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Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the Emergency Department (ED) staff followed the CAH's policies and ensure that 1 of 20 patients reviewed (Patient #2) who presented to the ED with an emergency medical condition received an appropriate medical screening examination. Failure to provide an appropriate medical screening exam at the CAH resulted in Patient #2 being transported back to their home, which resulted in a delay of Patient #2 receiving an appropriate medical screening exam for more than 18 hours. The administrative staff identified an average of 300 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy "Transfer and Emergency Examination (EMTALA)," 05/2021, revealed in part, "Definitions ... Comes to the Emergency Department ... the individual is in a ground or air non-Hospital-owned ambulance on Hospital grounds that has presented the patient for examination and treatment for a medical condition at the Hospital's [Dedicated Emergency Department]." "Hospital Property. The entire main Hospital campus, including parking lots, sidewalks and driveways ..."

"The Hospital will provide to any individual, ..., an appropriate Medical Screening Examination (MSE) ... The MSE will be conducted by an individual(s) determined qualified by Hospital bylaws ..."


2. Review of the "Medical Staff Bylaws For Alegent Health Community Memorial Hospital d/b/a CHI Health Missouri Valley, ("CHI Health Missouri Valley) Missouri Valley, IA," approved 6/2021, revealed in part, "Qualified Medical Professional: Those licensed independent practitioner (LIP) (sic) designated as qualified to perform the medical screening examination and determine that an emergency medical condition does exist without assistance from another LIP. The following are designated as [Qualified Medical Practitioners]: ... Physician's Assistants ..."


3. Review of Patient #2's EMS medical record revealed that the EMS staff presented to Patient #2's residence on 12/14/21 at 5:33 PM. EMT B documented that EMT B found Patient #2 in Patient #2's garage, on the floor. The EMS staff assisted Patient #2 to the EMS cot, and the EMS staff transported Patient #2 to the CAH, so Patient #2 could receive treatment for "failure to thrive" (a condition where a patient declines, usually from chronic diseases, resulting in weight loss, depression, and decreased functional ability).

When the ambulance arrived at the CAH at 6:24 PM, the CAH ED staff informed the EMS staff that the CAH ED staff did not have a bed available for Patient #2. RN A evaluated Patient #2 in the ambulance and indicated that the CAH ED staff did not have room for Patient #2. RN A informed Patient #2 and the EMS staff that patients in the CAH's Emergency Department (ED) and in the ED's waiting room had been exposed to COVID-19, and RN A would not like Patient #2 to enter the ED until the ED staff had a room available for Patient #2.

The medical record lacked evidence that Patient #2 received a Medical Screening Examination from a Qualified Medical Personnel.


4. Review of Patient #2's CAH medical record revealed Registered Nurse (RN) A created an Emergency Department (ED) medical record for Patient #2 on 12/14/21. RN A retrieved Patient #2's demographics, allergies, and reported home medications from the CAH's electronic medical record system. RN A then documented that Patient #2 arrived at the CAH via ambulance at 6:27 PM on 12/14/21, with a chief complaint of "fatigue."

At 7:19 PM (55 minutes after Patient #2 arrived at the CAH), RN A documented that the CAH ED staff did not allow the EMS staff to transfer care of Patient #2 to the CAH ED staff, as the CAH ED staff "do not have a bed available in the ED at this time, and we have 3 active COVID-19 patients in the Emergency Room." Patient #2's Spouse had the EMS staff transport Patient #2 to the Emergency Department, as Patient #2's Spouse was unable to continue providing care for Patient #2 at home. After RN A explained that the CAH's ED had multiple COVID-19 patients and RN A offered for a hospice nurse to evaluate Patient #2.

Since Patient #2's Spouse, due a a fear of exposure to COVID-19, did not want Patient #2 or Patient #2's Spouse to enter the ED, RN A informed Patient #2's Spouse that they would need to sign an AMA (Against Medical Advice, indicating that the hospital staff advised the patient on a course of treatment and the patient did not want to follow that course of treatment) form for Patient #2 to leave the ED. Patient #2's Spouse, at the urging of RN A, signed the AMA form and had the EMS staff transport Patient #2 to their home. Patient #2 left the hospital via ambulance at 7:19 PM.

The medical record lacked evidence that Patient #2 received a Medical Screening Examination from a Qualified Medical Personnel.


