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Based on document review and staff interview, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to follow the CAH's policies and procedures for 2 of 24 patients (Patients #1 and 18) selected for review from October 2011 to March 2012, when they failed to perform an adequate and sufficient medical screening examination for 2 of 24 patients (Patient #1 and #18), and when they failed to provide an appropriate mode of transfer for 1 of 24 patients (Patient #18). The CAH administrative staff identified an average of 320 patients per month who presented to the ED for medical care, and the ED staff transferred an average of 18 patients per month to another hospital.

Failure to perform an adequate medical screening examination resulted in a patient failing to receive appropriate stabilizing treatment, and resulted in the patient experiencing additional pain and discomfort, until they received the appropriate stabilizing treatment. Failure to provide an appropriate mode of transfer could potentially result in the patient developing a life threatening medical condition during the transfer, and the transfer staff lacking the appropriate training to treat the patient's medical condition.

Findings include:

1. "Emergency Examination & Transfer" dated 12/05 revealed in part, "Medical Screening Examination (MSE): An examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the ED, to determine with reasonable clinical confidence whether an EMC exists...
Prompt Screening: All individuals entitled to a MSE shall be examined promptly within the capabilities of the Emergency Department...

2. Review of Patient #1's medical record revealed:
Patient #1 presented to the ED on 12/24/11 at 11:23 PM with complaints of pain, in the sternum, mid abdomen, and the suprapubic areas. Practitioner A documented "tenderness to palpation in the left upper quadrant as well as the right upper quadrant which is actually a 'Positive Murphy's sign." Practitioner A ordered laboratory test and a full upper abdominal X-ray.
Practitioner A ordered the medication "GI cocktail" which provided Patient #1 relief from the abdominal pain. Practitioner A instructed Patient #1 to stop the IBP [Ibuprofen] and to take Tylenol for pain relief.

On 1/1/12 at 1:03 AM Patient #1 presented to the ED due to continued pain in abdomen. Practitioner A documented an exam of the abdomen and ordered lab test. The lab test for the White Blood Count (WBC) revealed an increase from 7.2 K/ul to 10.9 K/ul (normal 4.8 - 10.8 K/ul. Practitioner A ordered pain medication (Toradol 30 mg intramuscular (IM) and Morphine 4 mg IV x 2) and 2 GI cocktails which provided the patient some relief. Practitioner A encouraged the patient to call their gastroenterologist within the next week for a follow up.

Patient #1 returned to the ED on 1/2/12 at 3:20 PM (next day) due to fever with continued abdominal, pelvic, and lower back pain. The Practitioner B, Advanced Registered Nurse Practitioner (ARNP) ordered labs and Computed Tomography (CT) scan of the abdomen and pelvis with IV & oral contrast. The ARNP B documented a diagnosis of "Acute Cholecystitis." Lab results revealed an increase in the WBC to a 17.2 K/ul. The CT scan results revealed in part, "Grossly inflamed, moderately distended gallbladder with suspected poorly calcified gallstones..." Practitioner E admitted the patient to the CAH and documented a diagnosis of "Acute Cholecystitis."

Patient #1 underwent surgery for Cholecystitis on 1/3/12. Patient #1's pathology report revealed in part, "Gallbladder, cholecystectomy: Necrotizing acute Cholecystitis..."

3. During an interview on 3/21/12 at 8:00 AM, Practitioner C, MD, ED Director, stated, "My concerns are with the second visit, it took more medication to control the pain then the 1st visit. Reading the ER record I felt [Practitioner A name] started down a path and didn't look at the complete issue. So to me, the increase of pain medication to control the patient's pain should have been a red flag and [Practitioner A name] should have proceeded to an ultra sound. I felt [Practitioner A name] missed the diagnosis." See C-2405 for additional information.

4. "Emergency Examination & Transfer" dated 12/05 revealed in part, "...Prompt Screening: All individuals entitled to a MSE shall be examined promptly within the capabilities of the Emergency Department...
If the MSE reveals that the individual has an EMC, the Hospital shall provide either...Appropriate transfer to another medical facility...
Registered Nurses: MSE may include a mental health assessment. If the mental health assessment results in a finding of an EMC, contact an on-call practitioner capable of providing further examination and treatment related to mental health status..."
...Registered Nurses: If an individual is transferred:
a. contact the treatment center to confirm that space and qualified personnel are available to treat the individual and to confirm that the transfer will be accepted...
b. Prepare copies to send with transferee of all records related to the EMC, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of test, the Transfer Record form...
c. confirm that qualified personnel and transportation equipment are used to transfer the patient...
d. Ensure that medical treatment is provided that minimizes the risks to the individual's health..."


