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Based on document review, record review, policy review and interview the critical access hospital (CAH) failed to ensure the Emergency Medical Treatment and Labor Act (EMTALA) requirements were met by failing to provide stabilizing treatment and failing to appropriately transfer patients who presented to the emergency department seeking medical care and were found to have an emergency medical condition (EMC). Failure to appropriately stabilize and transfer patients with an EMC places them at risk for deterioration of their condition and harm.

Findings Include:

The CAH failed to provide stabilizing treatment for 1 (Patient 5) of 20 patients reviewed. (Refer to C2407)

The CAH failed to appropriately transfer an unstable patient safely to a receiving facility for a higher level of care for 1 (Patient 16) of 13 patients reviewed for transfers. (Refer to C2409)

Based on interview, record review and policy review, the critical access hospital (CAH) failed to provide stabilizing treatment for 1 (Patient 5) of 20 patient records reviewed. Failure to provide stabilizing treatment places patients with an emergency medical condition at risk for deterioration of their conditions and harm.

Findings Include:

Review of the CAH policy titled, "Compliance with EMTALA" last reviewed 05/2024, revealed, " ...2. The emergency medical screening examination includes the use of ancillary services routinely available to patients in the hospital to help in determining whether an emergency medical condition exists. 3. Based upon this examination, if it is determined that the patient has an emergency medical condition, the hospital shall provide treatment to stabilize the medical condition within the capabilities of the hospital and staff and the facilities, or shall arrange for an appropriated transfer of the individual to another medical facility ..."


Patient 5

Review of Patient 5's "ED [Emergency Department] Nursing Triage" document revealed Patient 5 arrived at the facility on 03/09/25 at 10:45 AM. The triage note revealed the Patient 5 was brought in by a family member because of concerns regarding increased paranoia, self-harm, and increased anger over the prior three days. The record indicated that Facility 2 called a nurse in the ED prior to the patient's arrival to inform them that the patient had refused screening by a mental health agency, and Patient 5 was advised to go to the ED for screening.

Review of Patient 5's " History and Physical," dated 03/09/25 and conducted by Medical Doctor (MD) 2, revealed that, on 03/09/25, Patient 5 was agitated, with a flat affect and intermittent bursts of manic laughter. Further review revealed the patient was ripping items off the wall and stripping their clothing off in the ED room. The record indicated law enforcement was called to sit with the patient in the ED room. The record revealed Facility 2 was contacted to request a one-to-one sitter for Patient 5, who was on an involuntary emergency hold. The record revealed a law enforcement officer informed a physician and registered nurse (RN) that the patient would be taken into police protective custody due to aggression that occurred prior to the patient presenting to the ED. Further review revealed a mental health screening was conducted, and the mental health screener requested laboratory samples be drawn prior to Patient 5 being placed on a waiting list at Facility 3. Further review revealed laboratory testing and vital sign results were relayed to Facility 3, and the patient was awaiting admission to Facility 3. The record indicated that the patient presented a danger to themselves, or others and MD 2 recommended involuntary placement.

Review of Patient 5's "Mental Health Screening Form," dated 03/09/25, revealed Patient 5 received a telehealth mental health screening on 03/09/25 at 2:00 PM while in the ED. The mental health screening revealed that Patient 5 was manic, with hallucinations and delusions. The screening also indicated that, due to Patient 5's behavior at a family member's house and at the hospital, the patient was at risk of being a danger to others. The screening revealed the clinician recommended involuntary inpatient hospitalization for stabilization of the patient's symptoms, medication evaluation in a secured setting, and "24-hour structured therapeutic milieu" to implement the treatment plan. The record revealed the patient's provider, MD 2, was present during the assessment and was aware of the disposition.


Review of Patient 5's "ED Nursing Documentation," dated 03/09/25, revealed the law enforcement officer advised facility staff that the patient had been accepted to Facility 3, but would be taken to jail for holding until a bed was available. The record indicated Patient 5 was taken into custody by law enforcement at 7:05 PM and was discharged from the facility with law enforcement.


Patient 5's medical record showed the CAH failed to provide antipsychotic medications to stabilize Patient 5 and reduce the risk of self-harm or injury to others while waiting an undetermined amount of time for a bed at an inpatient psychiatric facility. Instead, the CAH discharged Patient 5 to jail, which would not help stabilize his acute psychiatric condition. The medical record also revealed no Emergency Medical Treatment and Labor Act (EMTALA) form was completed, including no documentation of a discussion of risk and benefits of the transfer, patient or legal representative signature consenting to the transfer, indication of acceptance to Facility 3, or physician certification for the transfer.

During an interview on 04/30/25 at 12:45 PM, MD 2 stated that she was Patient 5's primary care provider (PCP) when he arrived at the ED. MD 2 stated Patient 5 appeared to be reacting to stimuli that were not visible or audible to others in the room. She stated Patient #5 was screened by a state screener and was a candidate for placement due to the patient having active auditory and visual hallucinations. MD 2 stated she was notified by law enforcement that Patient 5 was in police protective custody due to issues prior to his arrival in the ED. MD 2 stated that, prior to Patient 5's arrival, Patient 5 was hitting the patient's head. She noted she did not have the ability to hold psychiatric patients due to not having enough staffing for one-to-one observation and not having security staff.