5. During an interview on 12/21/21 at 4:40 PM, Physician's Assistant (PA) C revealed that when the EMS staff brought Patient #2 to the CAH's ED on 12/14/21, the ED staff told the EMS staff that Patient #2 would need to wait in the ambulance, as the ED staff did not have room for Patient #2 in the ED. The ED had 4 patients at the time Patient #2 presented to the CAH on 12/14/21, and 2 patients had COVID-19. The ED was not the proper place for Patient #2. PA C had Hospice RN D evaluate Patient #2 for hospice, while Patient #2 was still in the ambulance. Hospice RN D determined Patient #2 would qualify for hospice. When Patient #2's Spouse was informed that the CAH's ED had COVID-19 patients and Patient #2 qualified for hospice, Patient #2's Spouse wanted Patient #2 to go home. PA C verified they did not perform a medical screening examination to determine the presence of an emergency medical condition prior to the EMS staff leaving the CAH and transporting Patient #2 to Patient #2's home.


6. During an interview on 12/22/21 at 1:12 PM, Emergency Medical Technician (EMT) B revealed they responded to Patient #2's home on 12/14/21. Patient #2's Spouse indicated that Patient #2 required more care at home than Patient #2's Spouse could provide. EMT B agreed to transport Patient #2 to the CAH for evaluation in the CAH's ED. During the transport to the CAH, EMT B contacted PA C to inform them that EMT B was bringing Patient #2 to the CAH for emergency medical care. PA C asked EMT B on multiple occasions why EMT B was bringing Patient #2 to the CAH and what emergency Patient #2 was experiencing. PA C informed EMT B "get in line, we're busy, [and] you'll have to wait in the ambulance [garage]."

When EMT B arrived at the CAH with Patient #2, a nurse came into the ambulance garage and informed EMT B "don't bring the patient in, we're busy." EMT B went into the CAH's ED and spoke with PA C. EMT B asked to transfer Patient #2 to the CAH's ED triage room and transfer Patient #2's care to the CAH ED staff, so the EMS staff could return to service. PA C informed EMT B "no, there's COVID[-19] in here and I don't want [Patient #2]."

Patient #2's Spouse was in the ED waiting room and the CAH staff informed Patient #2's Spouse that the CAH did not have room for Patient #2 and Patient #2 should wait in the ambulance for the CAH staff to assume care.

A nurse came out to the ambulance garage, and while Patient #2 was still in the ambulance, asked Patient #2 a few basic questions to determine if Patient #2 was oriented. The nurse indicated that Patient #2 possibly needed hospice care instead of an ED visit. EMT B asked the nurse if the CAH staff intended to assume care for Patient #2, and the nurse indicated that "[Patient #2's name] was leaving AMA."

The CAH staff asked EMT B to transport Patient #2 back to Patient #2's home, as the CAH did not have room for Patient #2. EMT B verified that neither PA C, or another provider, performed a medical screening examination to determine if Patient #2 had an emergency medical condition prior to the CAH staff instructing the EMS staff to transport Patient #2 back to Patient #2's home.



Please refer to C-2406 for additional information.

Based on document review and staff interviews, the administrative staff failed to ensure the critical access hospital's (CAH's) ED staff provided 1 of 20 emergency patients reviewed (Patient #2) with an appropriate medical screening examination after presenting to the Emergency Department (ED) by ambulance seeking medical care. Failure to provide an appropriate medical screening exam at the CAH resulted in EMS staff transporting Patient #2 to home, which resulted in a delay of Patient #2 receiving an appropriate medical screening exam by more than 18 hours. The CAH's administrative staff identified an average of 300 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.

Findings include:


1. Review of Patient #2's EMS medical record revealed that the EMS staff presented to Patient #2's residence on 12/14/21 at 5:33 PM. EMT B documented that EMT B found Patient #2 in Patient #2's garage, on the floor. The EMS staff assisted Patient #2 to the EMS cot, and the EMS staff transported Patient #2 to the CAH, so Patient #2 could receive treatment for "failure to thrive" (a condition where a patient declines, usually from chronic diseases, resulting in weight loss, depression, and decreased functional ability).

When EMT B called report to the hospital, prior to the ambulance's arrival at the CAH, Physician's Assistant (PA) C asked "What is [Patient #2's] actual emergency?" "[Patient #2 is] going to have to wait in [the ambulance] until [the ED staff] have room."

When the ambulance arrived at the CAH at 6:24 PM, the CAH ED staff informed the EMS staff that the CAH ED staff did not have a bed available for Patient #2. RN A evaluated Patient #2 in the ambulance and indicated that the CAH ED staff did not have room for Patient #2. RN A informed Patient #2 and the EMS staff that patients in the CAH's Emergency Department (ED) and in the ED's waiting room had been exposed to COVID-19, and RN A would not like Patient #2 to enter the ED until the ED staff had a room available for Patient #2.

