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I. Based on review of records, policies/procedures, and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to follow the CAH's policies and did not provide stabilizing treatment or appropriately transfer 1 ED patient (Patient # 30) who presented to the ED with an emergency, out of 40 cases selected for review from May 2011 to September 2011. The CAH administrative staff identified an average of 285 emergency room visits per month.

Failure to provide stabilizing treatment within the CAH's capabilities for a patient with an unstable emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications including death.

Findings include:

1. Review of the medical record revealed a 76-year-old patient (# 30) presented to the ED by ambulance on 8/31/11 at 5:30 AM after falling at the nursing home. Documentation sent from the nursing home to the ED revealed Patient # 30 was confused at times and that she fell, "possibly face forward - has a large abrasion and raised area to upper left eye" and complained of pain when moving her arms, legs, and back.

The ED Physician Assistant (PA) examined Patient # 30 at 5:30 AM and documented her past medical history included diabetes, chronic kidney disease, hypertension, anxiety and depression and listed her multiple daily medications. Further documentation revealed Patient # 30's fall was un-witnessed, that she was unable to state what happened and that she had an abrasion and bruise on the left side of her forehead. At 6:10 AM, the PA ordered a CT scan of the head and cervical spine (neck) which revealed Patient # 30 had an (1) acute intracranial bleed - "most likely subdural hematoma with extradural component on the left side measuring 6 mm (millimeters) in width predominantly in frontal parietal region on the left side." "No midline shift." (2) "Large left frontal scalp hematoma" (3) "C-spine negative." At 6:20 AM lab results revealed Patient # 30 had critically elevated Creatinine (3.03) and Blood Urea Nitrogen (68) levels (measures of kidney function) and at 6:41 AM a high Prothrombin Time (blood test that measures how long it takes the blood to clot). At 6:30 AM, the ED nurse documented that Patient # 30 received intravenous fluids of Normal Saline at 250 cc per hour per order. At 7:59 AM, the ED nurse documented Patient # 30 received an injection of Vitamin K (Coumadin antidote) and then began the process of preparing the patient for discharge from the ED. At 8:30 AM, the ED nurse documented that Patient # 30 vomited green liquid and contacted the on call physician for orders. Also at 8:30 AM, the ED nurse documented the discontinuation of Patient # 30's intravenous infusion. At 8:35 AM, the ED nurse administered Promethazine (a medication sometimes used to prevent or treat motion sickness, more frequently used to relax and sedate a patient). At 8:58 AM, the ED nurse documented that Patient # 30 was sleeping and at 9:07 AM placed on a stretcher and sent by ambulance back to the nursing home to discontinue the patient's daily Coumadin (medication that prevents formation of blood clots).

At 4:48 AM, The EMS ambulance report stated upon arrival to the nursing home where the patient had fallen prior to going to the emergency room, the nursing home staff stated Patient # 30 was talking to them with appropriate sentences prior to the ambulance personnel arrival.

2. During an interview on 9/14/11 at 2:45 PM, CAH ED Registered Nurse (RN) A reported Patient # 30 was confused when she came into the emergency room. RN A stated Patient # 30 had a head bleed and discharged back to the nursing home.

3. During an interview on 9/14/11 at 2:10 AM, the on call Physician A stated he did not see the patient while she was in the emergency room. Physician A reported Patient # 30 was initially confused when they came to the emergency room. Physician A acknowledged he was aware Patient # 30 vomited while in the emergency room and stated he gave the order for Promethazine while the patient was in the emergency room. Physician A stated the medication could have made the patient more somnolent. Physician A stated Patient # 30 developed sudden pulmonary edema later the same day after the transfer of the patient back to the nursing home and the patient died of an unrelated cardiac event.

4. Review of the policy titled "General EMTALA Responsibilities", dated reviewed 1/13/11, revealed in part, "Monroe County Hospital will follow the special responsibilities of Medicare hospitals as defined in the EMTALA regulations. . . . If an emergency medical condition exists, Monroe County Hospital and physicians will provide necessary stabilizing treatment within the capability and capacity of its staff and facilities.

The CAH ED staff failed to follow the policy and did not provide stabilizing treatment within their capabilities including an appropriate transfer of Patient # 30.

Refer to tag A-2407 for further details.


II. Based on review of records, policies/procedures, and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to follow the CAH's policies and did not provide a medical screening exam within the capabilities of the CAH for 1 ED patient (Patient # 31) who presented to the emergency room requesting care out of 40 cases selected for review from May 2011 to September 2011. The CAH administrative staff identified an average of 285 emergency room visits per month.

