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Based on observation and staff interview the Critical Access Hospital (CAH) failed to post signs in all areas specifying the rights of individuals, who present to the ED (Emergency Department) seeking health care services for emergency medical conditions or for women in labor. Findings include:

During tour of the Emergency Department (ED) on 9/17/12 at 11:00 AM the only EMTALA sign posting was observed in the patient waiting room. No other area of the department including the ambulance entrance, admitting area or treatment areas had signs posted specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor. This was confirmed, at the time of tour, by the ED Nurse Manager.

Based on staff interview and record review the CAH failed to assure that an appropriate MSE (Medical Screening Examination), to determine whether or not an Emergency Medical Condition (EMC) existed, was conducted for Patient #1 who presented to the ED (Emergency Department) complaining of difficulty breathing and right upper quadrant pain radiating to their back. Findings include:
Per record review on 9/17/12 , Patient #1 arrived in the Emergency Department (ED) on 5/31/12 at 00:59 with a chief complaint of difficulty breathing, only comfortable when standing and right upper quadrant pain radiating to their back. Vital signs at 01:07 include: B/P 150/85, Pulse 102, respirations 12, temp 36.4 and pulse oximetry 98% (oxygen level) on room air. Acuity level at the time of Triage was assessed to be "4" using the Emergency Severity Index scoring of 1-5 (level 1 is acute-level 5 is minor . However the nurse failed to obtain a pain rating from Patient #1, as per hospital policy Emergency Department Triage Policy and Procedure ( last revised 9/2011) which is required for correctly determining level of acuity.

At approximately 0133 Physician #1 begins a Medical Screening Exam (MSE) of Patient #1 and documents the onset of symptoms began at 14:00, with the patient initially unable to take a deep breath and the "Severity of Pain: in the emergency department the pain is unchanged". After a physical exam and review of systems Physician #1 notes; " Cardiovascular: "Positive for chest pain, worse with inspiration sharp with cough, with movement, Negative for edema, palpations, paroxysmal nocturnal dyspnea" (sudden difficulty breathing while sleeping in a reclining position). Pulses in both legs were evaluated and were within normal limits. Respiratory assessment for Patient #1, the physician concludes: " Positive for shortness of breath, negative for cough, orthopnea (abnormal breathing condition), sputum production, wheezing". Per interview on 9/18/12 at 8:15 AM, when asked if s/he assessed Patient #1's breath sounds by auscultation, Physician #1 stated s/he believed they had, however there was no evidence in the documentation to confirm this assessment was performed.

Physician #1 ordered an EKG, chemistry studies, hepatic panel, Troponin I (to rule/out acute coronary ischemia), D-Dimer (a test to rule/out the presence of a clot), hematology and Chest X-rays. Results included: Troponin I was negative at <0.04, the patient ' s electrolytes were below normal, the EKG results were " No acute ischemic changes" and the chest x-ray was determined to be normal. Results also noted the D-Dimer was elevated at 959 with the laboratory noting the cutoff for ruling out a Pulmonary Embolism and Deep Vein Thrombosis (blood clot) is < 500 ng/mlFEU.

Physician #1's differential diagnosis for the patient included: coronary artery disease, cholelithiasis, chest wall pain and pulmonary embolism. S/he also states at 03:21: "Assessment and Plan; chest wall pain reproduces symptoms. Although D-Dimer elevated, there is no tachypnea or tachycardia." However, there was no documented evidence during the course of treatment Patient #1 was placed on continuous cardiac monitoring and no further vital signs were taken by nursing since triage. At 1:53 the patient was administered 81 mg of Aspirin. Two minutes prior to discharge, at 03:27, Patient #1 was administered Potassium Chloride 40 mEq (to treat a low Potassium level) and Percocet 5 mg-325 mg 2 tablets for the patient ' s persistent pain. At 03:29 Patient #1 was discharged from the ED to home. Physician #1 recommended follow-up with patient's primary care provider (PCP) the following day noting "Condition is stable" "Problem is new" and "Symptoms unchanged".

Upon discharge Patient #1's symptoms persisted and s/he sought treatment on the afternoon of 5/31/12 with their primary care provider who noted Patient #1 was experiencing symptoms of shortness of breath and continued pain. The patient was emergently transported via EMS ambulance from the PCP's office to a tertiary facility with a diagnosis of pulmonary embolism (PE) and right pulmonary effusion requiring acute hospitalization and anticoagulation treatment.

