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Based on medical record review of Hospital K and Hospital L, Nursing Home S, patient and staff interviews, the critical access hospital's administrative staff failed to ensure hospital emergency department (ED) staff provided the following within their capabilities for patients that presented to the ED seeking medical care from 7/1/23 to 1/9/24:

1) a complete ED log for 1 of 21 sampled patients (Patient #21) to track the care provided to each individual who comes to the hospital seeking care for a potential emergency medical condition (EMC);

2) an appropriate medical screening (MSE) for 1 of 21 sampled patients (Patient #21);

3) appropriate stabilizing treatment for 1 of 21 sample patients (Patient #21) that had a EMC; and,

4) an appropriate transfer for 1 of 21 sampled patients (Patient #21) that had an EMC and required a transfer.

Failure to maintain a complete log may result in the hospital's inability to track the care provided to each individual who comes to the hospital seeking care for a potential EMC.

Failure to provide an appropriate MSE places patients at risk for an undiagnosed emergency medical condition resulting in a deterioration in health and at a potential risk for death.

Failure to provide all patients with appropriate stabilizing treatment and appropriate transfer placed patients at risk for a worsening EMC and at a potential risk for death.

Findings include:

1. Review of policy "Emergency Medical Treatment and Labor Act (EMTALA)", dated 10/2022, revealed in part "... Provide and appropriate MSE to any individual who comes to the emergency department; Provide necessary stabilizing treatment to an individual with an EMC or an individual in labor; Provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC ... "

2. Review of "Procedure MercyOne New Hampton Medical Center", dated 10/2022, revealed in part "... A medical screening examination is conducted when a request is made on behalf of the individual by someone other than the individual, even if the person requesting the examination is not the individual' s legally responsible person ... a log on each individual who comes to the ED will be maintained ... "

3. Review of Patient #21's medical chart from Hospital K revealed:

a. On 1/4/24 at approximately 11:29 AM, Patient #21 presented to Hospital K ED registration desk asking for outpatient lab work. Patient #21 presented without orders from a practitioner.

b. (late entry; encounter time unknown) On 1/4/24 at 12:30 PM ED RN F documented they requested that Nursing Home S provide laboratory orders for the patient.

c. On 1/4/24 at 11:42 AM lab work performed at Hospital K resulted abnormal potassium level (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L).

d. (late entry; encounter time unknown) On 1/4/24 at 6:05 PM ED MD A documented the following, "I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21' s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG" ... "I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]" ... "I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment." Patient #21 prepared the patient's ride to Hospital L for evaluation and treatment.

e. The medical record lacked documentation of the time when the patient left the ED.

4. During an interview on 1/22/24 at 11:00 AM, ARNP O reported Patient #21' s routine monthly laboratory blood draw at Dialysis Center R on 1/3/24 resulted a critical potassium level of 7.7 mmol/L which prompted order sent to Hospital L for repeat potassium blood draw on 1/4/24. ARNP O recalled due to transportation issues Patient #21 presented to Hospital K and colleague ARNP I ordered repeat potassium blood draw on 1/4/24 at Hospital K. ARNP O reported Hospital K phoned with Patient #21' s results of a critical potassium level of 6.9 mmol/L. ARNP O recalled telling ED MD A at Hospital K this was an emergency and advised to obtain EKG and lower the potassium level with insulin and glucose or albuterol. ARNP O reported with an untreated critical potassium level, Patient #21 could have had an arrhythmia resulting in a cardiac arrest in transport.

5. On 1/4/24 at 6:05 PM ED MD A documented the following, "I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21 ' s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG" ... "I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]" ... "I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment."