5. Review of Patient #18's medical record revealed:
Patient #18 presented to the ED on 10/04/2011 with complaints of suicidal ideation for past 2 weeks, "but more so this AM." Documentation revealed Patient #18 stated there was a court order to receive mental health services at a treatment center. The Staff C, ED RN contacted law enforcement and received confirmation they had a court order to commit Patient #18 to a treatment center. The law enforcement dispatch center informed the RN C there was no need to contact the treatment center of the transfer due to they would be expecting the patient. The law enforcement staff arrived at the CAH, took Patient #18 into legal custody for a transfer to a treatment center in a sheriff's deputy's squad car.

Further review of Patient #18's medical record revealed the medical record lacked documented evidence of the following:
a. That a physician, or qualified medical person provided a Medical Screening Exam (MSE) or a mental screening exam
b. The ED staff contacted the treatment center to verify bed availability
c. The ED staff confirmed the treatment center had qualifying staff available to care for Patient #18
d. That a physician, or qualified medical person, certified the benefits outweighed the risks of the transfer
e. That the ED staff ensured Patient #18's medical condition allowed the sheriff's deputy to safely transfer Patient #18 to the treatment center in a sheriff's deputy's squad car.

6. Interviews with the ED RNs, ED Coordinator, Clinical Director of Behavioral Health Unit, and the ARNP confirmed the staff did not follow the correct procedure for a patient with suicide ideation by failure to consult with the on-call Southwest Iowa Mental Health Services or a Psychiatrist.
The interviewees confirmed:
a. A physician, or qualified medical person, did not provided a MSE or a mental screening exam
b. ED staff did not contacted the treatment center to verify a treatment center had available space
c. ED staff did not confirmed the treatment center had staff to care for Patient #18
d. A physician, or qualified medical person, did not certified the benefits outweighed the risks of the transfer
e. ED staff did not ensured Patient #18's medical condition allowed the sheriff's deputy to safely transfer Patient #18 to a treatment center in a sheriff's deputy's squad car.
See C-2406 for additional information.

The ED Medical Director stated, "In the strictest sense of the law, the patient did not receive a MSE." The Medical Director went on to say, "Did the staff follow the strict reading of EMTALA for a MSE, then a psychiatric evaluation, No."

Based on document review and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to provide an appropriate or sufficient medical screening examination for 2 ED patient (Patient #1 and #18), out of 24 patients selected for review from October 2011 to March 2012. The CAH administrative staff identified an average of approximately 320 patients per month who requested emergency medical care at the CAH.

Failure to provide an appropriate medical screening examination resulted in a patient with an emergency medical condition not receiving appropriate care, potentially leading to disability, loss of limb, or death.

Findings include:

1. "Emergency Examination & Transfer" dated 12/05 revealed in part, "Medical Screening Examination (MSE): An examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the ED, to determine with reasonable clinical confidence whether an Emergency Medical Condition (EMC) exists...
Prompt Screening: All individuals entitled to a MSE shall be examined promptly within the capabilities of the Emergency Department..."

2. Patient #1:
A. Review of Patient #1's medical record revealed...
Patient #1 presented to the ED on 12/24/11 at 11:23 PM with complaints of pain, in the sternum, mid abdominal and the suprapubic areas. Practitioner A, Doctor of Osteopath (D.O.), documented, "tenderness to palpation in the left upper quadrant as well as the right upper quadrant which is actually a 'positive Murphy's sign'." Practitioner A ordered laboratory (lab) tests and a full upper abdominal X-ray.
Practitioner A ordered the medication "GI cocktail" (Maalox 30 ml with Lidocaine 20 ml) which provided the patient relief from their abdominal pain. Practitioner A provided discharge instruction for Patient #1 to stop the Ibuprofen (IBP) and to take Tylenol for pain relief.

Patient #1 returned to the ED on 1/1/12 at 1:03 AM (7 days later) with complaints of continued pain, over left breast and across upper chest into right rib area. Practitioner A documented an exam of the abdomen and ordered lab tests. The lab test for White Blood Cells (WBC) showed an increase from 7.9 K/ul to 10.9 K/ul (normal 4.8 - 10.8 K/ul). Practitioner A ordered pain medication (Toradol 30 mg IM and Morphine 4 mg IV x 2) and 2 "GI cocktails" which provided the patient some pain relief. Practitioner A provided discharge instruction to include the patient to call their gastroenterologist within the next week for follow up.

