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Based on medical record review, document review, and staff interview, the critical access hospital (CAH) failed to provide a timely and appropriate medical screening exam sufficient enough to determine whether a patient (Patient # 49) had an emergency medical condition (EMC) that required transfer to a higher level of care for 1 out of 21 records reviewed from May 2014 to July 2015.

Findings include:

- Medical Staff Rules and Regulations reviewed on 8/11/15 read in part: 29. The Hospital will provide an appropriate medical screening exam within the capability of the hospital's Emergency Room department, including ancillary services routinely available to the Emergency Department, for each individual who requests a medical exam or treatment to determine if an emergency medical condition exists. 30. The Hospital, with Medical Staff approval, will develop policies and procedures for medical screening exams, determination of emergency medical conditions, stabilization and transfers. 31. The medical screening exam, to determine if an emergency medical condition exists, must be performed by a qualified medical provider. The Hospital, in concurrence with the Medical Staff, defines a qualified medical provider as a physician or a physician's assistant, advanced registered nurse practitioner or registered nurse in consultation with a physician. Consultations with physicians or physician's assistant or advanced nurse practitioner may be made by telephone; however; when an emergency medical condition requiring interhospital transfer exists, the medical screening exam shall be subsequently performed by a physician.

- Emergency Room policy titled, "Initial Screening Exam", reviewed on 8/12/15 directed: 2. This initial screening exam will be completed by an attending physician after the patient has been initially assessed by the RN staff in the ER. 3. If the patient is deemed to have an emergency medical condition, the emergency department will provide further examination and treatment (within the departments capabilities) to stabilize the medical condition or make an appropriate transfer in accordance with the inter hospital transfer policy.

- Emergency Room (ER or ED) policy titled, "Patient Assessment and Care" reviewed on 8/12/15 read in part: 3. Patient presenting to the ER will be evaluated buy the ER staff under the supervision of the attending physician. The physician will be responsible for determining the appropriate treatment and disposition of the patient.

- Personnel and Medical Staff record review on 8/12/15 lacked evidence that 11 of 11 nursing staff and 7 of 7 practitioners (MDs, Physician Assistants, Nurse Practitioners) had any EMTALA (Emergency Medical Treatment and Labor Act) training.

- Director of Nursing (DON) interviewed on 8/12/15 at 1:00 pm stated that they had not provided any EMTALA education to the staff.

- Refer to Findings for tag C 2406 -- Medical Screening Exam

The hospital failed to provide a timely and appropriate medical screening exam sufficient enough to determine whether a patient (Patient # 49) had an emergency medical condition (EMC) that required transfer to a higher level of care for 1 out of 21 records reviewed.


The CAH's failure to determine the patient had an emergency medical condition beyond their capabilities to stabilize potentially led to the patient's death.

Based on medical record review, document review, and staff interview, the critical access hospital (CAH) failed to provide a timely and appropriate medical screening exam (MSE) sufficient to determine whether a patient (patient #49) had an emergency medical condition (EMC) that required transfer to a higher level of care for 1 out of 21 records reviewed from May 2014 to July 2015.

The CAH's failure to provide an appropriate MSE for a patient with an emergency medical condition beyond their capabilities potentially led to the patient's death.

Findings include:

- Document titled "Services Offered by (Hospital Named Above)" reviewed on 8/11/15 read in part:
Observation Room: This is the ongoing short term treatment, assessment, and reassessment of a patient while deciding whether the patient will require further treatment as hospital inpatient or if they are able to be discharged.

- Hospital/CAH database worksheet completed on 8/11/15 revealed the CAH did not provide: Intensive Care Unit Services, Cardio-Thoracic Surgery, or a CT Scanner.

- Review of a closed medical record on 08/11/15 revealed a 53 year old male patient with no known medical problems (patient #49) presented to the Emergency Department (ED) on 5/3/14 (time of admission not documented) with complaints of coughing with productive cough (clear sputum), elevated temperature (patient reported 103 (normal 98.6) on 5/1/14), aching, increased blood pressure. Review of form titled "Hanover Hospital ER, Outpatient, Inpatient, and Swing bed Admission Assessment" on 8/11/15 revealed registered nurse (RN) W documented on 5/3/14 at 6:15 am the patient had abnormal vital signs: increased Respiratory Rate 24 (normal adult 12-20), elevated Blood Pressure (BP) 184/98 (usual BP 120/80). Further documentation showed the patient reported he had some diarrhea, urinary frequency, and musculoskeletal weakness. RN W's physical assessment indicated patient # 49's skin was pale and moist, and that he had weakness, and persistent vomiting since Wednesday ( for 3 days). RN W documented that she called Physician T at 7:00 am and he gave orders to admit to outpatient observation.

