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Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the emergency department staff followed the CAH's policies and provide an appropriate medical screening exam. Failure to provide an appropriate medical screening exam to 3 of 24 patients (Patient #1, Patient #2, and Patient #3) placed the patients at risk for leaving the ED with an undetermined emergency medical condition. The CAH's administrative staff identified an average of 71 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.


Findings include:

1. Review of the policy, "EMTALA [Emergency Medical Treatment & Active Labor Act] Guidelines for Emergency Department Services", last revised 10/2018, revealed in part, "...Upon presentation on hospital property, an individual who is not otherwise a patient of the hospital shall be provided an appropriate medical screening examination...The purpose of the medical screening is to determine whether an emergency medical condition exists...If the individual or a person acting on behalf of the individual refused further examination and treatment, the individual must be informed of the risks and benefits of such examination and treatment."

"The following licensed health care professionals are qualified personnel, authorized to perform medical screening examinations as indicated:
A. RN Nursing Assessment Whenever a physician, physician's assistant or nurse practitioner is not present in the dedicated emergency department, a registered nurse may perform the medical screening examination, provided that the individual may not be discharged prior to the registered nurse's consultation with the on-call practitioner. The purpose of the medical screening is to determine whether an emergency medical screening exists. If so the on-call practitioner will come to the hospital to provide further examination and treatment, If (sic) the patient is determined by nursing assessment not to be in an emergency medical condition, the registered nurse, pursuant to the on call practitioner orders by telephone, may provide nursing services or discharge the individual with instructions.

B. Physician, PA, or NP exam A physician, physician's assistant, or nurse practitioner...shall be called immediately to perform or complete the medical screening exam in the even (sic) that any sign, symptom, complaint or condition is identified suggesting the presence of an emergency medical condition."

2. The policy does not differentiate how a nursing assessment provides an appropriate medical screening exam (MSE) sufficient to determine if an emergency medical condition (EMC) exists. Neither the Bylaws or the Rules and Regulations delineate the RN's qualifications for performing an appropriate MSE sufficient to determine if an EMC exists.

3. During an interview on 6/27/22 at 9:30 AM, DO E explained that they generally see each patient in the ED.

4. During an interview on 6/29/22 at 10:20 AM, PA-C G explained that migraines are the only diagnosis where they are not required to go into the ED to see the patient.

5. Review of PA-C G ' s signed Appointment Profile / Scope of Practice form with an effective date 11/01/20 - 10/31/22 showed the following "Emergency Medicine Privileges include assessment, work-up, and providing initial treatment to patients of all ages who present in the emergency department with any illness, injury, condition, or symptom."

Please refer to tag C2406 for additional findings.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 3 of 24 patients (Patient #1, Patient #2, and Patient #3) selected for review, who presented to the CAH for emergency care from 1/1/22 through 6/21/22, received an appropriate medical screening exam by a qualified medical personnel (QMP). Failure to provide an appropriate medical screening exam by a QMP at the CAH Emergency Department (ED) resulted in Patient #1, Patient #2, and Patient #3 leaving the CAH ED without an appropriate medical screening examination (MSE). The CAH's administrative staff identified an average of 71 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #1's medical record revealed:

On 5/9/22 at 10:05 PM, Registered Nurse A (RN A) documented that Patient #1 presented to the CAH ED with their mom after Patient #1 fell and cut their lip. Patient #1 had an approximate 1centimeter upper lip laceration (deep cut in the skin) that crossed the vermillion border (the line just above the colored portion that connects the lip tissue to the rest of the face). Per RN A's documentation, the mom denied Patient #1 lost consciousness after the fall, and that Patient #1 was talkative and interactive with RN A. RN A documented that Patient #1 would need stitches and that the Patient's mom wanted to know options for sedation. RN A documented calling ARNP B who advised the technique for repair would include numbing the area prior to stitches. The medical record did not contain evidence that RN A performed a medical screening examination prior to or after RN A's call with ARNP B. RN A documented that Patient #1's mom stated they were going to go to CAH A where Patient #1 had been born and where their doctor was located.

At 10:10 PM, Patient #1's mother signed the form, "Refusal of Exam/Treatment." RN A documented the risks of the exam were "discomfort during suture repair" and the benefits of the exam were "approximate wound edges to heal." In the area on the form to describe the "type of exam or treatment, or both that was refused", RN A documented "Mom would like more options for sedation prior to laceration repair." At 10:12 PM, RN A documented Patient # 1 left the ED.

At 10:17 PM, RN A documented contacting CAH A and telling them Patient #1 may be coming to their ED. RN A gave report to RN C. At 10:22 PM, RN A documented calling Patient #1's Mom and giving her CAH A's ED phone number and asking her to call CAH A's ED and talk to RN C.