6. During an interview on 1/17/24 at 11:30 AM, Hospital K ED MD A explained when ED staff registered a patient for an ED encounter, the ED staff performed an appropriate MSE. ED MD A reported Patient #21 was not registered for an ED encounter and lab work was ordered by an outside provider. ED MD A reported receiving a phone call from ARNP O requesting Patient #21 be evaluated and treated at Facility K for critical lab results. ED MD A recalled asking Patient #21 to be evaluated and treated in the ED at Facility K and Patient #21 expressed the desire to travel to Facility L. ED MD A notified ARNP O that Patient #21 did not want to be seen at Facility K and was planning on going to Facility L. ARNP O again expressed they did not have the capability to treat Patient #21 at Facility L. ED MD A relayed the additional information to Patient #21 and again Patient #21 expressed the desire to travel to Facility L. ED MD A recalled a conversation with Taxi Driver J to confirm that they were agreeable to drive Patient #21 to Facility L. ED MD A confirmed that Patient #21 did not receive an MSE and did not sign an AMA form.

7. See A 2405, 2406, 2407 and 2409 for further detailed information.

Based on medical record review of Hospital K and Hospital L, Nursing Home S record review, patient and staff interviews, the critical access hospital's administrative staff failed to ensure hospital emergency department (ED) staff maintained a complete ED log for 1 of 21 patients reviewed (Patient #21) who presented to the ED seeking medical care. Failure to maintain a complete log may result in the hospital's inability to track the care provided to each individual who comes to the hospital seeking care for a potential emergency medical condition (EMC).

Findings include:

1. On 1/16/24 Hospital K provided a copy of their ED log dated 7/1/23 to 1/9/24. Review of the hospital' s ED log for 1/4/24 revealed lack of an entry in the log for Patient #21.

2. During an interview on 1/22/24 at 6:23 PM, Patient #21 reported a history of dialysis (the process of removing excess water and waste products from the blood in people whose kidneys can no longer perform these functions naturally) treatment three times a week for three years at Dialysis Center R. Patient #21 reported an elevated potassium (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) level at Dialysis Center R on 1/3/24 which prompted ARNP I to order a repeat potassium level blood draw on 1/4/24. Patient #21 was told by LPN H at Nursing Home S (place of residence), that transportation had been arranged for the repeat blood draw at Hospital L. Patient #21 reported they did not want to ride the 45 minute trip each way to Hospital L and called Dialysis Center R. RN N at Dialysis Center R talked with the ARNP I, who gave permission to Patient #21 to have blood drawn at Hospital K. Patient #21 arrived at the ED entrance of Hospital K and Patient #21 stated they needed a blood draw. ED RN F stated outpatient registration and blood draw could be performed in the ED. Patient #21 recalled being placed in an ED room and blood draw was performed there. Patient #21 reported waiting in the ED room until ED MD A discussed laboratory blood draw resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L). Patient #21 further reported ED MD A had spoken to ARNP O and gave Patient #21 the options of going to Hospital L or being transported to another higher level of care facility. Patient #21 did not recall ED MD A explaining treatment was needed at Hospital K or the risk of leaving with a critical potassium level. Patient #21 reported they felt well at that time and promptly arranged their own transportation to Dialysis Center R.

3. Patient #21' s Nursing Home S record review revealed a Brief Interview for Mental Status (quick assessment of cognitive function; score of 15 indicates intact cognition) performed on 11/20/2023 resulted in a score of 15.

4. During an interview on 1/17/24 at 3:15 PM, Hospital K ED Tech G reported Patient #21 was registered as an outpatient.

5. During an interview 1/17/24 at 10:45 AM Hospital K ED Clinical Lead explained when staff checked a patient into the ED, the patient information populated in the hospitals electronic tracking software and the ED log. The ED Clinical Lead confirmed that ED staff did not check Patient #21 into the ED; and therefore, Patient #21 did not show up on the ED log.

6. During an interview 1/17/24 at 10:30 AM, Hospital K Chief Nursing Officer explained when staff checked a patient into the ED, the patient information populated in the hospitals electronic tracking software and the ED log. The Chief Nursing Officer confirmed no policy for maintaining an ED log.

7. During an interview 1/17/24 at 1:56 PM Hospital K Registration Supervisor confirmed no policy for maintaining an ED log.

Based on medical record review from Hospital K and Hospital L, Nursing Home S record review, patient and staff interviews, the Critical Access Hospital's administrative staff failed to ensure the Emergency Department (ED) staff at Hospital K provided, within the hospital's capabilities, an appropriate medical screening examination (MSE) to 1 of 21 emergency patients reviewed (Patient #21). Failure to provide an appropriate MSE to all patients presenting to the ED seeking medical care places them at risk for an undetected emergency medical condition.