Patient #1 returned to the ED on 1/2/12 at 3:20 PM (within 24 hours) due to a fever and increased abdominal, pelvic, and lower back pain. Practitioner B, Advance Registered Nurse Practitioner (ARNP), ordered lab test that revealed a WBC increase to 17.2 K/ul. ARNP B, then ordered a Computed Tomography (CT) scan of the abdomen and pelvis with IV & oral contrast. The CT scan results revealed in part, "Grossly inflamed, moderately distended gallbladder with suspected poorly calcified gallstones..." Practitioner E, Medical Doctor (MD) admitted Patient #1 to the CAH and documented a diagnosis of "Acute Cholecystitis."

Patient #1 underwent surgery for Cholecystitis on 1/3/12. Patient #1's pathology report revealed in part, "Gallbladder, cholecystectomy: Necrotizing acute Cholecystitis..."

B. During a phone interview on 3/20/12 at 9:30 AM, Practitioner A stated the palpations of Patient #1's abdomen did reveal a Positive Murphy sign. Practitioner stated this test was usually associated with Gall Bladder problems. The GI cocktail prescribed for Patient #1 seemed to alleviate the abdominal pain.

Practitioner A reviewed the ED record for Patient #1's second visit on January 1st. Practitioner A stated he questioned the patient about stressors and the patient stated their spouse passed away in the summer, so "I questioned if there could be some anxiety due to this."

(Medical record physician documentation revealed in part, "...denies any emotional content to the pain...spouse passed away in the middle of summer and...over that now and has no stress in life in regards to that...")

Practitioner A went on to say, the GI cocktails and pain medications seemed to relieve Patient #1's stomach problems. Practitioner A acknowledged the WBC lab test results were a little higher and stated, "but that could be due to a multiple of reasons."
Practitioner A stated when discharge instruction were given, "I encouraged the patient to set up an appointment with the gastroenterologist."

Practitioner A stated, "On the 2nd visit, if the GI cocktail and pain medications had not relieved the pain or if the labs would have been elevated, I would have ordered a CT scan."

During an interview on 3/19/12 at 4:00 PM ARNP B, stated [Patient #1] returned to the ED due to a fever and continuation of pain. Patient #1's lab test results revealed an increase in the WBC, so "I ordered a CT scan." ARNP stated, the CT scan confirmed the gall bladder diagnosis, so we admitted the patient to the CAH for gall bladder surgery.
ARNP B stated she remembered Patient #1 called the hospital and was upset that it took 3 visits to the ED to find the cause of the pain.

During an interview, on 3/19/12 at 1:30 PM, Staff A, RN, ED Coordinator stated Patient #1 placed a complaint about concerns that it took 3 ED visits get the gall bladder problem diagnosis. RN A explained to Patient #1 the ED records would be reviewed and the results of the review would be sent in a letter. RN A stated Practitioner C, Medical Doctor (MD), the ED Director, received the ED records for review.

During an interview, on 3/21/12 at 8:00 AM, Practitioner C, MD, ED Director, acknowledged she reviewed Patient #1's ED records and had concerns with the second visit to the ED. Practitioner C stated, "My concerns are the second visit, it took more medication to control the pain then the 1st visit. Reading the ED record I felt [Practitioner A name] started down a path and didn't look at the complete issue. So to me the increase of medication to control the patient pain should have been a red flag and proceeded to an ultra sound. I felt the [Practitioner A name] missed the diagnosis."

3. Patient #18
A. Review of Patient #18's medical record revealed, Patient #18 presented to the ED on 10/14/11 with suicide ideation. The nursing notes revealed the patient stated he/she was "court committed" to a treatment center and then stated, "I would rather die than go back there." The nurse documented after speaking with the sheriff deputy it was understood the deputy was to take the patient to the treatment center at 8:30 AM. The deputy arrived at the ED at 6:10 AM and took Patient #18 into custody until the patient could be transferred to the assigned treatment center.

The medical record lacked documented evidence Patient #18 received a MSE by the ED provider on duty or the attending nurse.
The medical record lacked documented evidence the staff questioned Patient #18 if any medications had been taken, if the patient had possession of any harmful items (knives etc) or if the patient had immediate plans for suicide.
The medical record lacked a copy of the "court order" regarding law enforcement to take custody and transfer Patient #18 to the treatment center.

B. During an interview on 3/20/12 at 1:20 PM, Staff B, RN, Clinical Director of Behavioral Health Unit, stated, the Behavioral Health nurse performs the routine ED psych evaluation during the day hours. On the evenings and weekends, the ED staff calls the practitioner on the on-call list from the Southwest Iowa Mental Health Services. The ED practitioner calls the on-call provider after the MSE by the ED practitioner. The ED practitioner does the mental status exam and then would consult with the on-call psych provider for further evaluation.

