HospitalInspections.org

Based on policy review, medical staff bylaws/rules and regulations 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 4 of 22 emergency department (ED) records (Patients #1, #2, #3, and #4) reviewed.

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements at 489.24. Failure of the CAH to enforce their Emergency Medical Treatment and Labor Act policy limited the CAH's ability to determine if the patient had an emergency medical condition, and to ensure safe care of patients transferred from the emergency department.

Findings include:

The CAH failed to ensure an ED provider conducted an appropriate medical screening examination within the capability of the CAH's ED (Refer to C2406); and failed to ensure a qualified medical provider signed a certification stating the medical benefits of a transfer outweighed the risks for patients with unstabilized medical conditions (Refer to 2409).

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a qualified individual performed an appropriate medical screening examination for 1 of 22 patient records reviewed (Patient #1) of patients who presented to the CAH's emergency department. Failure to perform a medical screening examination limited the CAH's ability to determine if the patient had an emergency medical condition.

Findings include:

Review of the policy "The Ashley Medical Center Medical Screening in Emergency Room" occurred on 10/23/24. This undated policy, stated, ". . . Any patient who comes to the hospital requesting emergency services is entitled to and will receive a Medical Screening Examination performed by individuals qualified to perform such examination to determine whether an emergency medical condition exists. . . . D. How to Provide the Medical Screening Examination. . . . 3. Individuals coming to the emergency department must be provided a Medical Screening Examination beyond initial triage. . . ."

Review of Patient #1's medical record from 09/03/24 occurred on 10/22/24. Nurse's notes dated 09/03/24 stated:
* 1:15 a.m., "Patient brought in by . . . CNA [certified nurse aide], from his apartment, via wheelchair, apparently pressed the emergency button and complaining of severe pain, requesting to be brought in to ED."
* 1:17 a.m., "Routine ED admission protocol carried out. . . . stated his pain is a 9 on the left groin . . ."
* 1:20 a.m., "Provider, [provider name], notified by phone."

Patient #1's record lacked evidence of performance of a medical screening examination by a qualified individual to determine whether an emergency medical condition existed.

During an interview on 10/23/24 at 8:39 a.m., provider (#3) confirmed she failed to perform a medical screening examination for Patient #1.

Based on policy review, record review, medical staff bylaws/rules and regulations review, and staff interview, the Critical Access Hospital (CAH) failed to ensure completion of the physician's certification of transfer for 3 of 7 sampled records (Patients #2, #3, and #4) of Emergency Department (ED) patients transferred to other facilities. Failure to complete physicians' certifications to transfer, limited the CAH's ability to make informed decisions regarding the transfers.

Findings include:

Review of the policy "The Ashley Medical Center Emergency Policies" occurred on 10/23/24. This undated policy stated, ". . . Procedure: . . . Provide an appropriate transfer of an unstabilized patient to another medical facility if: A physician has signed the certification that the benefits of the transfer of the patient to another medical facility outweigh the risks. . . ."

Review of the policy "The Ashley Medical Center Emergency Department Transfer Policy" occurred on 10/23/24. This undated policy stated, "Any transfer of an individual with an emergency medical condition must be initiated either by the written request from the patient or the legally responsible person acting on the patient's behalf for such transfer or by a physician order with the appropriate physician certification. . . . Procedure: . . . 6. For a patient who has not been stabilized, a physician must have signed a certification . . . . 7. . . A stabilized patient may be transferred upon request or pursuant to pre-arranged transfers/treatment . . . if the following conditions are met: a) documentation of patient stabilization has been prepared by a physician or a qualified medical person in consultation with a physician (physician's counter-signature is required on documentation); 8. If a physician is not physically present in the emergency department at the time a patient is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations), may sign a certification after a physician, in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. . . "

Review of the medical staff's bylaws and rules and regulations occurred on 10/23/24. These bylaws, rules and regulations, approved by the Governing Board 02/19/07, stated, "Article III Membership, Section I Qualifications: A nurse practitioner or physician's assistant/extender may also be a member of the medical staff, subject to all limitations imposed by his/her delineation of privileges and these By-Laws, Rules and Regulations. Allied health professionals may apply for clinical privileges with collaboration and/or supervision of a member of the medical staff."

-Review of Patient #2's emergency department medical record occurred on 10/23/24. This record dated, 09/07/24, stated, "History of Present Illness, Chief Complaint: Stroke Code. Signs and Symptoms: patient presents to ER [Emergency Room] per EMS [Emergency Medical Staff]. EMS reports patient combative and not following commands upon arrival. Stroke code activated. . . Patient was incontinent of urine and stool in the bed. Patient moving all extremities. Upon arrival to ER patient continued to be combative, pulling IV [intravenous fluid] and monitoring wires. She was verbal, but not making any sense. Thrashing arms and legs. . . .Physical exam: General: Confused, Combative. Heart: Tachycardia [rapid heart rate]. Neurologic: Patient confused, combative, not following commands, thrashing arms and legs. Verbal but not making sense. Unable to complete full NIH [stroke scale] due to patient being combative and not following commands. Patient able to maintain airway. ED Course: Labs drawn, WBC [white blood count] 2.9 L [low], Platelets 77 L, Glucose 73 L, Liver enzymes elevated, Lactic acid 7.6 H [high], Troponin 0.37 H. EKG [electrocardiogram] done, sinus tachycardia.
Assessment: Sepsis, ARF [acute renal failure], Tachycardia, Hypoglycemia [low blood sugar], Elevated Troponin, Elevated Lactic Acid, Confusion, Low platelet, and Elevated Liver Enzymes. Plan: Admit to ER. Insert IV saline lock x [times]2. 0.9% [percent] NS [normal saline] bolus x 2000ml [milliliter]. Ativan 1mg [milligram] total. . . . Results discussed with patient's husband. CT [computed tomography Scan] head ordered but unable to complete due to patient thrashing and combative. Chest XR [xray] one view ordered, but unable to complete due to patient combativeness. Foley catheter attempted x3, unable to place. . . . 1 amp [ampule] Dextrose given for hypoglycemia. [name of receiving hospital] contacted after labs returned for patient transfer due to severity of Sepsis. [name of receiving physician] given report and did agree to accept patient for emergency transfer. . . Flight team contacted for emergent transport of patient. Medications given. . . Upon arrival flight team given report on patient. They did decide to intubate patient for flight. Patient discharged to [name of service] flight team for transfer to [name of receiving hospital] with accepting [name of receiving physician]."
The record lacked evidence the provider determined patient #2 was stable for transfer. The record lacked evidence a physician co-signed a certification stating the benefits of transfer outweigh the risks.