Findings include:

1. During an interview on 1/22/24 at 6:23 PM, Patient #21 reported a history of dialysis (the process of removing excess water and waste products from the blood in people whose kidneys can no longer perform these functions naturally) treatment three times a week for three years at Dialysis Center R. Patient #21 reported an elevated potassium (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) level at Dialysis Center R on 1/3/24 which prompted ARNP I to order a repeat potassium level blood draw on 1/4/24. Patient #21 was told by LPN H at Nursing Home S (place of residence), that transportation had been arranged for the repeat blood draw at Hospital L. Patient #21 reported they did not want to ride the 45 minute trip each way to Hospital L and called Dialysis Center R. RN N at Dialysis Center R talked with the ARNP I, who gave permission to Patient #21 to have blood drawn at Hospital K. Patient #21 arrived at the ED entrance of Hospital K and Patient #21 stated they needed a blood draw. ED RN F stated outpatient registration and blood draw could be performed in the ED. Patient #21 recalled being placed in an ED room and blood draw was performed there. Patient #21 reported ED MD A discussed laboratory blood draw resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L). Patient #21 further reported ED MD A had spoken to ARNP O and gave Patient #21 the options of going to Hospital L or being transported to another higher level of care facility. Patient #21 did not recall ED MD A explained treatment was needed at Hospital K or the risk of leaving with a critical potassium level. Patient #21 reported they felt well at that time and promptly arranged for transportation to Dialysis Center R.

2. Patient #21' s Nursing Home S record review revealed a Brief Interview for Mental Status (quick assessment of cognitive function; score of 15 indicates intact cognition) performed on 11/20/2023 resulted in a score of 15.


3. During an interview on 1/22/24 at 11:00 AM, ARNP O reported Patient #21' s routine monthly laboratory blood draw at Dialysis Center R on 1/3/24 resulted a critical potassium level of 7.7 mmol/L which prompted an order sent to Hospital L for repeat potassium blood draw on 1/4/24. ARNP O recalled due to transportation issues Patient #21 presented to Hospital K and colleague ARNP I ordered repeat potassium blood draw on 1/4/24 at Hospital K. ARNP O reported Hospital K phoned with results of a critical potassium level of 6.9 mmol/L. ARNP O recalled telling ED MD A at Hospital K this was an emergency and advised to obtain EKG and lower the potassium level with insulin and glucose or albuterol. ARNP O reported with an untreated critical potassium level, Patient #21 could have had an arrhythmia resulting in a cardiac arrest in transport.

4. Review of Patient #21's medical chart from Hospital K revealed:

a. On 1/4/24 at approximately 11:29 AM, Patient #21 presented to Hospital K ED registration desk asking for outpatient lab work. Patient #21 presented without orders from a practitioner.

b. (late entry; encounter time unknown) On 1/4/24 at 12:30 PM ED RN F documented they requested that Nursing Home S provide laboratory orders for the patient.

c. On 1/4/24 at 11:42 AM lab work performed at Hospital K resulted abnormal potassium level of 6.9 mmol/L.

d. (late entry; encounter time unknown) On 1/4/24 at 6:05 PM ED MD A documented the following, "I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21' s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG" ... "I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]" ... "I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment." Patient #21 prepared patient's own ride to Hospital L for evaluation and treatment.

e. The medical record lacked documentation of the time when the patient left the ED.

5. During an interview on 1/17/24 at 11:30 AM, Hospital K ED MD A explained when ED staff registered a patient for an ED encounter, the ED staff performed an appropriate MSE. ED MD A reported Patient #21 was not registered for an ED encounter and lab work was ordered by an outside provider. ED MD A reported receiving a phone call from ARNP O requesting Patient #21 be evaluated and treated at Facility K for critical lab results. ED MD A recalled asking Patient #21 to be evaluated and treated in the ED at Facility K and Patient #21 expressed the desire to travel to Facility L. ED MD A notified ARNP O that Patient #21 did not want to be seen at Facility K and was planning on going to Facility L. ARNP O again expressed they did not have the capability to treat Patient #21 at Facility L. ED MD A relayed the additional information to Patient #21 and again Patient #21 expressed the desire to travel to Facility L. ED MD A recalled a conversation with Taxi Driver J to confirm that they were agreeable to drive Patient #21 to Facility L. ED MD A confirmed that Patient #21 did not receive an MSE and did not sign an AMA form.

