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Based on documentation review and staff interviews, critical access hospital's (CAH) Emergency Department (ED) staff failed to follow the CAH's policies when the ED staff failed to provide an adequate medical screening examination to 2 of 30 sampled patients (Patient #14 and Patient #25) that presented to the ED and requested care. The administrative staff identified average of 18 patients per day who requested emergency medical care at the facility's dedicated emergency department.

Failure to follow the CAH's policies that required the ED staff to provide an adequate medical screening examination within the CAH's capabilities resulted in the CAH ED staff transferring a pregnant patient by her own car, without first determining if she could safely travel between the facilities and would not deliver her baby without medical staff present to assist her if she began to deliver the baby. Failure to provide an adequate medical screening examination also resulted in the CAH's ED staff discharging a patient complaining of left sided chest pain, without determining the cause of the chest pain, and who was found dead 2 days later.

Findings included:

1. Review of the policy "Obstetrical Patient, Assessment and Management," revised 5/2015, revealed in part, "The medical screening for an obstetrical patient with chief complaint related to pregnancy will include fetal well-being and labor status in addition to the standard assessment parameters of an ER assessment." The section Early/False Labor directed the nurse to "provide for and assist the physician with a sterile vaginal exam to determine: cervical dilation [the cervix normally opens to 10 cm prior to delivery], effacement [the cervix changes position as the baby moves closer to delivery], fetal descent [the baby's location in the birth canal], status of amniotic membranes [if the patient's water broke]."

2. Review of the policy "Patient Transfers...EMTALA," revised 5/2015, revealed in part, "Patients may be transferred to another hospital facility when: Evaluation and stabilization has been done in the Emergency Department..." "Patient is not in active labor with delivery imminent."

3. Review of Patient #14's closed ED medical record revealed that Patient #14 presented to the ED on 2/23/17 at 6/01 PM, complaining of vaginal bleeding and low abdominal and back pain every 10 minutes. Patient #14 was 37 weeks pregnant (nearly full term and ready to deliver the baby at any time). Patient #14 reported she saw her obstetrician (OB, a doctor who specialized in care of pregnant patients) approximately 5 hours prior to presenting to the ED. Patient #14 reported she was was 3 centimeters (cm) dilated and 80% effaced. (At the time of delivery, the cervix is 10 cm dilated and 100% effaced).

Registered Nurse (RN) B checked a box in Patient #14's medical record labeled "pelvic exam" to indicate the ED physician performed a pelvic examination in the presence of RN B. The ED record lacked specific assessment information from the pelvic examination, including if Patient #14 was likely to imminently deliver the baby, how far dilated the cervix was, the position of the cervix (effacement), location of the baby in the birth canal, or if Patient #14's water broke. RN B documented Patient #14 experienced cramps every 10 minutes.

Patient #14's medical record revealed the CAH staff provided transfer/discharge instructions on 2/23/17 at 7:00 PM. The discharge instructions told Patient #14 to drive their own vehicle to another hospital with specialized obstetrical capabilities approximately 73 miles from the sending CAH.

4. During an interview on 6/7/17 at 4:20 PM, RN B stated Patient #14 presented to the ED complaining of vaginal bleeding and this was her first pregnancy. RN B determined Patient #14 did not have active vaginal bleeding because RN B did not observe blood when Patient #14 changed her clothes. Physician's Assistant (PA) C visualized Patient #14's external genitalia, so RN B "checked" the box indicating PA C performed a pelvic exam. PA C did not complete a pelvic examination and/or insert his fingers into Patient #14's vagina to assess Patient #14's cervix. While PA C performed his examination, RN B was in the ED room with Patient #14 and did not observe what RN B believed were contractions.

5. During an interview on 6/7/17 at 2:08 PM, PA C stated Patient #14 presented to the ED complaining of vaginal bleeding and low abdominal pain/cramping, who was 37 weeks along in her pregnancy (full term is between 36 to 40 weeks). PA C failed to perform an internal pelvic examination because if Patient #14 was in active labor, the CAH did not provide labor and delivery services. PA C chose to defer performing the pelvic examination so an obstetrician at another hospital with more experience with pregnancy could examine Patient #14 at the receiving hospital.