During a follow up interview on 05/01/25 at 3:38 PM, MD 2 stated that she contacted Facility 3 regarding Patient 5. MD 2 stated that the sheriff deputy who was in the ED with Patient 5 was contacted by Facility 3 and was informed that Patient 5 was accepted to Facility 3. MD 2 stated that the sheriff deputy told her he was going to take Patient 5 to jail. MD 2 stated that the EMTALA form was not completed because Patient 5 was in police custody, and police were going to transport Patient 5.

During an interview on 05/01/25 at 12:25 AM, the Chief of Medical Staff stated the facility did not have staff available to hold psychiatric patients waiting for placement, mostly because there was no security staff and the sheriff's department was short-handed.

Based on interview, record review, and policy review, the critical access hospital (CAH) failed to appropriately transfer patients with an unstable emergency medical condition (EMC) to a receiving facility for 1 (Patient 16) of 13 patients reviewed for transfers. Failure to ensure an appropriate transfer places patient's safety at risk which can lead to deterioration of their condition.

Findings Include:

Review of a CAH policy titled, "Patient Transfers," revised 05/2024, indicated, "4. Transfer shall not be made unless the hospital has contacted the receiving hospital and the receiving hospital has accepted the patient, fulfilling the responsibility of within their capacity and capability to provide treatment ie.[sic] qualified personnel and available space to treat the patient. 5. The transferring facility shall assure that all patients shall be transferred by an appropriate mechanism with appropriate personnel to meet the specific needs of each patient for their specific condition. The transferring Physician/Mid-Level in conjunction with the Physician at the receiving facility shall determine the appropriate mode of transport." Further review under a section titled "Procedure for Transfer to Another Facility" revealed, "4. Mode of transport: a. Transfer shall be by a method with sufficient safety equipment as required by the patient's medical condition. b. The patient shall be accompanied by qualified personnel as required by the patient's medical condition. c. The patient shall not be transferred by non-medical, private vehicle. d. The patient's condition shall be documented in the medical record and shall support the mode of transport selected. If the patient refuses any recommended mode of transportation, that refusal shall be documented in the medical record."

Patient 16

Review of Patient 16's "ER [Emergency Room] Note," dated 09/04/24 and conducted by Physician Assistant (PA) 4, revealed an "Admission Date/Time" for Patient 16 of 09/04/24 at 7:15 PM with a chief complaint of mental health screening. The record revealed Patient 16 had a history of depression, anxiety, and previous suicidal ideation. Further review revealed Patient #
16 had superficial cuts to their right upper thigh thought to be three to four days old. Per the document, the physical examination conducted by PA 4 indicated Patient 16 presented with an anxious mood, flat effect, and active suicidal ideation with no plan.

Review of Patient 16's "ED Nursing Documentation," dated 09/04/24, revealed the patient's family member was unable to travel to the hospital, so the patient was brought to the ED via private vehicle by unrelated community members. The record indicated Facility 4 was called and Patient 16 was placed on Facility 4's waiting list for acceptance at 7:20 PM. The record revealed the facility called Patient 16's family member at 9:15 PM and requested the family member arrange transportation to Facility 4, but the family member was unable to transport Patient 16. The record indicated that, at 9:30 PM, a nurse attempted to contact transport services and also noted the sheriff's office was unable to transport Patient 16. The record revealed Patient 16 was discharged to the care of the unrelated community members and was to be transported by private vehicle to Facility 4 by the unrelated community members at 10:35 PM.

Review of an "AUTHORIZATION FOR TRANSFER BY PRIVATE VEHICLE" document, dated 09/04/24, revealed, "I, [Patient 16's legal representative's name], have been offered to be transferred by ambulance from [Facility Name], but have made the decision to transport myself by private vehicle to [Facility 4]. The Physician/Qualified Medical Personnel has explained the risks and benefits of being transported by private vehicle." The document revealed it was not signed by Patient 16's legal representative but was signed by the patient's unrelated community member. The document contained a statement denoting "I also understand that I am to drive straight to [not applicable] to be seen for further treatment." There was no signature indicating that the driver understood to drive straight to the receiving medical facility for further treatment.

During an interview on 04/30/25 at 1:20 PM, PA 4 stated Patient 16 was brought in by unrelated community members and, after conducting a screening, it was determined Patient 16 should be transferred to Facility 4. PA 4 stated Patient 16 was having thoughts of self-harm, but did not have a plan and, because the patient did not have a plan, PA 4 thought the patient was stable for transport with the unrelated community members.

During an interview on 05/01/25 at 12:25 PM, the Chief of Medical Staff stated he expected patients who presented with active suicidal ideation to be transported by emergency medical services (EMS) for safety.