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Based on review of policy and procedures and staff interviews the Critical Access Hospital (CAH-A) failed to ensure 2 of 20 sampled patients (Patients 6 (Pt. 6) and 15 (Pt. 15)) were provided medical screening exams (MSE) and transfered appropriately following facility policy while in the Emergency Department (ED). Pt. 6 and Pt. 15's electronic medical records (EMR) both failed to have documentation regarding the Nurse Practitioners (NP-A and NP-C) consultation with back up medical provider (MD-D). CAH-A failed to stabilize Pt. 6's emergency medical condition (EMC) prior to discharging Pt. 6 to home with instructions to proceed to CAH-B. CAH-A also failed to provide medical treatment that minimized the risks to the Pt. 15's health prior to transfer in an unstable condition for dangerous abnormal lab results.
These failures to follow the hospital's policy and procedures for transfers has the potential to cause harm or death due to delay in treatment. According to the facility provided information the ED sees an average of 49 patients per month.

Findings include:

See also 2406, 2407 and 2409

A. Review of facility policy "Transfer of Patient to Another Facility", approved 1/2023, revealed the purpose was to ensure adequate care was given to each patient and if unable to continue care, offer specialty care or higher level of care, patient is to be transferred to an appropriate facility. The document identified the following transfer papers would be completed:
- Physician Authorization for transfer acceptance form
- Patient transfer Acceptance or Refusal form
- Physician Certification Medically for transfer form
- Transfer Summary Form

B. Review of facility policy "Transfer and Emergency Examination", approved 1/2023, revealed the following:
"Effecting Transfer. Transfer of an individual in an unstable EMC to another medical facility requires the following:
Medical treatment must be provided to minimize the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child.
Responsibilities:
Physician Assistant or Nurse Practitioner:
When a transfer of an individual with unstable EMC is considered, contact the supervising physician to weigh the medical benefits reasonably expected from the provision of appropriate medical treatment at the receiving facility against the increased risks to the individual (and in the case of labor, to the unborn child) from effecting the transfer. "

C. The hospital failed to follow their policy titled Transfer of Patient to Another Facility (Last Approved 1/2023) by not transferring Pt. 6 to an appropriate facility once it was decided that the NP-A was unable to continue care. Additionally, the facility failed to complete transfer papers including physician authorization for transfer acceptance form, patient transfer acceptance or refusal form, physician certification medically for transfer form and, transfer summary form. NP-A failed to contact the supervising physician (MD-D) for consultation of the EMC prior to discharge.

D. During an interview on 7/12/23 at 11:17AM NP-A confirmed that Pt. 6 was discharged, and transfer paperwork was not completed. NP-A confirmed that Pt. 6 should have been transferred and sent with the appropriate transfer forms.

E. NP-C failed to follow the facility's policy: Transfer and Emergency Examination (Last Approved 1/2023) by not providing medical treatment to minimize the risks to Pt. 15's health prior to transfer to Hospital-C. NP-C also failed to contact supervising physician (MD-D) regarding the transfer of an individual with an unstable EMC.

Based on record reviews, policy reviews and staff interview the facility failed to ensure 2 (Patient 6 and Patient 15) of 20 sampled patients were provided with a complete medical screening examination (MSE) to determine within the hospital's capabilities the presence of an emergency medical condition (EMC). This failure has the potential for all patients presenting to the Emergency Department (ED) to have an untreated MSE which could result in harm or death due to delay in treatment. According to the facility provided information the ED sees an average of 49 patients per month.

Findings include:

A. Review of facility policy "COBRA/EMTALA Requirements", approved 2/2023 revealed, in the event that an EMC is present this hospital will provide such additional medical examination and treatment as may be required to stabilize the medical condition within the capability of the staff and facilitates available at CAH-A. If an individual at the hospital has an EMC which has not been stabilized, the hospital may not transfer the individual unless: After an appropriate medical screening, when a physician is not physically present in the ED at the time an individual is transferred (a qualified medical person: NP or Physician Assistant (PA)) has received orders for and signed the physician certification for transfer, listing risks and benefits upon the certification is based, after consultation with the physician.