-Review of Patient #3's emergency department medical record occurred on 10/23/24. This record dated, 05/08/24, stated, "History of Present Illness, Chief Complaint: CVA [brain bleed/clot] Stroke Code Activated. Signs and Symptoms: Patient to ER per EMS. Call into EMS around 10:30, patient at home with daughter and fell to knees beside chair. Daughter concerned patient is having a stroke. She has had previous CVA x3. Patient is not following commands and is unable to speak. Upon arrival patient maintaining airway and sent straight to CT of head. Patient's VS [vital signs] stable. She is not verbalizing or following commands. Daughter present reports patient recently diagnosed with pneumonia and is on antibiotics. She ate breakfast around 0930 [9:30 a.m.] and was her normal. She does have right sided weakness from previous CVA. Physical Exam: Eyes: Pupils are equal, round and reactive to light. Heart: Regular rate and rhythm, Paced. ED Course: Labs drawn, 12 lead EKG, paced, CT Head without contrast: Impression: Large, remote appearing left parietal, occipital, and temporal lobe [parts of brain] infarct [blood clot]. . . . Assessment: CVA, Plan: Admit to ER. Stroke protocol orders. . . . Patient's daughter present and updated on all results and findings. Call to [receiving hospital] and report given to [name of physician], Neurology who did agree with transfer to [name of receiving hospital]. . . Report given to [name of receiving physician], [name of receiving hospital] who accepted patient for transfer to their facility. [name of service] Flight called for transport. Patient's family in agreement to transfer per flight. . . Report given to [name of service] Flight team and care of patient transferred to flight team. Discharged to [name of receiving hospital] per flight team. Critical care time: 1 hour."
The record lacked evidence the provider determined Patient #3 was stable for transfer. The record lacked evidence a physician co-signed a certification stating the benefits of transfer outweigh the risks.

-Review of Patient #4's emergency department medical record occurred on 10/23/24. This record, dated, 04/23/24, stated, "History of Present Illness: Chief Complaint: Weakness. Signs and Symptoms: Patient had initially presented to the clinic today for review of lab work. She was seen in the clinic yesterday and the provider that was on-call instructed her to return today and have follow-up lab work completed. . . her kidney function has worsened overnight. Patient reports that her only complaint is feeling very weak today. She states she is unable to walk while standing upright. She reports that she has had a cough and does feel short of breath when ambulating. She denies any chest pain. She states that she has had diarrhea since last Friday. She reports she is feeling slightly dizzy. She denies headache. She denies any nausea. She is cold and diaphoretic. She denies having any fevers. She states she only has a slight sore throat. She denies any pain to her ears. She reports that she only has a pressure sensation to the abdomen. Yesterday at the clinic she was given a 1000 ml of normal saline and 1 g [gram] of ceftriaxone [antibiotic] for possible UTI [urinary tract infection] and then she was sent home and instructed to come back today. Physical Exam: Labs drawn: WBC 26.5 H, Glucose 65 L. 12 Lead EKG: possible anteroseptal infarct [blood clot in heart]. CT chest/abdomen/pelvis done. Assessment: Acute Kidney Injury versus Acute Renal Failure, Hypoxia, Hypoperfusion, Hypotension, Possible sepsis, Concern for anteroseptal infarct, and Diarrhea, Dehydration and CHF [chronic heart failure] exacerbation. Plan: Admit to ER. Patient's initial blood pressure was 150/80, within 5 minutes her blood pressure drop [sic] to 80/30. . . . Unable to obtain accurate O2 [oxygen] saturation reading due to hypoperfusion [decrease blood flow]. . . . Patient was initially placed on 4 L [liters] per nasal cannula and then was moved to 15 L of oxygen per non-rebreather. . . . Patient does show worsening of acute kidney failure. Foley catheter placed. . . . Patient is worsening. . . . Patient was updated. Call was placed to [name of receiving hospital] for accepting as we were unable to figure out what was causing patient's acute decompensation. [name of receiving physician] was given report and did agree to accept patient. . . . Patient maintained GCS [glasgow coma scale] of 15. [name of service] flight team was called for patient transport due to her acute decompensation. . . . Upon flight team arrival they were given report. Discharge to [name of receiving hospital] per [name of service] flight team.
The record lacked evidence the provider determined Patient #4 was stable for transfer. The record lacked evidence a physician co-signed a certification stating the benefits of transfer outweigh the risks.

During an interview on 10/23/24 at 1:00 p.m., Provider #2 stated documentation on the discharge of an ED patient does not include the verbiage "discharge in stable or unstable condition."