2. During an interview on 6/23/22 at 12:30 PM, RN A confirmed they did not perform a medical screening examination. RN A recalled confirming that Patient #1 would need stitches and explained to Patient #1's Mom that they would wrap the child to help keep them secure, numb the area, and then stitch up the lacerations. RN A called ARNP B to confirm that ARNP A would not use any type of sedation for the procedure. RN A explained to Patient #1's Mom that it can be hard to suture a lip laceration on a child's lip because their mouth is always moving when they are talking or crying. RN A confirmed telling Patient #1's Mom that sometimes the procedure doesn't work and RN A told Mom they would then send them to a bigger hospital. RN A shared with Patient #1's mom that RN A also worked at another hospital where they did use sedation during sutures to help a child relax. Patient #1's mom said Patient #1 was born at CAH A and they would take her there for treatment and started to leave the ED. RN A confirmed that they could not speak for CAH A and whether or not they could provide the necessary treatment. RN A confirmed calling CAH A to tell them that Patient #1 was coming to their ED with a lip laceration. RN A talked to RN C who relayed that they were not sure their doctor was going to want to sedate the child and felt the child might need to see a plastic surgeon. RN A then called Patient #1's mom to tell her that CAH A said they weren't sure they would be able to take care of it for them. RN A gave Patient #1's mom the number for CAH A ED and told her to call and talk to RN C. RN A called CAH A ED back and told them to let RN C know that RN A had talked to Patient #1's mom and she would be calling RN C.

3. During an interview on 6/23/22 at 11:30 AM, ARNP B recalled receiving a call from RN A who told ARNP B that Patient #1 was in the ED with a 1-centimeter laceration that looked like it was going to require stitches. Patient #1's mom wanted to know how they would fix it, ARNP B explained to RN A that they would swaddle Patient #1 in a blanket to help hold them, numb the area with lidocaine, and then once numb ARNP B would suture the laceration. ARNP B confirmed to RN A that they would not use sedation.

ARNP B did not talk to Patient #1's mom directly, all information was relayed to them through RN A. ARNP B said they did offer to come out to the ED to see Patient #1, but was told mom said they were going to go to CAH A.

4. During an interview on 6/27/22 at 6:45 AM, RN C recalled receiving a call from RN A that a two-year-old had a laceration that went across the vermillion border and there wasn't anything they could do to repair it there. Patient #1 would have to go to a bigger hospital. Patient #1's parent had left AMA, and RN A had instructed them to come to CAH A. RN C confirmed telling RN A to have the mom call CAH A ED first. RN C confirmed talking to Patient #1's dad and he wanted to know if CAH A had everything ready to repair Patient #1's lip. RN C told him they would be happy to see Patient #1, conveyed they would examine Patient #1 and the provider would determine the appropriate treatment. RN C confirmed that Patient #1 did not come to CAH A ED for examination and treatment.

5. The medical record did not contain evidence that the scheduled provider presented to the ED to examine Patient #1.

6. "Review of the Provider ED Call Schedule"...revealed ARNP B was the provider on call to examine and treat ED patients on 5/9/22.

7. Review of ARNP B's signed Appointment Profile/ Scope of Practice form with an effective date 11/29/22- 11/23/23, showed the following "Emergency Medicine Privileges include assessment, work-up, and providing initial treatment to patients of all ages who present in the emergency department with any illness, injury, condition, or symptom."

8. Review of Patient #2's medical record revealed:

9. On 5/17/22 at 7:40 PM, Patient #2 presented to the ED with complaint of migraine that started at 9:00 AM. Patient #2 had some relief with home medications, now rated pain as 8 on a scale of 10, and was sensitive to light. Patient #2 relayed that they were experiencing increased stress due to recent cancer diagnosis of two friends. RN A documented Patient #2 was alert and oriented to time, place and person and they were moving all extremities. Patient #2's speech was clear and understandable. Blood pressure was 160/59 (top number should not be more than 120).

At 7:50 PM, RN A notified PA-C G of assessment. Orders were obtained, patient consented to a tele-health visit.

At 7:59 PM, RN A gave Patient #2 intramuscular injections (shots) of Toradal 60 milligrams (medication used for pain), Norflex 60 milligrams (medication used to relax muscles), and Zofran 4 milligrams (medication used for nausea). At 8:20 PM RN A documented that Patient #2 reported they felt better and wanted to get home and go to bed.

At 8:25 PM RN A documented reviewing discharge instructions with Patient #2, and that the patient left with their husband.

10. On 5/25/22 at 12:44 AM (8 days after ED visit), PA-C G documented that they had examined Patient #2 on 5/17/22 via tele-health for a migraine headache. The medical record lacked evidence PA-C G presented to the ED to perform an MSE on Patient #2.

