HospitalInspections.org

Based on document review and medical record review the Critical Access Hospital (CAH) failed to follow their policies and procedures and did not provide a medical screening exam (MSE) to a patient who presented on hospital property by ambulance to determine if an emergency medical condition (EMC) existed for one of 20 sampled patients (Patient 1) from 07/2019 through 11/2019.

Failure to perform an MSE for every patient presenting to the emergency department (ED) seeking care has the potential for patients to leave the CAH with an unidentified EMC and delay the necessary stabilizing treatment, placing them at risk for further complications or death.

Findings Include:

Document review of the policy titled "Medical Screening Exam Emergency Department", reviewed 02/10/19, directs "All patients presenting for care in the Emergency Department will receive a Medical Screen Exam to be used in determination if a medical emergency exists." The policy further shows persons (including visitors) presenting themselves at any area of the hospital other than the ED must receive an MSE if they request or a request is made on their behalf.

Document review of the policy titled "EMTALA Screening, Stabilization, and Transfer Policy," last review date, 06/19/19, directs an appropriate MSE will be performed for all individuals who present to the ED to determine the presence of an emergency medical condition (EMC) and the ED physician is responsible for the care of all ED patients and the decision to transfer a patient for an emergency medical condition if the hospital cannot provide stabilizing treatment is made by the ED physician.

Document review of the policy titled "Emergency Department Scope of Care" last reviewed date, 12/26/18 directs, if needed equipment is not available for a patient presenting with an EMC the hospital will arrange for transfer of the patient to an appropriate facility.

Review of the Patient 1's ambulance run sheet, "Patient Narrative" dated 11/14/19 showed: ..."Once inside the residence, pt [patient] was found on her couch, pale, moaning, and slumped. Patient's daughter was there and could speak some English. She stated that she woke up and found her mother not responsive. She stated that she had to push on her chest for 10 minutes to wake her up" ... Initial vitals showed high blood pressure and sinus bradycardia [slow heart rate] with bigeminy PAC's [premature atrial contraction] (an irregular premature heart beat that originates in the upper chamber of the heart and does not pump blood very effectively causing the body to not receiving enough oxygen that may cause the patient to feel light headed and faint) ... "Enroute to NRH [Newman Regional Hospital], report was called into NRH staff. I gave the nurse report and she stated that they aren't taking cardiac (heart) patients. So, then I gave report to [Staff E, ED Physician] and he stated that they cannot perform a proper workup on the patient and to not bring them to Newman. At this time, we were already in the NRH parking lot and was told once again not to bring the pt inside." We were then diverted to [receiving hospital]."

During a telephone interview on 11/21/9 at 10:18 AM, Staff S, EMS Paramedic stated on the night in question the ambulance was pulled up in front of the ambulance bay. Staff S contacted the ED to report their arrival with Patient 1. Report was given to an unidentified CAH staff member who told EMS personnel the hospital ED was on diversion. Staff S EMS Paramedic stated an awareness of the diversion, but also stated the CAH was the closest ED, the ambulance was on hospital grounds, and EMS staff wanted Patient 1 to be assessed. Staff S then spoke with Staff E, ED physician who stated twice "not to bring the patient into the ED," the lab was down, and the CAH was unable to perform a proper workup of a patient with potential cardiac issues.


Observation of hospital security video dated 11/14/19 at 4:18 AM with Staff W, Facilities Director showed an ambulance in the hospital parking lot pulled alongside the ambulance bay on hospital property. An unidentified individual got out of the vehicle and walked to a car behind the ambulance. Continuous feed of the video shows the car behind the ambulance turning and leaving the parking lot followed by the ambulance at 4:22 AM.

Based on observation, policy review and staff interview, the hospital failed to conspicuously post all required signage in places likely to be noticed by all individuals entering the emergency department (ED). This deficient practice has the potential to result in all individuals entering the ED or waiting for treatment to be unaware of their rights.

Findings Include:

Review of CAH policy titled "EMTALA Screening, Stabilization, and Transfer Policy," reviewed 06/19/19 states the CAH must comply with applicable laws and regulations related to the provision of emergency services.

During a tour of the ED on 11/20/19 at 1:30 PM showed Emergency Medical Treatment and Active Labor Act (EMTALA) signage in English and Spanish posted at the walk-in entrance into the ED reception/waiting area. If a patient presented to the ED from a different entrance, such as the entrance used by ambulances, the patient would not see the signage specifying their rights to receive a medical examination and treatment for an emergency medical condition. Entrance from the ambulance bay into the ED failed to have EMTALA signage posted.

During an interview on 11/20/19 at 1:30 PM, Staff C, Risk Manager and Staff D, ED Director acknowledged the signage, and both stated there was no EMTALA signage anywhere else in the ED.

Based on record review, interview, video observation and policy review the facility failed to perform an appropriate medical screening exam (MSE) to determine whether or not an emergency medical condition (EMC) existed for one of 20 medical records reviewed (Patient 1) who was in an ambulance on hospital property when the Emergency Department (ED) Physician was notified of their presence. This deficient practice has the potential to place patients at risk for worsening of an emergency medical condition or even death.