6. During an interview on 6/7/17 at 2:45 PM, Physician E stated he provided oversight to PA C. Physician E signed Patient #14's medical record to indicate Physician E was available to PA C by phone and reviewed Patient #14's medical record. Physician E stated if a patient presented at 37 week gestation, her cervix was dilated to 3 cm (out of a maximum of 10 cm), was 80% effaced (out of 100% and fully ready to give birth), experiencing low abdominal/back pain every 10 minutes that lasted 1 minute, the patient could be in labor. Physician E stated PA C should have performed a pelvic examination prior to transferring Patient #14 to another hospital.

7. Review of the policy "Medical Screening Exam (MSE)," reviewed 5/2017, revealed in part, "Purpose: To ensure that any individual who comes to the Hospital, and on whose behalf a request for examination or treatment for a medical condition is made, an appropriate medical screening examination shall be provided ... and within the capabilities of the Emergency Department (and ancillary services routinely available to the Emergency Department) to determine whether or not an emergency medical condition (EMC) exists ...A physician or [nurse practitioner] ... shall be called to perform the medical screening examination in the event that any of the following symptoms or conditions is identified: ... Chest Pain ..."

8. Review of Patient #25's closed medical record revealed Patient #25 presented to the Emergency Department (ED) on 5/2/17 at 10:25 AM complaining of left sided chest pain. Advanced Registered Nurse Practitioner (ARNP) H ordered a chest x-ray. The chest x-ray did not reveal any broken ribs. ARNP H failed to order any further diagnostic testing to determine the cause of Patient #25's chest pain. According to the record review upon returning from radiology following the chest x-ray to evaluate the rib pain, staff documented Patient #25 was sitting up in a wheelchair and vomited. ARNP H discharged Patient #25 on 5/2/17 at 11:43 AM with rib pain and a recent vomiting episode. Patient #25 left the ER with a friend.

9. During an interview on 6/7/2017 at 4:30 PM, ARNP H revealed he ordered a check X-ray to rule out fractured ribs and pneumonia. He did not do any further testing to determine reason for Patient #25's continued chest pain, nausea and dizziness. ARNP H stated he knew Patient #25 was diabetic and ARNP H did not perform any testing to check Patient #25's blood sugar level.

10. During an interview on 6/7/2017 at 2:00 PM, Physician K revealed he would have performed laboratory testing, including checking Patient #25's blood sugar, performed a check x-ray, and further laboratory testing to identify the cause of Patient #25's chest discomfort. Physician K stated until he received the information from the testing, he could not know if Patient #25 was experiencing something minor like a muscle strain or something major like a heart attack.

11. Review of the death certificate revealed Patient #25 died in his/her home on 5/4/17. Physician L signed the death certificate and listed Patient #25's cause of death as "sudden cardiac arrest syndrome."

Please refer to C-2406 for additional information.

Based on documentation review and staff interviews, critical access hospital's (CAH) Emergency Department (ED) staff failed to an adequate medical screening examination within the CAH's capabilities prior to discharging or transferring 2 of 30 sampled patients that presented to the Emergency Department (ED) for evaluation of possible emergency medical conditions (Patient #14 and #25). The administrative staff identified average of 18 patients per day who requested emergency medical care at the facility's dedicated emergency department.

Failure to provide an adequate medical screening examination within the CAH's capabilities resulted in the CAH ED staff transferring a pregnant patient by her own car, without first determining if she could safely travel between the facilities and would not deliver her baby without medical staff present to assist her if she began to deliver the baby. Failure to provide an adequate medical screening examination also resulted in the CAH's ED staff discharging a patient complaining of left sided chest pain, without determining the cause of the chest pain, and who was found dead 2 days later.