6. Review of Patient #21's medical chart from Hospital L revealed:

a. On 1/4/24 at 1:59 PM, Patient #21 presented to Hospital L ED from Dialysis Center R with elevated potassium level, previously drawn on 1/4/24 at Hospital K. ED DO P was contacted by ARNP O and discussed evaluation, treatment, stabilization, and transfer to a higher level of care. ED DO P performed MSE, provided treatment and repeat potassium level decreased to 6.1 mmol/L. Hospital V accepted Patient #21 and transfer was made by ground ambulance.

7. During an interview 1/22/24 at 10:30 AM, Hospital L ED DO P recalled Patient #21 arrived to Hospital L ED from Dialysis Center R. ED DO P reported Patient #21 arrived to Dialysis Center R via taxi. ED DO P reported ARNP O called and discussed pending arrival of Patient #21 for further evaluation and treatment of critically elevated potassium level of 6.9 mmol/L hours earlier at Hospital K where no MSE, treatment or appropriate transfer was arranged. ED DO P reported Patient #21 should have had the potassium level decreased by Hospital K prior to transport in order to lower the risk for cardiac instability which could have led to cardiac arrest. ED DO P reported due to a critical potassium level, the expectation would be Hospital K completed an MSE, performed stabilizing treatment and transfered Patient #21 by ground ambulance.

8. During an interview 1/17/24 at 3:04 PM, Hospital K ED RN F reported Patient #21 was told that they could be registered for outpatient services at the ED desk.

9. During an interview on 1/17/24 at 3:15 PM, Hospital K ED Tech G reported Patient #21 was registered as an outpatient encounter. ED Tech G reported never witnessing ED MD A refusing to treat anyone that presented to the ED at Facility K.

10. During an interview on 1/23/24 at 1:00 PM Hospital K Laboratory Staff T reported receiving a lab order via fax on 1/4/24 at 11:34 AM from ARNP I. Laboratory Staff T reported performing a lab draw on Patient #21 in the ED on 1/4/24 at 11:42 AM.

11. During an interview on 1/17/24 at 10:45 AM Hospital K ED Clinical Lead confirmed that Patient #21 was not registered with an ED encounter and they did not sign an AMA form. ED Clinical Lead reported hospital staff complete education on EMTALA training at orientation, complete annual online competency modules, and have EMTALA reminders at monthly nursing meetings.

Based on medical record review from Hospital K and Hospital L, Nursing Home S record review, patient and staff interviews, the Critical Access Hospital's administrative staff failed to ensure the Emergency Department (ED) staff at Hospital K provided, within the hospital's capabilities, an appropriate medical screening examination (MSE) to 1 of 21 emergency patients reviewed (Patient #21). Failure to provide all patients with appropriate stabilizing treatment placed (Patient #21) at risk for a worsening emergency medical condition and at a potential risk for death.

Findings include:

1. During an interview on 1/22/24 at 6:23 PM, Patient #21 reported a history of dialysis (the process of removing excess water and waste products from the blood in people whose kidneys can no longer perform these functions naturally) treatment three times a week for three years at Dialysis Center R. Patient #21 reported an elevated potassium (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) level at Dialysis Center R on 1/3/24 which prompted ARNP I to order a repeat potassium level blood draw on 1/4/24. Patient #21 was told by LPN H at Nursing Home S (place of residence), that transportation had been arranged for the repeat blood draw at Hospital L. Patient #21 reported they did not want to ride the 45 minute trip each way to Hospital L and called Dialysis Center R. RN N at Dialysis Center R talked with the ARNP I, who gave permission to Patient #21 to have blood drawn at Hospital K. Patient #21 arrived at the ED entrance of Hospital K and Patient #21 stated they needed a blood draw. ED RN F stated outpatient registration and blood draw could be performed in the ED. Patient #21 recalled being placed in an ED room and blood draw was performed there. Patient #21 reported ED MD A discussed laboratory blood draw resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L). Patient #21 further reported ED MD A had spoken to ARNP O and gave Patient #21 the options of going to Hospital L or being transported to another higher level of care facility. Patient #21 did not recall ED MD A explained treatment was needed at Hospital K or the risk of leaving with a critical potassium level. Patient #21 reported they felt well at that time and promptly arranged for transportation to Dialysis Center R.