11. During an interview on 6/29/22 at 10:20 AM, PA-C G explained Patient #2 was well known to them and they did not go into the ED to see Patient #2 because they are not required to go into the ED to see patients that have chronic, intermittent migraines. PA-C G said that many times they will use the RN's assessment, and they can talk to the RN and the patient in person via video. Use of tele-health video is their discretion, but PA-C G confirmed that they would come to the ED in person if the patient or the RN wanted them to come in.

PA-C G's understanding was that migraines are the only diagnosis where they not required to go into the ED to see the patient. Migraines are a little bit different, they know the patients well, have a standard routine. There was no evidence in policy that providers are not required to go into the ED to examine patients that have chronic intermittent migraines.

PA-C G explained that if part of the screening exam is not documented on the ED nurse's assessment, then they will ask the nurse directly what they found on their exam, and tell the nurse they didn't document it.

12. Review of the policy, "Telehealth Services", last approved 07/21, revealed in part, "Telehealth services provide patients with timely consultation with a physician or other practitioner located at another site. Telehealth services can involve the furnishing of physician evaluation and management office visits, as well as can be used to supplement in-person services available at the Hospital, such as by making tele-stroke consultations available for patients in the Emergency Department..." The policy did not specify the use of telehealth in lieu of the ED physician or mid-level practitioner presenting to the ED to examine or treat a patient.

13. Review of Provider ED Schedule (ED physicians who are on call to provide an appropriate medical screening exam and necessary treatment to stabilize an individual presenting with an EMC to the ED), May 2022, revealed Physician Assistant-Certified (PA-C) G and DO E were the providers scheduled to examine and treat ED patients on 5/17/22.

14. The medical record did not contain evidence that the scheduled provider presented to the ED to examine patient #2.

15. Review of PA-C G's signed Appointment Profile / Scope of Practice form with an effective date 11/01/20 - 10/31/22 showed the following "Emergency Medicine Privileges include assessment, work-up, and providing initial treatment to patients of all ages who present in the emergency department with any illness, injury, condition, or symptom."

16. Review of ED log revealed on 5/17/22 three other patients presented to the ED for a potential emergency medical condition. DO E and ARNP B presented to the ED to examine those patients.

17. Review of medical record showed that Patient #2 presented to the ED for the second time on 6/1/22 at 8:46 PM with complaint of headache which they described as their normal migraine. Reported the migraine had started the prior evening but became worse that day and medication prescribed for migraine did not help. Rated headache severity a 7-8 on a scale of 10 (10 being the worst pain ever experienced, unspeakable pain). Patient #2 had no nausea or vomiting, was shielding their eyes due to light sensitivity.

On 6/1/22 at 9:00 PM RN D gave Patient #2 intramuscular injection of Toradal 30 milligrams (medication used for pain), Norflex 60 milligrams (medication used to relax muscles), and Zofran 4 milligrams (medication used for nausea).

On 6/1/22 at 9:11 PM RN D noted blood pressure was still high at 160/59. Patient #2's husband said Patient #2 had not taken their evening blood pressure medication.

On 6/1/22 at 9:25 PM Patient #2's headache had improved, rated pain severity a 2-3 on a scale of 1-10. Denied nausea.

On 6/1/22 at 9:27 PM RN D gave Patient #2 and their husband written and verbal discharge instructions. Husband to drive Patient #2 home.

The medical record lacked documentation that a provider on call was consulted for discharge instruction.

18. During an interview on 6/27/22 at 9:30 AM, DO E explained that they generally see each patient in the ED, but they had just seen Patient #2 in the clinic that day for their chronic migraine. DO E did not speak to Patient #2 and acknowledged that they relied on RN D to tell them that Patient #2's neurological exam was normal and Patient #2 was having their normal migraine. DO E felt confident in RN D's assessment and would have come to the ED if DO E had any concerns about Patient #2.

DO E did not feel Patient #2 had an emergency medical condition. Patient #2 had a medical condition that needed attention but it was not an emergency. DO E said Patient #2 had previously seen a neurologist and had some testing done, and they were currently in the middle of changing Patient #2's medications. Patient #2 had no other options than the ED for pain relief after regular clinic hours but there was nothing in the assessment that necessitated Patient #2 needing to be seen right then. If Patient #2's headache had not been controlled by the medications they were given in the ED, RN D would have called DO E and DO E would have come to the ED.

19. Review of 6/1/22 medical record showed that DO E entered late entry on 6/5/22 at 9:45 PM pertaining to 6/1/22 visit indicated a review of Patient #2 symptoms.