Findings included:

1. Review of the policy "Obstetrical Patient, Assessment and Management," revised 5/2015, revealed in part, "The medical screening for an obstetrical patient with chief complaint related to pregnancy will include fetal well-being and labor status in addition to the standard assessment parameters of an ER assessment." The section Early/False Labor directed the nurse to "provide for and assist the physician with a sterile vaginal exam to determine: cervical dilation [the cervix normally opens to 10 cm prior to delivery], effacement [the cervix changes position as the baby moves closer to delivery], fetal descent [the baby's location in the birth canal], status of amniotic membranes [if the patient's water broke]."

2. Review of the policy "Patient Transfers...EMTALA," revised 5/2015, revealed in part, "Patients may be transferred to another hospital facility when: Evaluation and stabilization has been done in the Emergency Department..." "Patient is not in active labor with delivery imminent."

3. Review of Patient #14's closed ED medical record revealed that Patient #14 presented to the ED on 2/23/17 at 6/01 PM, complaining of vaginal bleeding and low abdominal and back pain every 10 minutes. Patient #14 was 37 weeks pregnant (nearly full term and ready to deliver the baby at any time). Patient #14 reported she saw her obstetrician (OB, a doctor who specialized in care of pregnant patients) approximately 5 hours prior to presenting to the ED. Patient #14 reported she was was 3 centimeters (cm) dilated and 80% effaced. (At the time of delivery, the cervix is 10 cm dilated and 100% effaced).

Further review of the medical record revealed ED staff checked the fetal heart tones with initial fetal heart tone rate of 136 beats per minute. Registered Nurse (RN) B checked a box in Patient #14's medical record labeled "pelvic exam" to indicate the ED physician performed a pelvic examination in the presence of RN B. The ED record lacked specific assessment information from the pelvic examination, including if Patient #14 was likely to imminently deliver the baby, if her water had broken, how far dilated the cervix was, the position of the cervix (effacement), location of the baby in the birth canal, or if Patient #14's water broke. RN B documented Patient #14 experienced cramps every 10 minutes.

Patient #14's medical record revealed the CAH staff provided transfer/discharge instructions on 2/23/17 at 7:00 PM. The discharge instructions told Patient #14 to drive their own vehicle to another hospital with specialized obstetrical capabilities approximately 73 miles from the sending CAH.

4. During an interview on 6/7/17 at 4:20 PM, RN B stated Patient #14 presented to the ED complaining of vaginal bleeding and this was her first pregnancy. RN B determined Patient #14 did not have active vaginal bleeding because RN B did not observe blood when Patient #14 changed her clothes. Physician's Assistant (PA) C visualized Patient #14's external genitalia, so RN B "checked" the box indicating PA C performed a pelvic exam. PA C did not complete a pelvic examination and/or insert his fingers into Patient #14's vagina to assess Patient #14's cervix. While PA C performed his examination, RN B was in the ED room with Patient #14 and did not observe what RN B believed were contractions. RN B stated Patient #14 did not exhibit what RN B believed were signs of labor such as "excessive nervousness or fear of impending doom."

RN B acknowledged the CAH lacked a device to monitor contractions. Patient #14 was in the ED for 59 minutes and RN B did not provide continuous observation of Patient #14. RN B acknowledged she could possibly fail to observe Patient #14 have a contraction, although Patient #14 denied experiencing contractions. RN B stated possible signs of labor included low back pain or low abdominal pain. RN B acknowledged she lacked experience working with obstetrical patients and her only experience with obstetrical patients was 8 years prior in nursing school.

5. During an interview on 6/7/17 at 2:08 PM, PA C stated Patient #14 presented to the ED complaining of vaginal bleeding and low abdominal pain/cramping, who was 37 weeks along in her pregnancy (full term is between 36 to 40 weeks). PA C failed to perform an internal pelvic examination because if Patient #14 was in active labor, the CAH did not provide labor and delivery services. PA C chose to defer performing the pelvic examination so an obstetrician at another hospital with more experience with pregnancy could examine Patient #14 at the receiving hospital.