B. Review of facility policy "Transfer and Emergency Examination", approved 1/2023 revealed, physician responsibilities include when on call, and not physically present at the hospital, consult by telephone with non-physician personnel receiving individuals seeking examination and treatment.

C. Review of Emergency Room Visit provider note in medical record from CAH-A revealed on 5/18/23 at 5:09PM, Pt. 6 presented to the ED at CAH-A after slipping on wet grass and receiving a laceration to the right lower leg from a screw. At 5:15PM the wound was irrigated by the Registered Nurse (RN). NP-A presented at 5:18PM to examine Pt. 6. Examination of the wound noted a diagonal laceration to right lower leg measuring 9 centimeters (cm) long x 2 cm wide x 1cm deep. NP-A's examination of the wound noted adipose (fat) tissue as well as tendon and bone at the bottom of the wound bed. NP-A determined that the laceration was beyond her ability. The record review fails to find any documentation that NP-A consulted with the back up provider MD-D regarding Pt. 6's EMC of the deep laceration.

D. Review of Emergency Room Visit provider note in medical record from CAH-A revealed, Pt. 15 presented to the ED on 4/7/2023 at 8:10 PM with complaints of weakness and diaphoresis (excessive sweating). Patient has a history of low sodium and wanted a blood pressure check and an intravenous infustion (IV) (administer fluids directly into a vein) fluid infusion. Pt. 15 was provided a MSE including lab work. After lab was drawn the patient requested to use the bathroom. Upon standing up patient collapsed falling to the floor. Patient was alert and tried to sit up, patient then became unresponsive and started to seize (seizure-uncontrolled body movement). This lasted for around 30 seconds. The patient was alert and oriented after seizure and facility staff assisted Pt. 15 back to the cot.

Abnormal lab results reviewed in lab reports in medical record from CAH-A included a hemoglobin of 4.7 grams per deciliter (g/dl) (normal range 13.2-17.1), white blood cells (part of the blood to help fight infection) 19.6 per microliter (µl ) (normal range 3.8-10.9), Sodium (low sodium can cause weakness, confusion, nausea, seizures) 121 milliequivalents per liter (mEq/L)(normal range 136-145), Potassium (a blood chemical that if low can cause fatigue, muscle cramps and abnormal heart rhythm) 2.3millimoles per liter (millimol/L) (normal range 3.5-5.1), Urea Nitrogen (BUN-kidney function) 37milligrams per deciliter (mg/dL) (normal range 7-18). IV Fluid of Normal Saline with 20mEq Potassium to run at 500 milliliters per hour (ml/hr) was initiated. Pt. 15 admitted to falling 3 times during the day at home. Pt. 15 also admitted to having moderate amount of bright red blood in stool for the past week.

Decision to transfer was made by NP-C. Accepting hospital (Hospital -C) was 72.3 miles away. Ground Ambulance ALS (Advance Life Support) transport was contacted around 8:50PM. The accepting physician at the receiving hospital was confirmed at 9:45PM. The ambulance arrived at 10:44PM. Pt. 15 left the CAH-A in the care of the ambulance crew at 11:11PM for the transfer to Hospital-C. 72.3 miles away. Pt. 15 received 1 liter of IV fluids during the ED visit at CAH-A. NP-C marked that the patient was unstable on the Transfer Certification form 4/7/23 at 9:45PM. The medical record review failed to show any documentation that NP-C consulted with back up provider MD-D regarding Pt. 15's EMC and unstable condition for transfer.

E. In an interview with MD-D on 7/11/23 at 1:36PM, MD-D confirmed that NP-A did not contact her regarding Pt. 6 on 5/18/23 when she was NP-A's back up physician. MD-D confirmed that she is willing to come in and help the midlevels (PA or NP) if needed, and she is available by phone.

F. In an interview with MD-D on 7/12/23 at 8:54AM, she stated that if any critical patient comes into the ED she expects a call from NP's. All providers have access to telehealth ED services through contracted company 24 hours a day 7 days a week. She encourages all staff to utilize the service anytime. She stated that to her knowledge she was never called by NP-C regarding Pt. 15.