20. 19. The medical record did not contain evidence that the nurse consulted with scheduled provider or that the scheduled provider scheduled on 6/1/22 presented to the ED to examine patient #2.

21."Review of the Provider ED Call Schedule"...revealed DO (Doctor of Osteopathic Medicine) E was the provider on call to examine and treat ED patients on 6/1/22.

22. Review of ED log revealed on 6/1/22 one other patient presented to the ED for medical care. DO E presented to the ED to examine that patient.

23. Review of Patient 3's medical record revealed:

24. Review of Medical Record for Patient #3 presented to the ED on 5/31/22 at 9:12 PM with complaint of epigastric pain since 7:00 PM. RN A reported Patient #3 denied any radiation of the pain or diaphoresis (sweating). Patient #3 reported some shortness of breathing but has Chronic Obstructive Lung Disease (COPD) and said it is not any worse than normal. Did have some belching in route to the ED. Vital signs were normal with the exception of an elevated blood pressure of 146/97.

On 5/31/22 RN A gave report to ARNP F who ordered an EKG, chest x-ray and labs in addition to a "GI cocktail" (a mixture of medications used to treat symptoms of indigestion).

On 5/31/22 at 10:00 PM, Patient #3 reported that the "GI cocktail" was helpful and denied pain.

On 5/31/22 at 10:40 PM, RN A documented ARNP F reviewed test results and gave RN A follow up and discharge orders.

On 5/31/22 at 10:50 PM Patient #3 continued to deny pain or shortness of breath. Patient #3 was laughing and joking with staff. RN A gave Patient #3 their discharge instructions and they were discharged with their son at 10:54 PM.

On 6/1/22 at 11:36 AM, ARNP F documented Patient #3 was a patient of ARNP F that had presented to the ED with some epigastric pain that started around 7:00 PM after they had eaten some steak. Patient #3 denied chest pain but had some shortness of breath that was nothing unusual from Patient #3's COPD. Denied other complaints. Patient #3 had had a heart categorization two years ago that showed normal coronary arteries. Review of Systems was negative for fever, chills, palpitations or dizziness. No abdominal pain, vomiting, diarrhea or constipation. Reviewed labs, EKG and chest x-ray, noted medication given had relieved symptoms. Physical exam through video where noted Patient #3 was alert and oriented, no respiratory distress, and referenced nurse's medical screen done upon arrival to ED for further physical findings. Patient #3 was discharged and was to follow up with ARNP F with 48-72 hours.

25. During an interview on 6/23/22 at 12:30 PM, RN A recalled Patient #3 came to the ED by private car with their son complaining of chest pain. It could be cardiac but Patient #3 had also reported they'd been belching. Recalled ARNP F was the provider because RN A remembered ARNP F coming into the ED after Patient #3 to treat a different patient with a fracture. Patient #3 was better after their medication and was discharged home.


26. During an interview on 6/23/22 at 12:00 PM, ARNP F said Patient #3 was their patient and when they heard the complaint they assumed it was not cardiac related but wanted to make sure so ordered the workup to be safe. ARNP F would have been in the ED if testing would have showed anything concerning.

ARNP F explained that if a patient comes in during clinic hours they are two minutes from the CAH. The nurse will see the patient, do the medical screen, then they will call the provider who will decide if they are doing orders immediately, or if they will come to the ED to see the patient and then do orders. ARNP F explained that they instituted tele-health during COVID so they now have that option. ARNP F said they don't use telehealth very often, only with their own patients that they know.

27. The medical record did not contain evidence that the scheduled provider presented to the ED to examine patient #3.

28. "Review of the Provider ED Call Schedule" ... May 2022, revealed ARNP F was the provider on call to examine and treat ED patients on 5/31/22.

29. Review of ARNP F's signed Appointment Profile/ Scope of Practice form with an effective date 04/01/22 -03/31/24 showed the following "Emergency Medicine Privileges include assessment, work-up, and providing initial treatment to patients of all ages who present in the emergency department with any illness, injury, condition, or symptom."

30. Review of ED log for 5/31/22 revealed two other patients came to the ED seeking medical care. ARNP F presented to the ED to examine those patients.

31. During an interview on 6/29/22 at 8:30 AM, the Chief Nursing Officer (CNO) confirmed that the providers decide whether they perform a Tele-health versus or an in-person ER visit. It all depends on the results of the medical screen [nursing assessment] done by the RN. Once the medical screen is completed, the nurse will contact the on-call provider and relay the patient's chief complaint and the nurse's assessment. The provider will give orders at that time, if they decide they want to do a Tele-health visit but the nurse feels they need to come in and see the patient then the nurse will voice that concern to the provider. The CAH administrative staff feel it is appropriate for the provider to make that decision.