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Based on document review, audio review and staff interview, it was determined the Critical Access Hospital (CAH) failed to complete the Emergency Department (ED) central log and provide a Medical Screening Exam to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24. This has the potential to affect all patients receiving care in an Emergency Department that treats on average of 10 patients per day.

Findings include:

1. The CAH failed to ensure patients were documented on the ED central log. See deficiency cited at C2405.

2. The CAH failed to ensure a Medical Screening Exam was performed. See deficiency cited at C2406.

Based on document review and staff interview, it was determined for 3 of 4 (Pt #9, #12, #13) patients where an Against Medical Advice (AMA) form refusing treatment was signed, the Critical Access Hospital (CAH) failed to ensure patients were documented on the Emergency Department (ED) central log. This failure has the potential to affect all patients presenting to the ED.

Findings include:

1. The CAH policy dated, 8/29/2014, titled, "ER: PATIENTS LEAVING A.M.A. Under Procedure: 2. Explain the risk of leaving the ER before all medical care is given...6. Document "AMA" on the ER record in the appropriate care grid, along with the time and mode by which patient leaves."

2. On 1/11/18 at 9:50 AM, an interview was conducted with the ED Registered Nurse (RN) (E#2). E#2 recalled Pt#9 presenting to the ED parking lot. E#2 verbalized Pt #9's mother had called the ED and stated that Pt #9 was 9 months pregnant and had Factor Five (blood clotting disorder) and was having trouble speaking. Pt #9's mother stated that Pt #9's obstetrics (OB) doctor had been called and Pt #9 was instructed to go to a Missouri hospital. E#2 advised them to go to the Missouri hospital unless they felt uncomfortable, then call 911. Pt #9's mother stated that they were already on their way to the CAH and asked if they could just park in the lot and call 911. Pt. #9's mother was told "yes". E#2 stated, When I heard the dispatch call on the radio about EMS picking up someone from the hospital parking lot who was pregnant and having a seizure, I went out to check on the patient (Pt #9). I checked pulse, reflexes and asked questions. Then I felt her stomach and the baby was moving." E#2 reported she offered for Pt #9 to come in to ED and be examined. E#2 reported Pt #9's husband asked if they could take her to the hospital in Missouri themselves and E#2 said "yes". E#2 stated, " I had an AMA form signed by the husband and Pt #9 left by private vehicle."

3. The AMA form of Pt #12 was reviewed on 1/11/18 at 1:00 PM. Pt #12 was brought to ED by EMS on 1/13/17 at 0445. Chief complaint being found unresponsive in car on the interstate by police. Pt #12 refused treatment and signed an AMA form.

4. The AMA form of Pt #13 was reviewed on 1/11/18 at 1:15 PM. Pt #13 was brought to ED by EMS on 1/13/17 at 0445. Chief complaint being found unresponsive in car on the interstate by police. Pt #13 refused treatment and signed an AMA form.

5. The ED central log was reviewed on 1/11/18 at 10:30 AM. There was no documentation of Pt #9, #12, or #13 on the ED central log.

6. On 1/11/18 at 3:00 PM, an interview was conducted with the Administrator (E#1). E#1 reviewed the ED log for November 13, 2017, December 30, 2017 and the AMA forms of (Pt #9, #12, #13). E#1 confirmed the patients were not recorded on the ED log.

Based on audio recordings, document review and staff interview, it was determined for 1 of 1 patient (Pt #9) presenting to the Critical Access Hospital (CAH) Emergency Department (ED), the CAH failed to ensure a medical screening exam was performed. This failure has the potential to affect all patients presenting to the ED.

Findings include:

1. A review of audio recordings from communication between the CAH, 911 dispatch and Emergency Medical Services was conducted during the survey. The initial audio recording indicated Pt #9's mother requested 911 to send an ambulance to the local hospital to transport Pt #9 to a Missouri hospital. The 911 dispatcher questioned the mother regarding Pt #9's symptoms and told the mother to go to the emergency room at the local hospital where they were at the time. The audio indicated Pt #9's mother stated "They told us not to come here. They can't do anything to help us." The next audio indicated the 911 dispatcher called the local hospital and informed Registered Nurse (E #2), "There is a pregnant female in a private vehicle in their parking lot." E #2 stated "I know. Send an ambulance and take her straight to (other hospital)."

2. On 1/11/18 at 9:50 AM, an interview was conducted with the ED Registered Nurse (RN) (E#2). E#2 recalled Pt#9 presenting to the ED parking lot. E#2 verbalized Pt #9's mother had called the ED and stated that Pt #9 was 9 months pregnant and had Factor Five (blood clotting disorder) and was having trouble speaking. Pt #9's mother stated that Pt #9's obstetrics (OB) doctor had been called and Pt #9 was instructed to go to a Missouri hospital. E#2 advised them to go to the Missouri hospital unless they felt uncomfortable, then call 911. Pt #9's mother stated that they were already on their way to the CAH and asked if they could just park in the lot and call 911. Pt. #9's mother was told "yes". E#2 stated, When I heard the dispatch call on the radio about EMS picking up someone from the hospital parking lot who was pregnant and having a seizure, I went out to check on the patient (Pt #9). I checked pulse, reflexes and asked questions. Then I felt her stomach and the baby was moving." E#2 reported she offered for Pt #9 to come in to ED and be examined. E#2 reported Pt #9's husband asked if they could take her to the hospital in Missouri themselves and E#2 said "yes". E#2 stated, " I had an AMA form signed by the husband and Pt #9 left by private vehicle."

3. A telephone interview was conducted on 1/16/18 at 2:00 PM with the licensed practical nurse (E #4) who was on duty in the ED at the CAH on 12/30/17 during the time of the incident. E #4 stated "I took the initial call from the mother of (Pt #9). She said she had called Pt #9's doctor reporting the problems and was told to take her to the hospital in Missouri. Pt #9's mother said 'I don't know if we should stop there (CAH) or go on the hospital in Missouri.' E #4 reported she asked E #2 and E #2's response was, " 'Since we do not have OB on hand or a Dr. to monitor the baby, they should go on to hospital in Missouri or call 911.'

4. The Emergency Medical Services (EMS) "Patient Care Record" indicated a response to a 911 call made by Pt #9's mother on 12/30/17 at approximately 13:45. Documentation indicated "Dispatched by 911 for a 9 month pregnant female having a seizure in the parking lot at (CAH). Upon arrival found pt setting [sic] in the front passenger seat of a vehicle. Family and ER nurse present at her side. Mother and husband stated pt had become confused today when talking, she had also sent a text one them [sic] that didn't make any sense." Discussion between the registered nurse from the CAH ED (E#2) and the EMS staff (Z#1, Z#2) regarding Pt #9's symptoms of possible confusion took place at this time. EMS received instructions they could not transport until Pt #9 was seen by a physician. This information was provided to Pt #9's husband and mother who asked questions about the CAH's capabilities. EMS staff were unable to answer and stated that Pt #9 would need to be seen by a physician to determine treatment. Further documentation per EMS "Patient Care Record" indicated "Family advised that once she was evaluated we could transfer her to another hospital if it was required. Nurse from local ER asked family if they just wanted to driver [sic] her themselves. Family discussed it and decided to take pt. EMS advised family to call 911 if any change in pt status." Pt #9 did not enter the hospital building and did not receive an emergency medical screening.

5. A telephone interview was conducted with the ED Manager (E#3) on 1/11/18 at 1:50 PM. E#3 confirmed through her investigation Pt #9 did present on hospital property and was not provided a medical screening. E#3 stated, "She should have been brought in to be assessed and seen by the doctor."


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