2. Patient #21' s Nursing Home S record review revealed a Brief Interview for Mental Status (quick assessment of cognitive function; score of 15 indicates intact cognition) performed on 11/20/2023 resulted in a score of 15.

3. During an interview 1/22/24 at 10:30 AM, Hospital L ED DO P recalled Patient #21 arrived to Hospital L ED from Dialysis Center R. ED DO P reported Patient #21 arrived to Dialysis Center R via taxi. ED DO P reported ARNP O called and discussed impending arrival of Patient #21 for further evaluation and treatment of critically elevated potassium level of 6.9 mmol/L hours earlier at Hospital K where no MSE, treatment or appropriate transfer was arranged. ED DO P reported Patient #21 should have had the potassium level decreased by Hospital K prior to transport in order to lower the risk for cardiac instability which could have led to cardiac arrest. ED DO P reported due to a critical potassium level, the expectation would be Hospital K completed an MSE, performed stabilizing treatment and transfered Patient #21 by ground ambulance.

4. During an interview on 1/22/24 at 11:00 AM, ARNP O reported Patient #21' s routine monthly laboratory blood draw at Dialysis Center R on 1/3/24 resulted a critical potassium level of 7.7 mmol/L which prompted order sent to Hospital L for repeat potassium blood draw on 1/4/24. ARNP O recalled due to transportation issues Patient #21 presented to Hospital K and colleague ARNP I ordered repeat potassium blood draw on 1/4/24 at Hospital K. ARNP O reported Hospital K phoned with results of a critical potassium level of 6.9 mmol/L. ARNP O recalled telling ED MD A at Hospital K this is an emergency and advised to obtain EKG and lower the potassium level with insulin and glucose or albuterol. ARNP O reported with an untreated critical potassium level, Patient #21 could have had an arrhythmia resulting in a cardiac arrest in transport.

5. Review of Patient #21's medical chart from Hospital K revealed:

a. On 1/4/24 at approximately 11:29 AM, Patient #21 presented to Hospital K ED registration desk asking for outpatient lab work. Patient #21 presented without orders from a practitioner.

b. (late entry; unknown encounter time) On 1/4/24 at 12:30 PM ED RN F documented they requested that Nursing Home S provide laboratory orders for the patient.

c. On 1/4/24 at 11:42 AM lab work performed at Hospital K resulted abnormal potassium level of 6.9 mmol/L.

d. (late entry; unknown encounter time) On 1/4/24 at 6:05 PM ED MD A documented the following, "I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21' s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG" ... "I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]" ... "I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment." Patient #21 prepared patient's ride to Hospital L for evaluation and treatment.

e. The medical record lacked documentation of the time when the patient left the ED.

6. During an interview on 1/17/24 at 11:30 AM, Hospital K ED MD A explained when ED staff registered a patient for an ED encounter, the ED staff performed an appropriate MSE. ED MD A reported Patient #21 was not registered for an ED encounter and lab work was ordered by an outside provider. ED MD A reported receiving a phone call from ARNP O requesting Patient #21 be evaluated and treated at Facility K for critical lab results. ED MD A recalled asking Patient #21 to be evaluated and treated in the ED at Facility K and Patient #21 expressed the desire to travel to Facility L. ED MD A notified ARNP O that Patient #21 did not want to be seen at Facility K and was planning on going to Facility L. ARNP O again expressed they did not have the capability to treat Patient #21 at Facility L. ED MD A relayed the additional information to Patient #21 and again Patient #21 expressed the desire to travel to Facility L. ED MD A recalled a conversation with Taxi Driver J to confirm that they were agreeable to drive Patient #21 to Facility L. ED MD A confirmed that Patient #21 did not receive an MSE and did not sign an AMA form.