Per interview on 9/18/12 at 8:15 AM, when asked why a CT scan was not ordered as part of the MSE to assist in determining whether or not Patient #1 had an emergency medical condition associated with a PE, Physician #1 stated the patient was allergic to the contrast dye used for the CT scan. Physician #1 confirmed s/he had not completely ruled out a PE, stating in ".....a normal situation s/he would have had a CT scan with contrast". When asked if a Ventilation-perfusion scan (V/Q scan) was then considered, the physician noted this test was not performed at night because it required nuclear medicine. Although s/he has worked in the ED since 1993, Physician #1 acknowledged s/he was unaware whether or not the Radiology department at the hospital had a protocol for pre-medicating a patient with a known allergy to contrast dye prior to a CT scan. Per interview on 9/18/12 at 8:30 AM the ED Medical Director, stated "We do have a protocol for that; I looked into that when looking at this case and radiology does have a protocol for administration of medication prior to CT scan for patients who are allergic to dyes". In addition, Physician #1 further stated s/he had in fact ordered a CT scan but then canceled it. However, in his review of Patient #1 ' s record, the Medical Director acknowledged there was no evidence a CT scan was ever ordered for Patient #1. Per interview on 9/18/12 at 1:08 PM the lead CT technologist confirmed the Radiology Department protocol for patients with known allergy to contrast dye consists of pre-medicating the patient with methyprednisolone 32 mg orally 12 hours and 2 hours prior to the procedure.

Although diagnostic testing was available, Physician #1 failed to consult with radiology on what the protocol was for ordering a CT Scan for a patient with contrast dye allergy. A Medical Screening Exam, appropriate to Patient #1 ' s presenting signs, symptoms and laboratory test results was not provided. Physician #1 failed to determine whether or not an Emergency Medical Condition ( Pulmonary Embolism) existed and failed to assure stability of Patient #1 ' s medical condition prior to discharging the patient to their home on 5/31/12.

Based on staff interview and record review, the CAH failed to assure stability of the medical condition prior to discharge for Patient #1, as evidenced by the facility's failure to complete an appropriate Medical Screening Exam to determine if an emergency medical condition existed. Findings include:

Per record review on 9/17/12 , Patient #1 arrived in the Emergency Department (ED) on 5/31/12 at 00:59 with a chief complaint of difficulty breathing, only comfortable when standing and right upper quadrant pain radiating to their back. Vital signs at 01:07 include: B/P 150/85, Pulse 102, respirations 12, temp 36.4 and pulse oximetry 98% (oxygen level) on room air.

At approximately 0133 Physician #1 begins a Medical Screening Exam (MSE) of Patient #1 and documents the onset of symptoms began at 14:00, with the patient initially unable to take a deep breath and the "Severity of Pain: in the emergency department the pain is unchanged". After a physical exam and review of systems Physician #1 notes; " Cardiovascular: "Positive for chest pain, worse with inspiration sharp with cough, with movement, Negative for edema, palpations, paroxysmal nocturnal dyspnea" (sudden difficulty breathing while sleeping in a reclining position). Pulses in both legs were evaluated and were within normal limits. Respiratory assessment for Patient #1, the physician concludes: " Positive for shortness of breath, negative for cough, orthopnea (abnormal breathing condition), sputum production, wheezing". Per interview on 9/18/12 at 8:15 AM, when asked if s/he assessed Patient #1's breath sounds by auscultation, Physician #1 stated s/he believed they had, however there was no evidence in the documentation to confirm this assessment was performed.

Physician # 1 ordered an EKG, chemistry studies, hepatic panel, Troponin I (to rule/out acute coronary ischemia), D-Dimer (a test to rule/out the presence of a clot), hematology and Chest X-rays. Results included: Troponin I was negative at <0.04, the patient ' s electrolytes were below normal, the EKG results were " No acute ischemic changes" and the chest x-ray was determined to be normal. Results also noted the D-Dimer was elevated at 959 with the laboratory noting the cutoff for ruling out a Pulmonary Embolism and Deep Vein Thrombosis (blood clot) is < 500 ng/mlFEU.