RN B stated, "You have to evaluate [patient name]. Even if we transferred [patient name] to a treatment center, you would need a doctor to doctor report, and the treatment center would need to have that information. Even if it was a court order, the treatment center would still need a doctor to doctor call."

RN B stated Patient #18 presented at the ED, the patient needed the same treatment as if there were no mention of the court commitment. If after hours, the ED providers might not call the behavioral health unit, they would call the psychiatrist, or the [SW Iowa Mental Health Services staff] on-call person.

RN B stated suicide ideation would be considered an EMC.


During an interview on 3/20/12 at 4:00 PM and 3/20/12 at 6:15 AM, Staff C ED, RN, stated the patient presented to the ED and told the staff he/she was court committed to a [treatment center]. RN C stated since the ED staff was not aware of this treatment center, so RN C called the police communication center. RN C stated the officer said they had been assigned to pick up Patient #18 at 8:30 AM but would come to the CAH's ED and pick up the patient earlier.

RN C acknowledged the CAH's ED must provide a MSE to determine if an EMC existed. RN C stated suicide ideation would be considered an EMC.

RN C stated the normal ED routine with suicidal patients would be the ED practitioner performs a MSE and mental assessment to determine if/when Southwest counselors are notified.

RN C acknowledged the ED staff did not fill out transfer papers nor call the facility the patient transferred to "because the police had court committal papers and knew where they were taking" the patient. RN C acknowledged the ED staff did not see or copy the "court commit papers" for Patient #18.

RN C stated, "Since the MSE is to determine if there is an EMC, I guess [Patient #18's name] should have had a MSE."


During an interview on 3/20/12 at 6:15 AM, Practitioner D ARNP, ED, stated when Patient #18 arrived at the CAH ED the nurse on duty assessed the situation. The ED nurse called the police communication center and was informed law enforcement would pick the patient up and transfer to a treatment center. ARNP D stated it was understood the patient was an elopement from the treatment center and the law enforcement were to take the patient into custody and transfer back to the treatment center.

ARNP D stated when a patient presents to the ED; the nurse initiates the assessment then calls the ED provider on duty. ARNP D stated the nurse called and stated Patient #18 presented to the ED, but the patient told the nurse of the court committal. ARNP D stated the nurse said the police were on their way with committal papers to pick up the patient and transfer to the treatment center.

ARNP D, reviewed Patient #18's ED record and stated, "I was not aware [Patient #18] had been suicidal, I didn't realize [Patient #18] stated had been suicidal for past 2 weeks, this would have been considered an EMC and I would have come to the ED to see the patient. I do the MSE on any patient who has complaints of suicidal thought or any patient we are going to transfer. I wasn't made aware of [Patient #18's ] suicidal thoughts, so I did not do a MSE."

ARNP D confirmed when a suicidal patient presents to the ED the routine would consist of a MSE to determine if an EMC exists, and then would notify the on-call psychiatric counselor for further consult. "This was not done."


During an interview on 3/20/12 at 4:00 PM and 3/21/12 at 11:20 AM, Staff A RN, ED Coordinator, stated the routine process for patients presented to the CAH ED with suicide ideation would be for the nurse to start the assessment then call the ED provider in to do a MSE. The provider, if during the day, can call the Behavioral unit to have a Behavioral nurse come to the ED and do a mental health screening. If the patient presents during evening or on the weekends, the ED provider would call the on-call Psychiatrist to consult with.
RN A stated it is the psychiatrist or a member of their team who would say if the patient meets all criteria for admittance to the CAH Behavioral Unit or if the patient needed to be transferred.

RN A reviewed Patient #18's ED record and stated the ED staff did not follow the routine process for a patient with suicidal thoughts. RN A confirmed the CAH's policy for a MSE was not followed for this patient.


During an interview on 3/21/12 at 11:30 AM, the Chief Nursing Officer (CNO) stated on 10/4/11 the CAH's Behavioral unit had a census of 2 patients with 2 beds available. The CNO stated there were beds available for admit on 10/4/11 when Patient #18 presented to the ED.


During an interview on 3/21/12 at 8:30 AM Practitioner E MD, ED Director reviewed Patient #18's ED record and stated, "In the strictest sense of the law, the patient did not receive a MSE." Practitioner E went on to say, "Did the staff follow the strict reading of EMTALA for a MSE, and then a psychiatric evaluation? No."