Failure to provide an appropriate medical screening exam within the CAH's capabilities could potentially results in patients with an emergency medical condition not receiving appropriate care, leading to disability, loss of limb, or death.

Findings include:

1. Review of the medical record revealed a 87-year old patient (# 31) presented to the ED per ambulatory on 8/31/11 at 2:57 PM. The ED nurse documented that Patient # 31 had prostate surgery on 8/26/11 and had the Foley catheter taken out yesterday (8/30/11). The ED nurse documented Patient # 31 stated he has been unable to void today except for a small trickle. The ED nurse documented Patient # 31 alert and mild distress. At 3:22 PM, the ED nurse documented - 16 F Foley catheter inserted per sterile technique with immediate return 850 ml urine. At 3:56 PM, the ED nurse documented - discussed delay with patient waiting for Dr. to arrive, patient denies having any needs at this time and states relief after Foley catheter inserted. At 4:01 PM, the ED nurse documented leg bag applied. At 4:28 PM, the ED nurse documented Patient # 31 discharge condition: stable; discharge to: home; Mode: ambulatory; Prescriptions given to patient:: None written; Discharge instructions: Written instructions, given to patient, patient verbalized understanding; Discharge time: 4:28 PM. At 4:30 PM, the ED nurse documented a telephone order from Physician A for Patient # 31 for a Foley catheter and discharge to home.

2. During an interview on 9/14/11 at 2:45 PM, CAH ED Registered Nurse (RN) A reported Patient # 31 had called his urologist who told the patient to go to the hospital and get another catheter put in. RN A stated Patient # 31's urologist did not call the ER with orders so RN A called Physician A and received an order to insert a Foley catheter. RN A stated Physician A did not come to the ER to see Patient # 31.

3. During an interview on 9/14/11 at 2:10 PM, the on call Physician A stated he did not see Patient # 31 while he was in the emergency room. Physician A stated Patient # 31 was referred to the emergency room by his urologist. Physician A stated Patient # 31 had a surgical procedure the week before and his catheter had been removed the previous day. Physician A stated the nurse called him from the emergency room and he gave an order to put a catheter in Patient # 31.

4. Review of the policy titled "Medical Screening Examination", dated reviewed 1/13/11, revealed in part, "Patients who present on hospital grounds requesting unscheduled examination or treatment will be treated as an ER patient and will receive a medical screening examination within the hospital's capabilities. . . . When on-call for the ER, active staff physicians must come to the hospital to perform medical screening examinations when any of the attached signs and symptoms listed is present (See Attachment A). . . ."

"Attachment A - Signs and symptoms that require the presence of the ER on-call physician to perform the medical screening examination. . . Symptomatic urine problems with fever, burning with urination, flank pain, urine retention. . . ."

The CAH ED staff failed to follow the policy that the ER on-call physician to perform the medical screening examination for a patient with symptomatic urinary symptoms.

Refer to tag A-2406 for further details.

Based on document review and interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to provide an appropriate medical screening examination for 1 ED patient (Patient # 31) who presented to the ED, out of 40 cases selected for review from May 2011 to September 2011. The CAH administrative staff identified an average of 285 emergency room visits per month.

Failure to provide an appropriate medical screening exam could potentially result in disability, loss of limb, or death in a patient with an emergency.

Findings include:

1. Review of the medical record revealed an 87-year-old patient (# 31) presented to the ED on 8/31/11 at 2:57 PM. The ED nurse documented that Patient # 31 had prostate surgery on 8/26/11 and had the Foley catheter taken out yesterday (8/30/11). The ED nurse documented Patient # 31 stated he has been unable to void today except for a small trickle. The ED nurse documented Patient # 31 was alert and mild distress. At 3:22 PM, the ED nurse documented - 16 F Foley catheter inserted per sterile technique with immediate return 850 ml urine. At 3:56 PM, the ED nurse documented - discussed delay with patient waiting for Dr. to arrive, patient denies having any needs at this time and states relief after Foley catheter inserted. At 4:01 PM, the ED nurse documented leg bag applied. At 4:28 PM, the ED nurse documented Patient # 31 was discharged with instructions to follow up with his urologist and return to the ED if needed. The medical record did not contain evidence that Patient # 31's abdomen or bladder was examined, that a urinalysis was performed to ensure the absence of a urinary tract infection or that Physician A came to the ED to examine Patient # 31 as required by CAH policy # 6231.1010. The policy specifies the ED on-call physician is required to examine any patient that presents with signs and symptoms of urinary retention. Review of the on-call list for the month of August 2011 confirmed Physician A was on call for the ED on 8/31/11.

