HospitalInspections.org

Based on document review and interview, it was determined the CAH (Critical Access Hospital) failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24 as evidenced by:

Findings include:

1. The CAH failed to ensure all individuals who presented to the ED (Emergency Department) were entered in the ED log. (Refer to tag A-2405)

3. The CAH failed to ensure individuals who presented to the ED were provided with a MSE (Medical Screening Examination). (Refer to tag A-2406)

Based on document review and staff interview, it was determined for 1 of 20 (Pt #1) patients who presented to the ED (Emergency Department), the CAH (Critical Access Hospital) failed to ensure all individuals were entered in the ED log. This has the potential to affect approximately 600 patients per month who present to the CAH's ED requesting emergency services.

Findings include:

1. During an interview on 11/7/17 at approximately 12:20 PM, E#1 (Vice President of Patient Care Services) stated the CAH conducted an investigation after the ED nurse and ED physician self reported an incident which occurred on 10/28/17. E#1 stated Pt #1 presented to the ED on 10/28/17 at approximately 2:00 AM with complaints of possible labor pains due to pregnancy and was immediately taken to ED room #1 by the ED nurse for an evaluation. E#1 stated the ED physician was notified and conducted a Medical Screening Examination. E#1 stated the ED nurse and ED physician informed Pt #1 the CAH did not have an obstetrical department and a transfer to a hospital who provided that service would be arranged. E#1 stated Pt #1 made arrangements with a family member to go to another hospital and left the department. E#1 stated Pt #1 was not entered into the ED log by the nurse on duty.

2. The ED report titled "Daily Summary Report" was reviewed on 11/7/17 at approximately 1:00 PM. The Daily Summary Report (ED Log) lacked documentation that any patient presented to the ED requesting emergency services between 10/27/17 at 8:04 PM and 10/28/17 at 9:51 AM.

Based on staff interview and document review, it was determined for 1 of 20 (Pt #1) patients who presented to the ED (Emergency Department), the CAH (Critical Access Hospital) failed to ensure a MSE (Medical Screening Examination) was provided. This has the potential to affect approximately 600 patients per month who present to the CAH's ED requesting emergency services.

Findings include:

1. During an interview on 11/7/17 at approximately 12:20 PM, E#1 (Vice President of Patient Care Services) stated the CAH conducted an investigation after the ED nurse and ED physician self reported an incident which occurred on 10/28/17. E#1 stated Pt #1 presented to the ED on 10/28/17 at approximately 2:00 AM with complaints of possible labor pains due to pregnancy and was immediately taken to ED room #1 by the ED nurse for an evaluation. E#1 stated the ED physician was notified and conducted a Medical Screening Examination. E#1 stated the ED nurse and ED physician informed Pt #1 the CAH did not have an obstetrical department and a transfer to a hospital who provided that service would be arranged. E#1 stated Pt #1 made arrangements with a family member to go to another hospital and left the department. E#1 stated Pt #1's name, address, date of birth, contact information, etc. was not entered/registered in the electronic medical record therefore no documentation regarding the visit was made. E#1 stated Pt #1's name was still unknown.

2. During an interview on 11/8/17 at approximately 11:20 AM, MD#3 (ED Physician) stated "I talked to Pt #1 for about 10 minutes about treatment options and transferring to another hospital. There were no signs of contractions to indicate Pt #1 was in active labor during our talk. I did not feel a pelvic (examination) was necessary and Pt #1 was agreeable. I did listen to Pt #1's heart and lung sounds and reviewed vital signs. Pt #1 called her mother and they decided to go to another hospital so I ok' d Pt #1 to go. I did not know Pt #1 had not been registered and there had been no chart created. I didn't have a name or anything so I couldn't document anything."

3. There was no documentation to indicate Pt #1 was seen or provided a MSE after arrival to the CAH.

4. The policy titled "Emergency Medical treatment and Labor Act (EMTALA) Compliance (approved 8/17) was reviewed on 11/7/17 @ 12:15 PM. The policy noted "Hospital personnel or the physician will document in the person's medical record the medical screening examination... name, sex and date of birth... date and time of arrival... complaint... description of medical screening exam offered or provided... diagnosis or determination..."