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Based on review of hospital policies and procedures, patient medical records, and staff interviews, the Critical Access Hospital (CAH) failed to provide an appropriate medical screening examination (MSE) within the hospital's
capacity and capabilities, to determine if an emergency medical condition existed for 1(Patient 21, P21) of 21 sampled patients who presented to the emergency department requesting emergency medical services and
failed to ensure all patients who presented to the ED for emergency care were registered on the hospital's ED log for purposes of tracking care provided to patients for 1 (Patient 21, P21) of 21sampled patients.

1. Failure to provide appropriate ED services within the hospital's capabilities resulted in P21 not receiving an appropriate MSE to determine whether the patient had an emergency medical condition (EMC) [see C-2406].

2. Hospital staff failed to register P21 on the hospitals ED log, which resulted in staff being unable to maintain a record of the patient's status, emergency services rendered by staff, and final disposition of the patient (e.g., admitted,
discharged) [see C-2405].

The hospital's combined failures placed all patients who presented to the ED seeking emergency services at risk for a worsening EMC.

Findings include:

Obstetrical Department. A central log shall be maintained in the Emergency department and the Obstetrical department on each individual who comes to the Emergency Department seeking assistance, recording whether he/she refused treatment, was admitted and treated, was stabilized and transferred, or was discharged ..."
c. Medical Screening Exam: "... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ... When an individual comes to the hospital for emergency care, the hospital must provide the individual with an appropriate medical screening examination (MSE) within the capability of the ED (including ancillary services routinely available to the emergency department) ..."

2. Review of the hospital's medical records revealed hospital staff failed to provide P21 with an appropriate MSE on 4/12/25 to determine whether the patient had an EMC and required stabilizing treatment or transfer to another medical facility.

3. Review of the hospital's ED log revealed hospital staff failed to register P21's request for emergency services on 4/12/25.

4. During an interview on 4/16/25 at 4:30 PM, Staff B (Paramedic) acknowledged P21 did not
receive an MSE, nor did staff provide instructions for the patient to enter the hospital to allow for the
provision of an MSE. Staff B noted they did not inquire about the patient's location at the time of
the call.

5. During an interview on 4/21/25 at 9:30 AM, Staff I (ED Medical Director) reported the ED had
various obstetric/gynecologic (OB/GYN) capabilities to perform assessments of a pregnant patient and fetus. Staff I acknowledged they expected staff to utilize available staff, equipment, and resources to provide an MSE to
all patients who presented to the ED requesting emergency services.

6. During an interview on 4/21/25 at 1:12 PM, Staff L (Director of Inpatient Services) acknowledged ED staff failed to register P21 on the ED log dated 4/12/25. Staff L reported the Emergency Medical Treatment and Labor Act
(EMTALA) required hospital staff to evaluate all patients who presented to the hospital requesting ED services, including patients who presented to the hospital parking lot.

Based on staff and patient interviews, hospital polices and procedures and ED logs, the Critical Access Hospital (CAH) failed to maintain a central ED log of all patients who presented to the Emergency Department requesting emergency care and services for 1 (Patient #21, P21) of 21 sampled patients.

Failure to maintain a complete ED log resulted in the inability of hospital staff to track the care provided to each individual who presented to the ED seeking care for a potential emergency medical condition (EMC).
Findings include:

1. Review of the 12/2024 policy "Emergency Medical Treatment and Labor Act (EMTALA)" revealed in part:
a. Purpose: "To ensure compliance with Emergency Medical Treatment and Labor Act (EMTALA) and related laws and requirements ..."

b. Central logs ... "The hospital logs reflect all patients who present seeking Emergency Medical Services, including those maintained by the Emergency Department and the Obstetrical Department. A central log shall be maintained in
the Emergency department and the Obstetrical department on each individual who comes to the Emergency Department seeking assistance, recording whether he/she refused treatment, was admitted and treated, was stabilized and transferred, or was discharged."

2. Review of the hospital's ED log showed no documentation of P21 presenting to the ED and requesting emergency services on 4/12/25.

3. During an interview on 4/16/25 at 11:40 AM, P21 reported presenting to the ED on 4/12/25 at 24 weeks of pregnancy with complaints of decreased fetal movement. The patient requested to be seen by a provider via phone call while in a parking lot on hospital premises, but staff reportedly advised the patient to go to another medical facility due to the hospital only having ultrasound capabilities on weekdays.

4. During an interview on 4/16/25 at 4:30 PM, Staff B (Paramedic) reported receiving a phone call from P21, in which the patient reported concerns about decreased fetal movement at 24 weeks of pregnancy and requested a medical evaluation. Staff B acknowledged they did not provide instructions for the patient to enter the hospital to be seen by a provider, and thus, staff did not document the patient's arrival on the ED log. Staff B noted they did not inquire about the patient's location at the time of the call.