G. In an interview with NP-A on 7/12/23 at 11:17AM, NP-A stated that the Pt. 6's laceration was located on her right leg with tendon and bone visualized in the wound bed. NP-A stated that the laceration was beyond her ability to suture and close. NP-A confirmed that MD-D was not contacted as the back up physician for consultation for the laceration.

Based on record review, review of receiving facility record, staff interviews and review of policy & procedures the CAH-A failed to ensure that 1 of 20 sampled patients (Pt. 6) presenting to the ED with an EMC received stabilizing care and appropriate transfer to another hospital. The hospital failed to provide Pt. 6 adequate care to treat a deep laceration to the right lower leg requiring sutures prior to discharge. Nurse Practitioner (NP-A) failed to follow the 1/2023 policy titled, Transfer of Patient to Another Facility, when the decision was made that Pt. 6 would need further care and was not transferred to another facility (CAH-B). This failure to stabilize an emergency medical condition or facilitate an appropriate transfer has the potential to cause harm or delay in treatment. According to the facility provided information the ED sees an average of 49 patients per month.

Findings include:

A. Review CAH-A's Emergency Room Visit provider note revealed on 5/18/23 at 5:09 PM Pt. 6 presented to the ED after slipping on wet grass and receiving a laceration to the right lower leg from a screw. At 5:15PM the wound was irrigated by the RN. NP-A presented at 5:18PM to examine Pt. 6. Examination of the wound noted a diagonal laceration to right lower leg measuring 9 cm long x 2 cm wide x 1cm deep. NP-A's examination of the wound noted, adipose tissue as well as tendon and bone at the bottom of the wound bed. NP-A decided that the laceration was beyond her ability. NP-A discussed with Pt. 6's mother where she would like to take the child for further care. Pt. 6's mother works at another CAH (CAH-B) 28.8 miles away and would like to take patient there for further care of laceration. NP-A called CAH-B to talk to on-call ED provider. NP-A visited with Physician Assistant (PA-B) who agrees to see patient upon discharge from CAH-A. Dressing was placed to Pt. 6's laceration and patient was discharged to home with understanding for mother to go straight to CAH-B for laceration repair. Pt. 6 was discharged from CAH-A on 5/18/23 at 5:45PM. Pt. 6's medical record lacked the proper transfer paperwork for a transfer.

B. Review of the medical record from CAH-B revealed Pt. 6 arrived at CAH-B in the ED on 5/18/23 at 6:15PM. PA-B examined the laceration noting that it went through the subcutaneous (deepest layer of skin) and adipose (body fat found under skin) tissue all the way down to the tibia (bone in lower leg). The area was contaminated with grass debris in the wound bed. PA-B irrigated the wound with saline and hibiclens (skin cleanser used to kill germs and bacteria) and debrided quite a bit of grass. The laceration was closed using sterile technique with 6 subcuticular (below the first layer of skin) interrupted sutures of 2-0 Vicryl (an absorbable suture) and 15 simple interrupted sutures of 2-0 prolene. Pressure dressing was applied. Pt. 6 received 1 gram of Ancef intramuscular (antibiotic injected into the muscle) in the ED. A prescription for Bactrim DS (antibiotic tablets) was sent to the pharmacy. Pt. 6 was discharged to home from the ED at CAH-B on 5/18/23 at 7:20PM.

C. During an interview on 7/12/23 at 11:17AM, NP-A stated that the laceration was beyond her ability to close or suture. NP-A confirmed that the back up provider was not called regarding Pt. 6 at any time while Pt. 6 was in the ED. NP-A confirmed that the patient was discharged, and transfer paperwork was not completed. NP-A stated that hindsight is 20/20 and Pt. 6 should have been transferred and sent with the appropriate transfer form.

D. The facility failed to follow their policy titled Transfer of Patient to Another Facility (Last Approved 1/2023) by not transferring Pt. 6 to appropriate facility once NP-A made the decsion that she was unable to continue care. The facility failed to complete transfer paperwork including physician authorization for transfer acceptance form, patient transfer acceptance or refusal form, physician certification medically for transfer form and, transfer summary form.