Findings Include:

Review of the Patient 1's ambulance run sheet, "Patient Narrative" dated 11/14/19 showed: ..."Once inside the residence, pt [patient] was found on her couch, pale, moaning, and slumped. Patient's daughter was there and could speak some English. She stated that she woke up and found her mother not responsive. She stated that she had to push on her chest for 10 minutes to wake her up" ... Initial vitals showed high blood pressure and sinus bradycardia [slow heart rate] with bigeminy PAC's [premature atrial contraction] (an irregular premature heart beat which may cause the heart to not effectively pump blood to the rest of the body causing the patient to feel light headed and faint) ... "Enroute to NRH [Newman Regional Hospital], report was called into NRH staff. I gave the nurse report and she stated that they aren't taking cardiac (heart) patients. So, then I gave report to [Staff E, Physician] and he stated that they cannot perform a proper workup on the patient and to not bring them to Newman's ED. At this time, we were already in the CAH parking lot and was told once again not to bring the pt inside." We were then diverted to [receiving hospital]."


During a telephone interview on 11/21/9 at 10:18 AM, Staff S, EMS paramedic stated on the night in question the ambulance was pulled up to the ambulance bay. Staff S contacted the ED to report their arrival with patient 1. Report was given to an unidentified CAH staff member who told EMS personnel the hospital ED was on diversion. Staff S EMS paramedic stated an awareness, but also stated the CAH was the closest ED, the ambulance was on hospital grounds, and EMS staff wanted patient 1 to be assessed. Staff S then spoke with staff E, ED physician who stated twice "not to bring the patient into the ED," the lab was down, and the CAH was unable to perform a proper workup of a patient with potential cardiac issues. At the end of the conversation Staff S stated she confirmed with Staff E that he indeed "wanted the patient taken to another facility and he said yes."


During a telephone interview on 11/22/19 at 10:50 AM, Staff T, EMS advanced emergency medical technician (AEMT) stated he was working with Staff S, EMS on 11/14/19, the night of the incident. Once stabilized they transported the patient to Newman Regional, Staff S, EMS paramedic was in the back and he was the driver. The window was open between them and he could hear her talking with the CAH ED staff. He further stated they pulled into the drive facing the ramp of the new ambulance bay. The ambulance bay door was open, however he stopped next to the old ambulance bay in the parking lot because Staff S was talking with Staff E, ED Physician, who told her not to bring the patient into the ED because the "heart machine and lab machines were not working". She asked him what heart machine and stated if he was referring to a 12 lead EKG they could use EMS's.

Staff T stated during the conversation, he got out of the ambulance and approached the patient's daughter who was following them in her car to tell her about the delay. He estimated the time was around 3:00 AM. When he returned to the ambulance Staff S told him Staff E, ED Physician refused to allow them to bring the patient into the ED and that they needed to go to another facility.

Observation of hospital security video dated 11/14/19 at 4:18 AM with Staff W, Facilities Director showed an ambulance in the hospital parking lot pulled alongside the ambulance bay on hospital property. An unidentified individual got out of the vehicle and walked to a car behind the ambulance. Continuous feed of the video shows the car behind the ambulance turning and leaving the parking lot followed by the ambulance at 4:22 AM.

During an interview on 11/20/19 at 12:30, Staff A, Chief Quality Officer stated the hospital emergency department (ED) is never on diversion. The only time patients may need transfer to another facility is when equipment essential to patient care fails and there is no back up available. When that happens, providers are alerted.

During an interview on 11/20/19 at 2:00 PM, Staff D, ED Director stated the hospital ED is never on diversion. He stated the physicians are ED dedicated, working 12 hour shifts and are in the ED the entire shift. He stated staffing and equipment are readily available, so diversion should not be necessary.

During an interview on 11/21/19 at 11:15 AM Staff L, RN stated that she was aware of the diversion because of broken lab equipment. She stated it was not a real diversion because the ED did not shut down, they were only not taking patients requiring lab the hospital could not perform. She stated when she came onto her shift at 6:00 AM on 11/14/19, she was instructed by Staff D, ED Director that the ED was not diverting patients and that all patients would be screened and stabilized before transferring.

During a telephone interview on 11/22/19 at 10:31 AM, Staff AA, EMS Captain confirmed that the ambulance crew transporting patient # 1 informed him they were on hospital property when the EMS crew were instructed to divert to another hospital. The EMS Captain confirmed that during a meeting on 11/14/19, the CAH's ED Director and Chief Quality Officer informed him that the ED never closes. The EMS Captain stated that this incident is the first time EMS was told not to bring a patient into the hospital.

Review of Patient 1's medical record from the receiving hospital showed she arrived at the emergency department (ED) by ambulance on 11/14/19 at 5:23 AM, the initial triage was completed at 5:29 AM with an assigned acuity level of "urgent." Further review showed that the receiving hospital's ED physician Y examined patient # 1 at 5:38 AM.