Given Patient #2's Spouse's concerns about Patient #2's chronic condition and failure to thrive, RN A suggested that a hospice nurse could evaluate Patient #2 in the ambulance. Hospice RN D evaluated Patient #2 in the ambulance. Hospice RN D indicated that if Patient #2 and Patient #2's Spouse agreed, the EMS staff could transport Patient #2 back to Patient #2's home, and hospice staff would visit Patient #2 in their home the next morning.

Patient #2 and Patient #2's Spouse agreed to have hospice staff evaluate Patient #2 the next morning, and agreed to sign an AMA (Against Medical Advice) form, and agreed to have the EMS staff transport Patient #2 back to Patient #2's home.

The medical record lacked evidence that Patient #2 received a Medical Screening Examination from a Qualified Medical Personnel.


2. Review of Patient #2's CAH medical record revealed Registered Nurse (RN) A created an Emergency Department (ED) medical record for Patient #2 on 12/14/21. RN A retrieved Patient #2's demographics, allergies, and reported home medications from the CAH's electronic medical record system. RN A then documented that Patient #2 arrived at the CAH via ambulance at 6:27 PM on 12/14/21, with a chief complaint of "fatigue."

At 7:19 PM (55 minutes after Patient #2 arrived at the CAH), RN A documented that the CAH ED staff did not allow the EMS staff to transfer care of Patient #2 to the CAH ED staff, as the CAH ED staff "do not have a bed available in the ED at this time, and we have 3 active COVID-19 patients in the Emergency Room." Patient #2's Spouse had the EMS staff transport Patient #2 to the Emergency Department, as Patient #2's Spouse was unable to continue providing care for Patient #2 at home. After RN A explained that the CAH's ED had multiple COVID-19 patients and RN A offered for a hospice nurse to evaluate Patient #2.

RN A informed PA C about Patient #2 and explained what happened with Patient #2. PA C agreed to have a hospice nurse evaluate Patient #2. Hospice Nurse D came to the CAH and evaluated Patient #2, while Patient #2 was still in the ambulance. Hospice Nurse D agreed to admit Patient #2 to hospice the next morning.

Since Patient #2's Spouse, due a a fear of exposure to COVID-19, did not want Patient #2 or Patient #2's Spouse to enter the ED, RN A informed Patient #2's Spouse that they would need to sign an AMA (Against Medical Advice, indicating that the hospital staff advised the patient on a course of treatment and the patient did not want to follow that course of treatment) form for Patient #2 to leave the ED. Patient #2's Spouse, at the urging of RN A, signed the AMA form and had the EMS staff transport Patient #2 to their home. Patient #2 left the hospital via ambulance at 7:19 PM.

The medical record lacked evidence that Patient #2 received a Medical Screening Examination from a Qualified Medical Personnel.


3. Review of Patient #2's medical record revealed that the CAH ED staff admitted Patient #2 back to the CAH on 12/15/21 at 1:54 PM (approximately 18.5 hours after Patient #2 left the CAH the prior night). Physician E admitted Patient #2 to the CAH for inpatient treatment.


4. During an interview on 12/21/21 at 3:47 PM, RN A revealed that when the EMS staff brought Patient #2 to the CAH, the CAH ED staff did not have an open room for Patient #2. Upon the ambulance arriving at the CAH, the EMS staff had to wait 10 minutes in the ambulance garage with Patient #2, until RN A went out to the garage. Patient #2 was not able to answer RN A's questions, so RN A spoke with Patient #2's Spouse. RN A asked Patient #2's Spouse if they knew about hospice. RN A informed Patient #2's Spouse that RN A had spoke with PA C, and PA C had RN A call Hospice RN D to assess Patient #2 for admission to hospice. PA C then instructed RN A to have Patient #2's Spouse sign an AMA form, so Patient #2 could leave the CAH. PA C did not assess or evaluate Patient #2 while Patient #2 was at the CAH.