- Physician T saw the patient on 5/3/14 at 11:00am (about 5 hours after the patient arrived seeking treatment) and wrote orders that included arterial blood gases (blood test that measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood) intravenous fluids and lab work to be completed between 4-6pm including a Chem23 (blood test to provide doctors with an overview of the patient's general health and to look for the underlying cause of a specific symptom the patient is experiencing), blood sugar checks every two hours with 10 units of Regular insulin (short acting insulin used to treat diabetes) stat (immediately) and set up sliding scale insulin per protocol (varies the dose of insulin based on blood sugar level), an antibiotic and a 1500 calorie diabetic diet. On form titled "Medical Record", Physician T documented admission date of 5/3/14 and patient slightly sweaty, clear breath sounds in upper chest but diminished breath sounds in the lower lobes (caused by conditions like pneumonia, and respiratory failure), high blood pressure, and blood sugars over 400. Imp (Impression): impending diabetic coma (a diabetic coma is a life-threatening diabetes complication that causes unconsciousness. If you have diabetes, dangerously high blood sugar (hyperglycemia) or dangerously low blood sugar (hypoglycemia) can lead to a diabetic coma) not previously diagnosed.

- Lab work drawn on 5/3/14 at 10:55am revealed patient # 49 had an elevated white blood cell (WBC) count 27.3 (normal 4.8-10.8) (high white blood cell count can indicate a problem, such as infection, stress, inflammation, trauma, allergy, or certain diseases...a high white blood cell count usually requires further investigation), elevated Hemoglobin A1C (test used to screen for, diagnose and monitor diabetes) 8.9 (normal 4.3-5.7), low sodium 124.6 (normal 136-145), low Carbon Dioxide (CO2) 17.6 (normal 21-31, low levels may be caused by hyperventilation (breathing that is deeper and more rapid than normal), elevated glucose 439 (normal 70-105) (high blood sugars are a sign of diabetes).

- At 3:00pm RN K documented in the nursing notes that patient # 49 stated he felt "terrible" and "I want to die." Further documentation showed the patient's blood sugar was critically elevated at 415. The RN administered 8 units of insulin. At 6:00pm additional insulin was administered for a blood sugar of 364. At 7:00 PM the nurse documented the patient's blood sugar remained high at 363, that he began to complain of chest pressure, that he was cool and clammy, and requested the air conditioning be turned on. The nurse documented Physicians T and S arrived at 7:30pm. RN V received orders to place the patient on a continuous heart monitor. An EKG showed abnormalities that the machine's interpretation said was indicative of pericarditis (a swelling and irritation of the membrane surrounding the heart). The medical record lacked evidence that Physician T or Physician S reviewed the EKG findings. Physician S wrote orders for labs, increase in IV fluids, and blood sugars every 2 hours with an increase in the sliding scale insulin dosage.

- Physician T documented on the Emergency Room Record 5/3/14 (no time documented), "Diabetic Coma, High blood pressure, Severe adult onset Diabetes, D-Dimer of 1020 (blood test that measures a substance released when a blood clot breaks up, normal is less than 250), and ruptured aortic aneurysm.

- During an interview with Physicians S and T on 8/12/15 at 12:45, Physician S pointed out that Physician T wrote the information on the ED record mentioned above after the patient died and he did not diagnose the patient with a ruptured aortic aneurysm on 5/3/14.

- At 11:00pm on 5/3/14, RN X notified Physician S about the patient's abnormal vital signs including a respiratory rate of 24 and BP of 160/100. RN staff X documented she received no new orders.

- The record indicated the patient remained hypertensive with elevated blood pressures on 5/4/14 including 12:00 am, 168/92; 1:00 am, 183/96; 3:00 am, 153/93; 6:00 am, 160/94; 8:00 am, 168/90, 10:00 am, 170/102; and 12:00 pm, 162/98. The record lacked evidence of any medical management for the high blood pressure.

