Physician G revealed that RN E informed ED Physician G that an ambulance with an obstetrical patient was on its way to the CAH. ED Physician G indicated they regularly provided obstetrical care to patients, ED Physician G was comfortable providing obstetrical care to Patient #1, and could have provided obstetrical care to Patient #1, including delivering Patient #1's baby if needed.

ED Physician G asked RN E to print off Patient #1's obstetrical history, so ED Physician G could best provide care to Patient #1 upon their arrival to the ED. ED Physician G indicated that if they knew Patient #1 was on the CAH's property, ED Physician G would have evaluated Patient #1.