7. Review of Patient #21's medical chart from Hospital L revealed:

a. On 1/4/24 at 1:59 PM, Patient #21 presented to Hospital L ED from Dialysis Center R with elevated potassium level, previously drawn on 1/4/24 at Hospital K. ED DO P was contacted by ARNP O and discussed evaluation, treatment, stabilization, and transfer to a higher level of care. ED DO P performed MSE, provided treatment and repeat potassium level decreased to 6.1 mmol/L. Hospital V accepted Patient #21 and transfer was made by ground ambulance.

8. 1/17/24 at 10:45 AM Hospital K ED Clinical Lead confirmed that Patient #21 was not registered with an ED encounter and they did not sign an AMA form. ED Clinical Lead reported hospital staff complete education on EMTALA training at orientation, complete annual online competency modules, and have EMTALA reminders at monthly nursing meetings.

Based on medical record review from Hospital K and Hospital L, Nursing Home S record review, patient and staff interviews, the Critical Access Hospital's administrative staff failed to ensure the Emergency Department (ED) staff at Hospital K provided, within the hospital's capabilities, an appropriate medical screening examination (MSE) to 1 of 21 emergency patients reviewed (Patient #21).
Failure to provide all patients with appropriate transfer placed Patient #21 at risk for a worsening emergency medical condition (EMS) and at a potential risk for death.

Findings include:

1. During an interview on 1/22/24 at 6:23 PM, Patient #21 reported a history of dialysis (the process of removing excess water and waste products from the blood in people whose kidneys can no longer perform these functions naturally) treatment three times a week for three years at Dialysis Center R. Patient #21 reported an elevated potassium (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) level at Dialysis Center R on 1/3/24 which prompted ARNP I to order a repeat potassium level blood draw on 1/4/24. Patient #21 was told by LPN H at Nursing Home S (place of residence), that transportation had been arranged for the repeat blood draw at Hospital L. Patient #21 reported they did not want to ride the 45 minute trip each way to Hospital L and called Dialysis Center R. RN N at Dialysis Center R talked with the ARNP I, who gave permission to Patient #21 to have blood drawn at Hospital K. Patient #21 arrived at the ED entrance of Hospital K and Patient #21 stated they needed a blood draw. ED RN F stated outpatient registration and blood draw could be performed in the ED. Patient #21 recalled being placed in an ED room and blood draw was performed there. Patient #21 reported ED MD A discussed laboratory blood draw resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L). Patient #21 further reported ED MD A had spoken to ARNP O and gave Patient #21 the options of going to Hospital L or being transported to another higher level of care facility. Patient #21 did not recall ED MD A explained treatment was needed at Hospital K or the risk of leaving with a critical potassium level. Patient #21 reported they felt well at that time and promptly arranged for transportation to Dialysis Center R.

2. During an interview on 1/22/24 at 10:34 AM Director of Nursing at Nursing Home S explained Patient #21 was determined to be of sound mind after a Brief Interview for Mental Status (quick assessment of cognitive function; score of 15 indicates intact cognition) performed on 11/20/2023 resulted in a score of 15.

3. During an interview 1/22/24 at 10:30 AM, Hospital L ED DO P recalled Patient #21 arrived to Hospital L ED from Dialysis Center R. ED DO P reported Patient #21 arrived to Dialysis Center R via taxi. ED DO P reported ARNP O called and discussed impending arrival of Patient #21 for further evaluation and treatment of critically elevated potassium level of 6.9 mmol/L hours earlier at Hospital K where no MSE, treatment or appropriate transfer was arranged. ED DO P reported Patient #21 should have had the potassium level decreased by Hospital K prior to transport in order to lower the risk for cardiac instability which could have led to cardiac arrest. ED DO P reported due to a critical potassium level, the expectation would be Hospital K completed an MSE, performed stabilizing treatment and transfer of Patient #21 by ground ambulance.

