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A complaint health survey for compliance with Emergency Medical Treatment and Labor Act (EMTALA) 42 CFR Part 489.20 Basic Section Commitments Relevant to Section 1867 Responsibilities and 42 CFR Part 4898.24 Special Responsibilities of Medicare Hospitals in Emergency Cases was conducted from 12/8/21 through 12/10/21. Based on the findings of the survey team, South Big Horn Hospital was found not in compliance with the requirement for A0407.

Based on medical record review, staff interview, review of policy and procedures, and review of professional standards, the facility failed to ensure the provision of stabilization treatment that was appropriate within the capability of the hospital prior to discharge for 1 of 25 sample patients (#11). The findings were:

1. Review of the emergency department medical record showed patient #11 was admitted on 11/16/21 at 5:21 PM with pre-existing diagnoses which included atrial fibrillation with rapid ventricular response, chronic hyponatremia, intellectual functioning disability, cardiomegaly, hypertension and epilepsy. Further review showed the patient was admitted in the emergency department for an unresponsive state, report of cardiac arrest and trauma. Review of the provider note dated 11/16/21 at 8:46 showed the patient from a local long term care facility was brought in by ambulance and reported as trauma code. The patient was reportedly found down (on the floor), following an unwitnessed fall, and was unresponsive. Cardio-pulmonary resuscitation (CPR) was immediately started by long term care center staff. The patient arrived in the emergency room obtunded, confused, not following directions, but breathing on his/her own. Emergency department treatment included diltiazem 20 mg IV push for control of atrial fibrillation. Laboratory orders included alcohol level, complete blood count, lactic acid level, prothrombin time, activated partial thromboplastin time, complete metabolic panel, troponin I level, urinalysis, and urine drug screen. Radiology orders included chest x-ray, computerized tomography (CT) with contrast of abdomen and pelvis, CT of chest, CT of head and brain, and CT of neck and cervical spine. The following concerns were identified:
a. Further review of the emergency department record showed the patient was discharged back to the long term care center at 8:12 PM the same day and hospital report given to the floor nurse at the long term care center. Review of the discharge instructions from the emergency department showed "Today you were seen in the emergency department for: unresponsive state, report of cardiac arrest, trauma. Important findings are as follows: there are no traumatic findings in your head or neck, in your chest there are multiple rib fractures, four on the left and 2 on the right. Additionally you have fractured the manubrium of your sternum. Your confusion is likely from post ictal state after the seizure. It is important for you to continue home medications. You will need to take tramadol for pain control, as well as Tylenol and ibuprofen, use ice in the affected areas, use the incentive spirometer 10 times per hour, and watch for atelectasis and potential pneumonia."
b. Review of an ambulance report dated 11/17/21 at 5:49 showed the ambulance again responded to the long term care facility. Patient #11 was found on the floor with staff attending. CPR was in progress. Review of the ambulance report further showed patient was "unresponsive, pulseless, apneic. Blood noted in the oropharynx, cyanosis to the lips and hands." The AED (automated external defibrillator) showed no shock advised. The electrocardiogram showed asystole in leads l, ll and lll. Pupils were fixed at 5 mm. The emergency room physician that saw the patient the previous day was contacted and agreed with the decision to stop resuscitation efforts.
c. Telephone interview with the emergency room physician on 12/9/21 at 3 PM regarding the patient's 11/16/21 discharge revealed the patient's heart rate was well-controlled and vital signs were stable at the time of discharge. The physician reported according to "published recommendations" the patient did not qualify for inpatient admission. The interview further revealed the physician offered the patient the option of being admitted locally or being transferred to another facility. It was reported the patient declined the proffered admission and wanted to return to the long term care center. However, review of the hospital medical record failed to show any documentation of this conversation.
d. Review of the policy and procedure titled "Code Blue-Medical Emergency and revised on 10/13/2015 states "Charge nurse/practitioner will determine appropriate medical interventions."
e. Interview with the chief nursing officer on 12/9/21 at 10 AM revealed the policy of the facility was to follow guidelines established by the American Heart Association.
f. Review of the 2020 American Heart Association Advanced Cardiovascular Life Support provider manual showed on page 150: "Merely restoring blood pressure and gas exchange does not ensure survival and functional recovery, and significant cardiovascular dysfunction can develop after return of spontaneous circulation. These dysfunctions can require active support of blood flow and ventilation, including intravascular volume expansion, vasoactive and inotropic drugs, and invasive devices."