Prior to Patient #1's discharge, Physician #1's differential diagnosis for the patient included: coronary artery disease, cholelithiasis, chest wall pain and pulmonary embolism. S/he also states at 03:21"Assessment and Plan; chest wall pain reproduces symptoms. Although D-Dimer elevated, there is no tachypnea or tachycardia." However, there was no documented evidence during the course of treatment Patient #1 was placed on continuous cardiac monitoring and no further vital signs were taken by nursing since triage. Physician #1 failed to provide any further interpretation why the D-Dimer results for patient #1 was elevated. At 1:53 the patient was administered 81 mg of Aspirin. Two minutes prior to discharge, at 03:27, Patient #1 was administered Potassium Chloride 40 mEq (to treat a low Potassium level) and Percocet 5 mg-325 mg 2 tablets for the patient ' s persistent pain. At 03:29 Patient #1 was discharged from the ED to home. Physician #1 recommended follow-up with patient's primary care provider the following day noting "Condition is stable" "Problem is new" and "Symptoms unchanged".

Per interview on 9/18/12 at 8:15 AM, when asked why a CT scan was not ordered as part of the MSE to assist in determining whether or not Patient #1 had an emergency medical condition associated with a PE, Physician #1 stated the patient was allergic to the contrast dye used for the CT scan. The physician confirmed s/he had not completely ruled out a PE, stating in ".....a normal situation s/he would have had a CT scan with contrast". When asked if a Ventilation-perfusion scan (V/Q scan) was then considered, the physician noted this test was not performed at night because it required nuclear medicine. Although s/he has worked in the ED since 1993, Physician #1 acknowledged s/he was unaware whether or not the Radiology department at the hospital had a protocol for pre-medicating a patient with a known allergy to contrast dye prior to a CT scan. Per interview on 9/18/12 at 8:30 AM the ED Medical Director, stated "We do have a protocol for that; I looked into that when looking at this case and radiology does have a protocol for administration of medication prior to CT scan for patients who are allergic to dyes". In addition, Physician #1 further stated s/he had in fact ordered a CT scan but then canceled it. However, in his review of Patient #1 ' s record, the Medical Director acknowledged there was no evidence a CT scan was ever ordered for Patient #1. Per interview on 9/18/12 at 1:08 PM the lead CT technologist confirmed the Radiology Department protocol for patients with known allergy to contrast dye consists of pre-medicating the patient with methyprednisolone 32 mg orally 12 hours and 2 hours prior to the procedure.

Although diagnostic testing was available, Physician #1 failed to consult with the radiology department to investigate what the protocol was for ordering a CT Scan for a patient with contrast dye allergy. A Medical Screening Exam, appropriate to Patient #1 ' s presenting signs, symptoms and laboratory test results was not conducted. Physician #1 had failed to determine whether or not an Emergency Medical Condition ( Pulmonary Embolism) existed and failed to assure stability of Patient #1 ' s medical condition prior to discharging the patient to their home on 5/31/12. Upon discharge Patient #1's symptoms persisted and s/he sought treatment on the afternoon of 5/31/12 with their primary care provider (PCP) who noted Patient #1 was experiencing symptoms of shortness of breath and continued pain. The patient was emergently transported via EMS from the PCP's office to a tertiary facility with a diagnosis of pulmonary embolism (PE) and right pulmonary effusion requiring acute hospitalization and anticoagulation treatment.

Based on record review and confirmed through staff interview the facility failed to ensure an appropriate transfer by failing to complete a written certificate of transfer for 1 patient. Findings include:

Per record review there was no evidence that a transfer certificate had been completed for Patient #20, who arrived at the ED in cardiac arrest on 5/26/12, and who was transferred, an hour and 16 minutes after arrival, in unstable condition to a tertiary care center. Although there was a note, dictated by the attending physician, which stated; "I was able to talk to (patient's) mother who will go to DHMC to be with (patient). She is aware of (patient's) critical status", there was no evidence that the family member had been informed of the risks of transfer. In addition there was no evidence of what, if any, patient information had been sent with the patient to the receiving hospital.
This was confirmed by the Vice President of Patient Care Services during interview at 4:11 PM on 9/18/12.