2. During an interview on 9/14/11 at 2:45 PM, CAH ED Registered Nurse (RN) A reported Patient # 31 had called his urologist who told the patient to go to the hospital and get another catheter put in. RN A stated Patient # 31's urologist did not call the ER with orders so RN A called Physician A and received an order to insert a Foley catheter. RN A stated Physician A did not come to the ER to see Patient # 31.

3. During an interview on 9/14/11 at 2:10 PM, the on call Physician A stated he did not see Patient # 31 while he was in the emergency room. Physician A stated Patient # 31 was referred to the emergency room by his urologist. Physician A stated Patient # 31 had a surgical procedure the week before and his catheter had been removed the previous day. Physician A stated the nurse called him from the emergency room and he gave an order to put a catheter in Patient # 31.

Based on review of policies/procedures, patient medical records, documents, and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to provide stabilizing treatment within its capabilities prior to discharging a patient (Patient #30) with an unstable emergency medical condition. The CAH administrative staff identified an average of 285 emergency room visits per month.

Failure to provide stabilizing treatment within the CAH's capabilities for a patient with an unstable emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications including death.

Findings include:

1. Review of the 8/31/11 emergency services ambulance report revealed the nursing home staff told paramedics that Patient # 30 was talking to them with appropriate sentences prior to their arrival at 4:48 AM.

2. Review of the hospital medical record revealed Patient # 30, a 76-year-old patient taking Coumadin (blood thinning medication) presented to the ED by ambulance on 8/31/11 at 5:25 AM after falling at the nursing home. Documentation sent from the nursing home to the ED revealed Patient # 30 was confused at times and that she fell, "possibly face forward - has a large abrasion and raised area to upper left eye" and complained of pain when moving her arms, legs, and back. The ED Physician Assistant (PA) examined Patient # 30 and documented her fall was un-witnessed and that she was unable to state what happened. At 6:10 AM, the PA ordered a CAT scan of the head and cervical spine (neck) which revealed Patient # 30 had an acute intracranial bleed - "most likely subdural hematoma with extradural component on the left side measuring 6 mm (millimeters) ...". At 6:41 AM the coagulation lab tests (Prothrombin Time and INR), evaluating the ability of Patient # 30's blood to clot, revealed the Coumadin medication she took at the nursing home was effectively thinning her blood (INR level 2.8). At 7:59 AM, the ED nurse documented Patient # 30 received an injection of Vitamin K (within 12 - 24 hours reverses the blood thinning effects of Coumadin) to stop the bleeding into her brain, and began the process of preparing the patient for discharge. At 8:30 AM, the ED nurse documented that Patient # 30 vomited green liquid and contacted on-call Physician A for orders. At 8:35 AM, the ED nurse administered Promethazine (a medication used to relax and make sleepy). At 8:58 AM, the ED nurse documented that Patient # 30 was sleeping and at 9:07 AM discharged her to the nursing home with instructions to discontinue the daily dose of Coumadin. The medical record did not contain evidence that Patient # 30 received stabilizing treatment within the hospital's capabilities: an infusion of fresh frozen plasma to rapidly reverse the blood thinning effects of Coumadin, ongoing monitoring of her neurological status or vital signs, or that Physician A came to the ED to provide further examination. Review of CAH policy #6231.1010 revealed that the ED physician is required to come to the ED to examine patients that have experienced a head injury. Review of the on-call list for the month of August 2011 confirmed Physician A was on call for the ED on 8/31/11.

3. During an interview on 9/14/11 at 2:45 PM, CAH ED Registered Nurse (RN) A reported Patient # 30 was confused when she came into the emergency room. RN A confirmed Patient # 30 had a head injury and that she contacted on call Physician A for orders after the patient vomited because she thought the PA had already left.

4. During an interview on 9/14/11 at 2:10 AM, the on call Physician A confirmed that he did not come to the ED to examine Patient # 30. Physician A stated that Patient # 30 was confused when she came to the emergency department and that he ordered the medication Promethazine after the nurse called to say she vomited. Physician A stated the medication could have made the patient more somnolent (sleepy, drowsy).

4. Review of a dictated note dated 8/31/11 and signed by Physician A revealed Patient # 30 died at 5:15 PM, approximately 8 hours after discharge from the ED.