Based on record review, review of the receiving hospital medical records, staff and provider interviews, and review of facilities policy: Transfer and Emergency Examination (Last Approved 1/2023), the CAH-A failed to ensure that 1 (Pt. 15) of 6 sampled transferred ED patients was provided an emergency transfusion prior to transfer for a critically low hemoglobin of 4.7 g/dl to stabilize the patient prior to transfer to Hospital -C. This failure to provide medical treatment within the hospitals capability to minimize the risks to the individual's health prior to transfer has the potential to cause harm or death to the patient. According to the facility provided information the ED transferred 34 patients from 1/1/23 - 6/30/23.

Findings include:

A. Review of CAH-A's medical record revealed, Pt. 15 presented to the ED on 4/7/2023 at 8:10 PM with complaints of weakness and diaphoresis. Patient has a history of low sodium and wanted a blood pressure check and an IV fluid infusion. Pt. 15 was provided a MSE including lab work. After lab was drawn the patient requested to use the bathroom. Upon standing up patient collapsed falling to the floor. Patient was alert and tried to sit up, patient then became unresponsive and started to seize (seizure-uncontrolled body movement). This lasted for around 30 seconds. Patient alert and oriented after seizaure and was assisted by facility staff back to cot.

Abnormal lab results included a hemoglobin of 4.7 g/dl (normal range 13.2-17.1), white blood cells 19.6 µl (normal range 3.8-10.9), Sodium 121 mEq/L (normal range 136-145), Potassium 2.3 millimol/L (normal range 3.5-5.1), Urea Nitrogen (BUN-kidney function) 37 mg/dL (normal range 7-18). IV Fluid of Normal Saline with 20mEq Potassium to run at 500 ml/hr was initiated. Pt. 15 admitted to falling 3 times during the day at home. Pt. 15 also admitted to having moderate amount of bright red blood in stool for the past week.
Decision to transfer was made by NP-C. The accepting Hospital -C was 72.3 miles away. Ground Ambulance ALS transport was contacted around 8:50PM. The accepting physician at receiving hospital was confirmed at 9:45PM. Ambulance arrived at 10:44PM. Pt. 15 left the CAH-A in the care of the ambulance crew at 11:11PM for the transfer to Hospital-C 72.3 miles away. Patient 15's IVs were saline locked (capped) prior to transport. Patient 15 received 1 liter of IV fluids during the ED visit at CAH-A. NP-C marked that the patient was unstable on the Transfer Certification form 4/7/23 at 9:45PM. The medical record review failed to show any documentation that NP-C consulted with back up provider MD-D regarding Pt. 15's EMC and unstable condition for transfer.

B. Review of medical record from Hospital-C revealed, Pt. 15 arrived to the ED at Hospital-C on 4/8/2023 at 12:25AM. Pt. 15 was evaluated in the ED prior to being admitted to Intensive Care Unit (ICU). While Pt. 15 was an inpatient at Hospital-C, 3 units of packed red blood cells (PRBC) were transfused (receiving donated blood products through an IV to replace blood lost due to surgery, illness, or diseases). Pt. 15 was discharged from Hospital-C on 4/11/23.

C. During an Interview on 7/12/23 at 8:54AM, MD-D stated that NPs are not required to call but, MD-D expects a call if any critical patient comes to the ED. MD-D stated that she would have transfused Pt. 15 with emergency unit of blood.

D. During an interview on 7/12/23 at 9:36AM, the Lab Director confirmed that there was 1 unit of universal blood (type O negative blood compatible with all blood types) for transfusion in house on 4/7/23 when Pt. 15 was in the ED.

E. NP-C failed to follow CAH-A's policy: Transfer and Emergency Examination (Last Approved 1/2023) by not providing medical treatment to minimize the risks to the individual's health prior to transfer to Hospital-C. NP-C also failed to contact supervising physician (MD-D) regarding the transfer of an individual with an unstable EMC.