PA C performed a medical screening examination of Patient #14's head, chest, abdomen, and a visual examination of Patient #14's external genitalia. PA C did not remember if Patient #14's water broke and can not recall if he checked for the presence of amniotic fluid, but acknowledged he did not document either way if he checked for amniotic fluid. PA C reviewed his findings with Obstetrician F at the receiving hospital, and they determined Patient #14 could safely transfer to the receiving hospital by her own vehicle. PA C stated he performed emergent deliveries in the past.

6. Review of PA C's credential file (a personnel file for PAs, ARNPs, and physicians) revealed the following:

a. PA C successfully completed continuing medical education (CME) that included obstetrical emergencies on 11/25/14.
b. The CAH's governing body granted PA C permission to perform emergent vaginal births on 9/29/15.

7. During an interview on 6/7/17 at 2:45 PM, Physician E stated he provided oversight to PA C. Physician E signed Patient #14's medical record to indicate Physician E was available to PA C by phone and reviewed Patient #14's medical record. Physician E stated if PA C was uncomfortable performing a procedure such as a pelvic examination, PA C should contact Physician E and Physician E would go to the ED and assess the patient.

Physician E stated if a patient presented at 37 week gestation, her cervix was dilated to 3 cm (out of a maximum of 10 cm), was 80% effaced (out of 100% and fully ready to give birth), experiencing low abdominal/back pain every 10 minutes that lasted 1 minute, the patient could be in labor. Physician E stated PA C should have performed a pelvic examination prior to transferring Patient #14 to another hospital.

8. Review of the policy "Medical Screening Exam (MSE)," reviewed 5/2017, revealed in part, "Purpose: To ensure that any individual who comes to the Hospital, and on whose behalf a request for examination or treatment for a medical condition is made, an appropriate medical screening examination shall be provided ... and within the capabilities of the Emergency Department (and ancillary services routinely available to the Emergency Department) to determine whether or not an emergency medical condition (EMC) exists ...A physician or [nurse practitioner] ... shall be called to perform the medical screening examination in the event that any of the following symptoms or conditions is identified: ... Chest Pain ..."

9. Review of Patient #25's closed medical record revealed Patient #25 presented to the Emergency Department (ED) on 5/2/17 at 10:25 AM complaining of left sided chest pain. Advanced Registered Nurse Practitioner (ARNP) H ordered a chest x-ray. The chest x-ray did not reveal any broken ribs. ARNP H failed to order any further diagnostic testing to determine the cause of Patient #25's chest pain. According to the record review upon returning from radiology following the chest x-ray to evaluate the rib pain, staff documented Patient #25 was sitting up in a wheelchair and vomited. ARNP H discharged Patient #25 on 5/2/17 at 11:43 AM with rib pain and a recent vomiting episode. Patient #25 left the ER with a friend.

10. During an interview on 6/7/2017 at 4:30 PM, ARNP H revealed he ordered a check X-ray to rule out fractured ribs and pneumonia. He did not do any further testing to determine reason for Patient #25's continued chest pain, nausea and dizziness. ARNP H stated he knew Patient #25 was diabetic and ARNP H did not perform any testing to check Patient #25's blood sugar level.

11. During an interview on 6/7/2017 at 2:00 PM, Physician K revealed he would have performed laboratory testing, including checking Patient #25's blood sugar, performed a check x-ray, and further laboratory testing to identify the cause of Patient #25's chest discomfort. Physician K stated until he received the information from the testing, he could not know if Patient #25 was experiencing something minor like a muscle strain or something major like a heart attack.

12. During an interview on 6/7/2017 at 2:45 PM, Physician L revealed he would have performed a 12-leak EKG (a detailed look at the heart's electrical system which can show if the patient was having a heart attack), ordered a chest x-ray, and ordered laboratory testing to determine the cause of the symptoms.

13. Review of the death certificate revealed Patient #25 died in his/her home on 5/4/17. Physician L signed the death certificate and listed Patient #25's cause of death as "sudden cardiac arrest syndrome."