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Based on document review and staff interview, the Critical Access Hospital (CAH's) administrative staff failed to ensure the Emergency Department (ED) staff followed the CAH's policies and provided all available and appropriate stabilizing treatment for 1 of 16 patients reviewed (Patient #16) who presented to the ED and requested care from 03/13/2019 through 10/21/2019. Failure of the CAH's ED staff to follow the CAH's policies and provide all available and appropriate stabilizing treatment within its capabilities resulted in the staff discharging Patient #16 to Long-Term Care (LTC) Facility C, while Patient #16 displayed symptoms of an altered mental status. The CAH staff's failure resulted in the staff at LTC Facility C transferring Patient #16 to Hospital B (approximately 37 miles away) less than 1 hour after Patient #16 arrived at LTC Facility C. The CAH's administrative staff identified an average of 280 patients per month who presented to the CAH's ED and requested emergency medical care.

Findings include:

1. Review of the policy "Cobra/EMTALA," effective 03/2019, revealed in part, "... the hospital is responsible for treating and stabilizing, within its capacity and capability, any individual who presents to a hospital with an emergency medical condition. The hospital will provide such care until the condition ceases to be an emergency or until the patient is properly transferred to another facility ... Patients that are potentially unstable will be treated in the hospital within the capabilities of the hospital prior to transfer ...."

2. Review of the medical record showed Patient #16 presented to the CAH's ED via ambulance at 4:32 PM on 10/21/19, for evaluation of symptoms of acute alcohol intoxication.

At 04:48 PM, Physician's Assistant (PA) D, working at the CAH, performed a history and physical which revealed Patient #16 was lethargic, confused, irritable, and tachycardic. Patient #16 had consumed a full bottle of whiskey (approximately 750 ml), in the preceding 3 hours, indicating the presence of an emergency medical condition. ED Registered Nurse (RN) E documented Patient #16 had irregular respirations, diminished lung sounds, slurred speech, confusion, and inappropriate word use. Physician's Assistant (PA-C) D ordered laboratory testing, intravenous (IV) fluids, and oral vitamin and mineral supplements. The laboratory tests revealed Patient #16 had a blood alcohol of 308 mg/dL (legal limit is 80 mg/dL). PA-C F, who assumed care of Patient #16 at approximately 5:00 PM, ordered the staff to administer 1 mg Ativan (a medication that causes relaxation and sedation) intravenously to Patient #16 at 8:13 PM because Patient #16 was yelling and screaming at the ED staff. Documentation in the medical record showed PA-C F documented Patient #16's disposition - "discharged back to [LTC Facility C's name] in medically stable condition, however intoxicated" at 8:15 PM. The ED staff discharged Patient #16 from the ED at 8:38 PM.

The medical record did not contain evidence that the CAH staff provided, within its capabilities, further examination to determine if Patient #16's emergency medical condition resolved prior to discharge. CAH A failed to re-evaluate Patient #16's blood alcohol level to determine if the level was normal and failed to monitor Patient #16's mental and respiratory status after administering IV Ativan. Without this information, PA-C F could not be reasonably assured that no respiratory or other problem would occur and that Patient #16 would not deteriorate after discharge.

Review of a second medical record showed that Patient #16 presented to Hospital B via ambulance at 10:02 PM on 10/21/2019, less than two hours after discharge from the CAH. Documentation showed Patient #16 presented with alcohol related complaints and altered mental status. ED Physician H ordered a head CT (special type of x-ray), chest x-ray, laboratory testing, and intravenous fluids. Laboratory testing revealed Patient #16 had a blood alcohol of 238 mg/dL (legal limit is 80 mg/dL) at the time of the second hospitalization.