5. During an interview on 4/21/25 at 1:12 PM, Staff L (Director of Inpatient Services) acknowledged ED staff failed to include P21 on the ED log dated 4/12/25. Staff L reported the hospital's Emergency Medical Treatment and
Labor Act (EMTALA) obligations for seeing a person began when they entered hospital property, including the parking lot of the hospital.

Based on staff and patient interviews and review of hospital documents and policies and procedures, the Critical Access Hospital (CAH) failed to provide an appropriate medical screening examination (MSE) within the hospital's
capabilities for 1 (Patient #21, P21) of 21 sampled patients who presented to the emergency department (ED) requesting evaluation and treatment related to symptoms of decreased fetal movements at 24 weeks
gestation.

Failure to provide all patients with an appropriate MSE could result in an increased risk of adverse
health outcomes, up to and including disability or death.

Findings include:

1. Review of the 12/2024 policy "Emergency Medical Treatment and Labor Act (EMTALA)"
revealed in part:

a. Purpose: "To ensure compliance with Emergency Medical Treatment and Labor Act (EMTALA) and related laws and requirements. To meet the hospital's obligations under EMTALA to treat all patients presenting to the Emergency
Room. The hospital will provide an appropriate medical screening examination, and if the individual has an emergency medical condition, either: a. provide any necessary stabilizing treatment, b. transfer the individual in compliance
with the requirements of EMTALA or; c. admit the individual as an inpatient."

b. Medical Screening Exam: "... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ... When an individual comes to the hospital for emergency care, the hospital must provide the individual with an appropriate medical screening examination (MSE) within the capability of the ED (including
ancillary services routinely available to the emergency department) to determine whether an emergency medical condition exists ... individual requests examination or treatment for a medical condition ... The MSE must be the same MSE that the hospital would perform on any individual coming to the hospital with the same signs and symptoms, regardless of diagnosis (labor, AIDS), financial status (uninsured, Medicaid), race, color, national origin, or disability. If the MSE indicates that the patient does not have an emergency medical condition, then appropriate staff must determine the level of care appropriately and manage as indicated, or refer the patient to the patient's primary care provider for further care ...Hospital staff may not take any action to suggest that the patient leave the hospital prior to an MSE ..."

c. When an MSE is required: ... A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC (emergency medical condition) exists ... The MSE and other emergency services need not be provided in a location specifically identified as a DED [dedicated emergency department]. The hospital may use areas to deliver emergency services. MSEs or stabilization may require ancillary services available only in areas or facilities of the hospital outside of the DED ..."

2. Review of requested, sampled patient records revealed no medical record and/or documentation of assessments, tests, history and physical, or physician evaluation on 4/12/25 when P21 presented and requested an evaluation related to symptoms of decreased fetal movements.

3. During an interview on 4/16/25 at 11:40 AM, P21 reported presenting to the ED on 4/12/25 at 24 weeks of pregnancy with complaints of decreased fetal movement. The patient requested to be seen by a provider via phone call while in the parking lot on the hospital's premises, but staff reportedly advised the patient to go to another medical facility due to the hospital only having ultrasound capabilities on weekdays, resulting in the patient commuting approximately 19 miles to Hospital B to obtain an appropriate MSE.

4. During an interview on 4/16/25 at 4:30 PM, Staff B (Paramedic) reported receiving a phone call from P21, in which the patient reported concerns about decreased fetal movement at 24 weeks of pregnancy and requested a medical evaluation. Staff B acknowledged the patient did not receive an MSE, nor did staff provide instructions for the patient to enter the hospital to allow for the provision of an MSE. Staff B noted they did not inquire about the patient's location at the time of the call.

5. During an interview on 4/17/25 at 9:30 AM, Staff E (ED Advanced Registered Nurse Practitioner (ARNP)) reported awareness of P21's request for a medical evaluation via phone on 4/12/25 but denied knowledge of the patient's location at the time of the call. Staff E reported the ED had the capability to perform a number of
assessments of the patient and fetus, including the collection and monitoring of vital signs and various laboratory assessments.

6. During an interview on 4/21/25 at 9:30 AM, Staff I (ED Medical Director) acknowledged they expected staff to provide an MSE to all patients who presented to the ED requesting emergency services. Staff I reported the ED had a number of obstetric/gynecologic (OB/GYN) capabilities available at the time of P21's ED encounter, which included a fetal doppler to assess fetal heart tones, a tocodynamometer (TOCO) to evaluate for contractions, nonstress test (NST) capabilities to evaluate fetal responsiveness, laboratory capabilities to perform a urinalysis
(UA), and nitrazine test strips to detect the presence of amniotic fluid, which may indicate whether the patient's amniotic membrane had ruptured (colloquially known as "water breaking").

7. During an interview on 4/21/25 at 1:12 PM, Staff L (Director of Inpatient Services) acknowledged the Emergency Medical Treatment and Labor Act (EMTALA) required hospital staff to evaluate all patients who presented to the
hospital requesting ED services, including patients who presented to the hospital parking lot.