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[The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This STANDARD is not met as evidenced by: Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to enforce policies to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 for 1 of 1 sampled patients (Patient #1) who presented to the emergencey department (ED) whithin 24 hours of a previous visit.

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of §489.24. Failure of the CAH to enforce their Emergency Medical Treatment and Labor Act policy limited the CAH's ability to track the quality of care and disposition of patients who presented to the emergency department, to ensure appropriate treatment for emergency department patients, and to ensure safe care of patients transferred from the emergency department.

Findings include:

The Critical Access Hospital (CAH) failed to ensure the emergency department (ED) provider conducted an appropriate medical screening examination within the capability of the hospital's ED (Refer to C2406).

Based on information from the complainant, policy review, bylaws review, credentialing file review, ambulance trip report review, staff interview and record review, the Critical Access Hospital (CAH) failed to provide an appropriate Medical Screening Examination (MSE) for 1 of 1 sampled patients (Patient #1) who presented to the emergency department (ED) within 24 hours of a previous visit. Failure to perform a MSE limited the CAH's ability to determine if the patient had an emergency medical condition.

Findings Include:

Review of the policy "Emergency/Trauma Transfer Protocol" occurred on 11/16/2022. This undated policy stated, ". . . PURPOSE: To ensure safe transfer of an individual according to EMTALA guidelines. . . . POLICY: All individuals who arrive at the Jacobson Memorial Hospital Care Center . . . will receive a medical screening exam to determine if an emergency condition exists. . . . PROCEDURE: A qualified medical person will consult with receiving physician to determine medical necessity . . . ."

Review of the medical staff's bylaws occurred on 11/16/22. These bylaws, revised February 27, 2018, stated, ". . . the Medical Staff is responsible for the quality and appropriateness of health care services provided at JMHCC [Jacobson Memorial Hospital Care Center] and must accept and assure this responsibility subject to the ultimate authority of the Governing Body, . . ."

Review of Providers #3 and #4's credentialing files occurred on 11/16/22. The governing body approved the following:
- Provider #3: Internal Medicine/Nephrology privileges for 01/01/21 - 12/31/22
- Provider #4: Affiliated Medical Staff Family Practice for 01/01/22 - 12/31/23

Review of Patient #1's record occurred on 11/16/22. The record indicated Patient #1 arrived at the ED by ambulance on 08/13/22 at 5:20 p.m. Patient #1 requested inpatient psychiatric (psych) treatment. CAH Staff contacted multiple facilities with no bed availability. CAH Staff treated and medicated Patient #1 throughout the night. During the morning hours Patient #1 stated he felt better, no longer wanted to be treated and wanted to go home. CAH Staff gave Patient #1 discharge instructions to follow up with psych provider and to pick up medication from the pharmacy. CAH Staff discharged Patient #1 home ambulatory on 08/14/22 at 9:25 a.m.

Review of the [name] Ambulance Service's trip report occurred on 11/16/22. This report, dated 08/14/22, stated EMS (Emergency Medical Services) was dispatched to Patient #1's home on 08/14/22 at 4:04 p.m. Patient #1 requested to be transferred to the hospital. An addendum on the trip report on 11/15/2022, stated, ". . . placed a call to JMHCC reporting we were bringing this patient to the ED. Upon arrival, we were met at the door by the ED provider as we were preparing to transfer the patient from the ambulance to the facility. The provider stated she didn't know what else she could do for this patient, . . . The crew sat in the ambulance with the patient while the provider stood just outside . . . the provider stated she was placing a call to the medical director . . . . After approximately 25 minutes of waiting, we were handed a face sheet by a charge nurse from JMHCC and proceeded to divert the patient to [name of treating hospital] ED per provider instruction. . . ."

The facility failed to have record of Patient #1's return arrival by ambulance on 08/14/22 and the performance of a MSE.

During an interview on 11/15/22 at 11:00 a.m., EMS Director #5 said he was aware of the situation, and he received two emails from EMS staff members in relation to the issue. EMS Director #5 had viewed video surveillance showing the EMS crew waited in the ED parking lot 20 minutes before leaving with Patient #1. EMS Director #5 said the issue was reported to Administrative Staff member #1.

During interview on 11/16/22 at 11:00 a.m., an administrative staff member (#1) stated the facility does not specifically list emergency department privileges when credentialing, but the services provided in the emergency department would be included in their general delineation of privileges.

During an interview on 11/16/22 at 3:00 p.m. an administrative staff member (#1) said he was aware of a situation with the ambulance crew transferring a patient. Administrative Staff Member #1 followed up with Provider #4, and stated it was Provider #3's decision.

During an interview on 11/16/22 at 3:30 p.m., Provider #3 said all providers must follow EMTALA regulations and expected them to do medical screening exams in the ED.

During an interview on 11/17/22 at 9:30 a.m. Provider #4 recalled when Patient #1 was brought to the ED by the ambulance on 08/13/22, the patient was intoxicated and had psychiatric issues. Patient #1 was suicidal and Provider #4 tried to find an inpatient admission. Patient #1 stayed in the ED through the night. Patient #1 was discharged in the care of his mother and had to follow up with his psych provider. Provider #4 said this patient returned to the ED later that day by ambulance. Provider #4 said she consulted with Provider #3 who told her to send the patient to a [name of hospital] hospital.