3. During an interview on 10/29/19 at 4:00 PM, Physician J, LTC Facility C's medical director, revealed the nursing staff at LTC Facility C contacted them on 10/21/19 regarding Patient #16's condition when Patient #16 returned to LTC Facility C. The nursing staff could not arouse Patient #16 without a sternal rub. Given the Patient #16's condition when Patient #16 returned to LTC Facility C, the nursing staff at LTC Facility C could not provide adequate nursing monitoring and supervision for Patient #16 to ensure Patient #16 did not experience further side effects from the alcohol intoxication or Ativan administered at the CAH. Physician J instructed the nursing staff to request the EMS staff transport Patient #16 back to the hospital.

4. During an interview on 10/30/19 at 8:35 AM, the CAH ED's Medical Director, Physician P, revealed that a patient who received Ativan would experience the most significant symptoms from the medication approximately 30 minutes after administration (approximately when the EMS staff returned Patient #16 to LTC Facility C). Physician P would be concerned about discharging a patient from the ED if the patient was not alert (Patient #16 was not alert at discharge) and aware of their surroundings (Patient #16 was not aware of their surroundings).


Please see C-2407 for additional information and findings.

Based on document review and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to provide all available and appropriate stabilizing treatment for 1 of 16 patients reviewed (Patient #16) who presented to the CAH's ED and requested care from 03/13/2019 through 10/21/2019. Failure of the CAH's ED staff to provide all available and appropriate stabilizing treatment within its capabilities resulted in staff discharging Patient #16 to Long-Term Care (LTC) Facility C, while Patient #16 displayed symptoms of an altered mental status. The CAH staff's failure resulted in the staff at LTC Facility C transferring Patient #16 to Hospital B (approximately 37 miles away) less than 1 hour after Patient #16 arrived at LTC Facility C. The CAH's administrative staff identified an average of 280 patients per month who presented to the CAH's ED and requested emergency medical care.

Findings include:

1. Review of the medical record showed Patient #16 presented to the CAH's ED via ambulance at 4:32 PM on 10/21/19, for evaluation of symptoms of acute alcohol intoxication.

At 04:48 PM, Physician's Assistant (PA) D, working at the CAH, performed a history and physical which revealed Patient #16 was lethargic, confused, irritable, and tachycardic. Patient #16 had consumed a full bottle of whiskey (approximately 750 ml), in the preceding 3 hours, indicating the presence of an emergency medical condition. ED Registered Nurse (RN) E documented Patient #16 had irregular respirations, diminished lung sounds, slurred speech, confusion, and inappropriate word use. Physician's Assistant (PA-C) D ordered laboratory testing, intravenous (IV) fluids, and oral vitamin and mineral supplements. The laboratory tests revealed Patient #16 had a blood alcohol of 308 mg/dL (legal limit is 80 mg/dL). PA-C F, who assumed care of Patient #16 at approximately 5:00 PM, ordered the staff to administer 1 mg Ativan (a medication that causes relaxation and sedation) intravenously to Patient #16 at 8:13 PM because Patient #16 was yelling and screaming at the ED staff. Documentation in the medical record showed PA-C F documented Patient #16's disposition - "discharged back to [LTC Facility C's name] in medically stable condition, however intoxicated" at 8:15 PM. The ED staff discharged Patient #16 from the ED at 8:38 PM.

The medical record did not contain evidence that the CAH staff provided, within its capabilities, further examination to determine if Patient #16's emergency medical condition resolved prior to discharge. CAH A failed to re-evaluate Patient #16's blood alcohol level to determine if the level was normal and failed to monitor Patient #16's mental and respiratory status after administering IV Ativan. Without this information, PA-C F could not be reasonably assured that no respiratory or other problem would occur and that Patient #16 would not deteriorate after discharge.

Review of a second medical record showed that Patient #16 presented to Hospital B via ambulance at 10:02 PM on 10/21/2019, less than two hours after discharge from the CAH. Documentation showed Patient #16 presented with alcohol related complaints and altered mental status. ED Physician H ordered a head CT (special type of x-ray), chest x-ray, laboratory testing, and intravenous fluids. Laboratory testing revealed Patient #16 had a blood alcohol of 238 mg/dL (legal limit is 80 mg/dL) at the time of the second hospitalization.