- The record indicated that the patient's blood sugars remained elevated on 5/3/14 and 5/4/14 as follows despite treatment with sliding scale insulin: 5/3/14: 3:00 pm, 415; 6:00 pm, 364; 7:00 pm, 363; 3:00 pm 338; 9:40 pm, 326; 23:00, 321; and on 5/4/15: 12:00 am, 332; 1:00 am, 338; 2:00 am, 263, 4:00 am, 268, 7:00 am, 263; 9:00 am, 286; and 11:00 am, 223.

- At 11:00am on 5/4/14, RN W documented that the patient had an abdominal sonogram. The medical record provided during survey on 8/12/15 lacked evidence of an abdominal sonogram report. On 10/22/2015, the Director of Nursing provided a copy of a report titled "Study Sonogram Screening" completed on 5/4/14 (not timed) and signed by Physician T that read in part: "Clinical History: Elevated white blood cells. Diabetes. Dyspnea (shortness of breath). Acidosis (increased acidity in your blood or other body tissues). Oliguria (abnormally small amounts of urine)." "Examination: Emergency Screening Examination only. Cardiac size is larger than normal. Aortic root (the junction of the aorta) in the 3 3/4 to 4 cm (centimeter) range and the aortic arch seems at or above normal size (enlargement of the ascending aorta entails a high risk of dissection or aortic rupture). Could be increased pulmonary congestion (a condition caused by excess fluid in the lungs). "Utilizing OB (Obstetrics) screening sonogram, further definitive conclusions are speculative at best."... "Recommend chest x-ray." The medical record lacked evidence Physician Staff T ordered any other diagnostic tests besides the chest x-ray to evaluate the sonogram findings or arrange a transfer for the patient to receive further testing unavailable at this CAH such as a CT angiogram (technique used to visualize arterial and venous vessels throughout the body) or for potential cardiothoracic-surgical intervention.

RN W documented that the patient did not tolerate the procedure (chest X-ray) and became short of breath. When patient returned from a chest X-ray at 12:30 pm, RN Staff W indicated the patient's ears, lips and nail beds were cyanotic (the appearance of a blue or purple coloration due to low oxygen saturation). 12:40pm Physician S and T here. O2 on 2 liters. 12:50 pm O2 changed to mask and increased to 6 liters. 12:55 pm ABGs obtained. 1:00 pm IV infiltrated. IV restarted and 40mg lasix (a diuretic) and 1 ampule of sodium bicarbonate (indicated in the treatment of metabolic acidosis which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, and/or cardiac arrest). 1:10 pm Physician staff T inserted a foley catheter (to collect urine). At 1:25pm, RN W documented that Physician S intubated (placement of a tube into the windpipe to maintain an open airway) patient #49. At 1:30pm the monitor showed ventricular tachycardia (a dangerous arrythmia in which the lower chambers of the heart (ventricles) beat very quickly). There is no mention of initiation of chest compressions, cardiac defibrillation (a process in which an electronic device gives an electric shock to the heart. This helps reestablish normal contraction rhythms in a heart having dangerous arrhythmia or in cardiac arrest), or administration of epinephrine (primarily used for its vasoconstrictive effects. Vasoconstriction is important because it will help increase blood flow to the brain and heart). And so, the medical record lacked evidence that demonstrated the facility staff followed well established basic/advanced life support guidelines to try to resuscitate patient #49. At 1:33pm RN W documented patient # 49's pupils were fixed and dilated (pupils do not respond to light or stimuli). Further documentation showed the patient experienced an agonal heart rhythm (often the last semblance of organized electrical activity in the heart prior to death). At 1:37pm on 5/4/14, Physician T pronounced the patient deceased.

- Physician T continued to treat the patient at the CAH in outpatient observation with a diagnosis of impending diabetic coma. In an interview about the CAH's ability to provide stabilizing treatment to patient #49 on 9/23/15 at 12:10 pm, Physician T stated "I treated his ketoacidosis (a serious diabetes complication where the body produces excess blood acids), I have treated ketoacidosis many times. At the time, I felt we had the capabilities of taking care of this patient here." "The patient had no history of cardiac problems. I did not consider moving him out. Patient was telling us he needed to leave to drive a truck, he got dressed and made several attempts to walk out. We had to tell him that he was very sick. Patient's ketoacidosis was resolving." "Retrospectively, I probably would have taken a different path."