4. During an interview on 1/22/24 at 11:00 AM, ARNP O reported Patient #21' s routine monthly laboratory blood draw at Dialysis Center R on 1/3/24 resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 7.7 millimoles per liter (mmol/L) which prompted order sent to Hospital L for repeat potassium blood draw on 1/4/24. ARNP O recalled due to transportation issues Patient #21 presented to Hospital K and colleague ARNP I ordered repeat potassium blood draw on 1/4/24 at Hospital K. ARNP O reported Hospital K phoned with results of a critical potassium level of 6.9 mmol/L. ARNP O recalled telling ED MD A at Hospital K this is an emergency and advised to obtain EKG and lower the potassium level with insulin and glucose or albuterol. ARNP O reported with an untreated critical potassium level, Patient #21 could have had an arrhythmia resulting in a cardiac arrest in transport.

5. Review of Patient #21's medical chart from Hospital K revealed:

a. On 1/4/24 at approximately 11:29 AM, Patient #21 presented to Hospital K ED registration desk asking for outpatient lab work. Patient #21 presented without orders from a practitioner.

b. (late entry; encounter time unknown) On 1/4/24 at 12:30 PM ED RN F documented they requested that Nursing Home S provide laboratory orders for the patient.

c. On 1/4/24 at 11:42 AM lab work performed at Hospital K resulted abnormal potassium level of 6.9 mmol/L.

d. (late entry; encounter time unknown) On 1/4/24 at 6:05 PM ED MD A documented the following, "I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21 ' s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG" ... "I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]" ... "I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment." Patient #21 prepared the patient's ride to Hospital L for evaluation and treatment.

e. The medical record lacked documentation of the time when the patient left the ED.

6. During an interview on 1/17/24 at 11:30 AM, Hospital K ED MD A explained when ED staff registered a patient for an ED encounter, the ED staff performed an appropriate MSE. ED MD A reported Patient #21 was not registered for an ED encounter and lab work was ordered by an outside provider. ED MD A reported receiving a phone call from ARNP O requesting Patient #21 be evaluated and treated at Facility K for critical lab results. ED MD A recalled asking Patient #21 to be evaluated and treated in the ED at Facility K and Patient #21 expressed the desire to travel to Facility L. ED MD A notified ARNP O that Patient #21 did not want to be seen at Facility K and was planning on going to Facility L. ARNP O again expressed they did not have the capability to treat Patient #21 at Facility L. ED MD A relayed the additional information to Patient #21 and again Patient #21 expressed the desire to travel to Facility L. ED MD A recalled a conversation with Taxi Driver J to confirm that they were agreeable to drive Patient #21 to Facility L. ED MD A confirmed that Patient #21 did not receive an MSE and did not sign an AMA form.

7. Review of Patient #21's medical chart from Hospital L revealed:

a. On 1/4/24 at 1:59 PM, Patient #21 presented to Hospital L ED from Dialysis Center R with elevated potassium level, previously drawn on 1/4/24 at Hospital K. ED DO P was contacted by ARNP O and discussed evaluation, treatment, stabilization, and transfer to a higher level of care. ED DO P performed MSE, provided treatment and repeat potassium level decreased to 6.1 mmol/L. Hospital V accepted Patient #21 and transfer was made by ground ambulance.

8. During an interview 1/17/24 at 3:04 PM, Hospital K ED RN F reported Patient #21 was told that they could be registered for outpatient services at the ED desk.

9. During an interview on 1/17/24 at 3:15 PM, Hospital K ED Tech G reported Patient #21 was registered as an outpatient encounter. ED Tech G reported never witnessing ED MD A refusing to treat anyone that presented to the ED at Facility K.

10. During an interview on 1/23/24 at 1:00 PM Hospital K Laboratory Staff T reported receiving a lab order via fax on 1/4/24 at 11:34 AM from ARNP I. Laboratory Staff T reported performing a lab draw on Patient #21 in the ED on 1/4/24 at 11:42 AM.

11. 1/17/24 at 10:45 AM Hospital K ED Clinical Lead confirmed that Patient #21 was not registered with an ED encounter and they did not sign an AMA form. ED Clinical Lead reported hospital staff complete education on EMTALA training at orientation, complete annual online competency modules, and have EMTALA reminders at monthly nursing meetings.