2. Review of Patient #16's EMS medical record for the trip to the CAH from the park revealed Patient #16 had limited mobility and required a wheelchair for mobility. However, Patient #16 could stand and pivot under their own power to transfer from their wheelchair to the EMS cot.

3. During an interview on 10/29/19 at 1:05 PM, RN E revealed Patient #16 presented to the CAH via ambulance. RN E revealed they received report which indicated Patient #16 was usually alert and oriented to person, place, and time. However, when Patient #16 presented to the ED, Patient #16 could not focus on RN E's questions, Patient #16 did not know their name, and had slurred speech. While in the ED, Patient #16 would have short periods where they quit breathing, but RN E was not concerned about Patient #16's ability to breath.

4. During an interview on 10/29/19 at 7:55 AM, RN M revealed they administered 1 mg (milligram) of Ativan to Patient #16 intravenously approximately 10 minutes before Patient #16 left the CAH's ED to return to LTC Facility C. The ED staff originally received an order for 2 mg of Ativan from PA-C F, but only administered 1 mg of Ativan "because [Patient #16] was not going to be [at the CAH] for us to monitor."

5. During an interview 10/28/19 at 3:45 PM, Licensed Practical Nurse (LPN) N revealed that a nurse from the CAH's ED called LPN N and informed LPN N the ED staff was not doing anything for Patient #16 and was sending Patient #16 back to LTC Facility C. When Patient #16 returned to LTC Facility C, Patient #16 was "totally incoherent." Patient #16 could not lift their head, was not answering the LTC Facility staff's questions correctly, and Patient #16 was not breathing normally.

6. During an interview on 10/29/19 at 9:55 AM, Critical Care Paramedic (CCP) O revealed that during the ambulance ride from the CAH to LTC Facility C, Patient #16 was very sleepy and CCP O had to use a sternal rub (pushing a knuckle hard into a patient's breastbone, to cause a painful, noxious stimulation used to arouse patients who do not respond to their name or gentle touches) to awaken Patient #16. Patient #16 was not coherent and could not carry on a conversation, as Patient #16 would not have had a clue during the conversation. At LTC Facility C, Patient #16 required the EMS staff to transfer Patient #16 from the EMS cot to Patient #16's bed at LTC Facility C (as opposed to Patient #16's ability to transfer to the EMS cot under their own power before Patient #16 went to the CAH's ED).

7. During an interview on 10/30/19 at 10:58 PM, LPN M revealed that when Patient #16 arrived at LTC Facility C, Patient #16 was passed out and was not able to function under their own power. LPN M had to use a sternal rub and calling out Patient #16's name to get Patient #16 to awaken. Patient #16's speech was almost unintelligible. Patient #16 required both CCP O and CCP O to transfer Patient #16 to their bed in LTC Facility C (as opposed to Patient #16's ability to transfer themselves to the EMS cot prior to going to the CAH's ED).

8. During an interview on 10/29/19 at 4:00 PM, Physician J, LTC Facility C's medical director, revealed the nursing staff at LTC Facility C contacted them on 10/21/19 regarding Patient #16's condition when Patient #16 returned to LTC Facility C. The nursing staff could not arouse Patient #16 without a sternal rub. Given the Patient #16's condition when Patient #16 returned to LTC Facility C, the nursing staff at LTC Facility C could not provide adequate nursing monitoring and supervision for Patient #16 to ensure Patient #16 did not experience further side effects from the alcohol intoxication or Ativan administered at the CAH. Physician J instructed the nursing staff to request the EMS staff transport Patient #16 back to the hospital.

9. During an interview on 10/30/19 at 8:35 AM, the CAH ED's Medical Director, Physician P, revealed that a patient who received Ativan would experience the most significant symptoms from the medication approximately 30 minutes after administration (approximately when the EMS staff returned Patient #16 to LTC Facility C). Physician P would be concerned about discharging a patient from the ED if the patient was not alert (Patient #16 was not alert at discharge) and aware of their surroundings (Patient #16 was not aware of their surroundings).