5. During an interview on 12/21/21 at 4:40 PM, Physician's Assistant (PA) C revealed that when the EMS staff brought Patient #2 to the CAH's ED on 12/14/21, the ED staff told the EMS staff that Patient #2 would need to wait in the ambulance, as the ED staff did not have room for Patient #2 in the ED. The ED had 4 patients at the time Patient #2 presented to the CAH on 12/14/21, and 2 patients had COVID-19. The ED was not the proper place for Patient #2. PA C had Hospice RN D evaluate Patient #2 for hospice, while Patient #2 was still in the ambulance. Hospice RN D determined Patient #2 would qualify for hospice. When Patient #2's Spouse was informed that the CAH's ED had COVID-19 patients and Patient #2 qualified for hospice, Patient #2's Spouse wanted Patient #2 to go home. PA C verified they did not perform a medical screening examination to determine the presence of an emergency medical condition prior to the EMS staff leaving the CAH and transporting Patient #2 to Patient #2's home.

6. During an interview on 12/21/21 at 2:15 PM and 1/5/22 at 4:00 PM, Patient #2's Spouse revealed that they summoned EMS staff because Patient #2 required more care than Patient #2's Spouse could provide Patient #2 at home and Patient #2 was unable to stand, walk, or otherwise move without someone carrying Patient #2. When Patient #2 arrived at the CAH's ED, Patient #2's Spouse went to the CAH ED registration desk to register Patient #2. The CAH staff informed Patient #2's Spouse that the CAH had a lot of sick patients. Since Patient #2's Spouse did not want to get sick, while Patient #2 (still in the ambulance) waited for an open ED room and the ED staff to assume care for Patient #2, Patient #2's Spouse waited in the ambulance garage.

RN A came into the ambulance garage and informed Patient #2's Spouse that every room in the hospital was full and every room in the ED was full. RN A did not want Patient #2 or Patient #2's Spouse exposed to COVID-19. RN A informed Patient #2's Spouse that the EMS staff would need to return Patient #2 to Patient #2's home and Patient #2's Spouse would need to sign a form indicating that Patient #2 left the hospital against medical advice. RN A informed Patient #2's Spouse that Patient #2 would be better off going home and that Patient #2's Spouse had to sign the AMA form. RN A did not inform Patient #2 or Patient #2's Spouse about the risks and benefits of staying at the hospital, nor did RN A attempt to encourage Patient #2's Spouse to agree to stay at the hospital. Instead, RN A did not give Patient #2's Spouse a choice to decide if Patient #2's Spouse wanted Patient #2 to stay at the hospital, and told Patient #2's Spouse the only thing Patient #2's Spouse could do was sign the AMA form.

The EMS staff transported Patient #2 from the CAH back to Patient #2's home.


7. During an interview on 12/22/21 at 1:12 PM, Emergency Medical Technician (EMT) B revealed they responded to Patient #2's home on 12/14/21. Patient #2's Spouse indicated that Patient #2 required more care at home than Patient #2's Spouse could provide. EMT B agreed to transport Patient #2 to the CAH for evaluation in the CAH's ED. During the transport to the CAH, EMT B contacted PA C to inform them that EMT B was bringing Patient #2 to the CAH for emergency medical care. PA C asked EMT B on multiple occasions why EMT B was bringing Patient #2 to the CAH and what emergency Patient #2 was experiencing. PA C informed EMT B "get in line, we're busy, [and] you'll have to wait in the ambulance [garage]."

When EMT B arrived at the CAH with Patient #2, a nurse came into the ambulance garage and informed EMT B "don't bring the patient in, we're busy." EMT B went into the CAH's ED and spoke with PA C. EMT B asked to transfer Patient #2 to the CAH's ED triage room and transfer Patient #2's care to the CAH ED staff, so the EMS staff could return to service. PA C informed EMT B "no, there's COVID[-19] in here and I don't want [Patient #2]."

Patient #2's Spouse was in the ED waiting room and the CAH staff informed Patient #2's Spouse that the CAH did not have room for Patient #2 and Patient #2 should wait in the ambulance for the CAH staff to assume care.

A nurse came out to the ambulance garage, and while Patient #2 was still in the ambulance, asked Patient #2 a few basic questions to determine if Patient #2 was oriented. The nurse indicated that Patient #2 possibly needed hospice care instead of an ED visit. EMT B asked the nurse if the CAH staff intended to assume care for Patient #2, and the nurse indicated that "[Patient #2's name] was leaving AMA."

The CAH staff asked EMT B to transport Patient #2 back to Patient #2's home, as the CAH did not have room for Patient #2. EMT B verified that neither PA C, or another provider, performed a medical screening examination to determine if Patient #2 had an emergency medical condition prior to the CAH staff instructing the EMS staff to transport Patient #2 back to Patient #2's home.