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Based on document review, policy review and interview the Critical Access Hospital (CAH) failed to follow policy and ensure an appropriate medical screening exam was performed for Patient 1 to determine if an emergency medical condition (EMC) exists. Failure of the CAH to conduct an appropriate MSE for all patients who come to the Emergency Department (ED) seeking assistance, has the potential to place patients at risk for an unidentified EMC causing delays in necessary stabilizing treatments, that may lead to deterioration of the person's condition, and including death.

Findings Include:

Review of an undated CAH document title, "Medical Staff Bylaws Rules and Regulations" showed, ..."6. All persons presenting to the ER [emergency room] or to the facility seeking care who are not defined as OP [outpatient] (see policies) will have an MSE performed by a physician or mid-level practitioner privileged by Stevens County Hospital. The provider will see the client within 30 minutes of being notified that a client has presented." ..."9. Emergency room patients will be stabilized within the capabilities of the Staff and resources of Stevens County Hospital prior to transfer to another facility."

Review of the CAH policy titled, "Admission of Patients to the Emergency Department" dated 06/2020, showed "Purpose: All patients entering the emergency department will be evaluated by a Registered Nurse (RN) while obtaining appropriate information from the patient. The ER provider will be notified of patients arrival to present to the ER to perform the medical screening exam (MSE). Policy: All persons who are on the premises and request medical attention will be admitted to the ED."

Review of the CAH policy titled, "Assessment of the ED Patient" dated 06/2020, showed, "Procedure: 1. All patients presenting to the Emergency Department (ED) will be assessed by a Registered Nurse. 2. All patients presenting to the ED will be triaged to determine the severity of their condition and categorized as Emergent, Urgent, or Non-urgent. Initially, the chief concern and brief examination of the patient will be performed and documented along with an initial set of vital signs. 3. The Provider responsible needs to be phoned as soon as possible of the patient presenting to the ER and given a brief description of reason patient presented to ER. The Provider will ask any questions he/she wants at this time and give any orders to be initiated at this time. The Provider MUST arrive to the ER department within 30 minutes of the patient's admit time."

During an interview on 07/21/21 at 10:00 AM, Staff F, Advanced Practice Registered Nurse, (APRN) stated that Patient 1's mother called the medical clinic the morning of 07/07/21 and spoke to the receptionist who reported to Staff F that the child had fallen down steps and hit her head the night before, vomited twice last night and twice this morning. Staff F stated that she did not know and had not seen Patient 1 before. She instructed the receptionist to tell the mother to go to the ED.

During an interview on 07/20/21 at 2:00 PM, Staff E, Registered Nurse, stated that Patient 1 arrived at the ED carried by her mother who asked to see Staff F, APRN. Staff E stated that she called Staff F who told her that they weren't supposed to come here because the CT scanner was not working. Staff E stated that she told the mother she need to take Patient 1 to Hospital AA. Staff E stated that Patient 1 was not seen by a physician/provider in the ED.

Review of the hospital ED log showed Patient 1 was not listed on the ED log and there was no ED record to review. Nursing staff told Patient 1's mother to take Patient 1 to an acute care hospital approximately 36 minutes away. (Refer to 2406)

Based on document review, policy review, record review and interview the Critical Access Hospital (CAH) failed to ensure an appropriate medical screen exam was completed for one of 22 patients reviewed (Patient 1). The CAH's failure to ensure an appropriate MSE was completed has the potential for patients to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition, including harm and death.

Findings Include:

During an interview on 07/21/21 at 10:00 AM, Staff F, Advanced Practice Registered Nurse, (APRN) stated that Patient 1's mother called the medical clinic the morning of 07/07/21 and spoke to the receptionist who reported to Staff F that the child had fallen down steps and hit her head the night before, vomited twice last night and twice this morning. Staff F stated that she did not know and had not seen Patient 1 before. She instructed the receptionist to tell the mother to go to the ED. After she told the receptionist to tell the mother to take Patient 1 to the ED, she overheard Staff G, Medical Doctor (MD) telling someone that the CT scanner was broken and didn't know when it would be fixed. She stated that my mind was on the child's safety and she needed a CT scan. Staff F stated that she then instructed the receptionist to call the mother back and tell her take Patient 1 to Hospital AA. Staff F stated that Staff E, ED RN then called stating Patient 1 was in the ED and ask what they needed to do. Staff F stated that she told Staff E that she had instructed the receptionist to call Patient 1's mother and tell her to go to Hospital AA. She stated that was the end of the conversation with Staff E. Staff F stated that this could have all been prevented had she been notified the CT scanner was not working. She stated that she was thinking of the safety of the child and had she known, she could have told the mother to take her immediately to Hospital AA.

During an interview on 07/20/21 at 2:00 PM, Staff E, Registered Nurse, stated that Patient 1 arrived at the ED carried by her mother. She stated that Patient 1's mother asked to see Staff F, APRN. Staff E stated that she called Staff F who told her that they weren't supposed to come here because the CT scanner was not working. Staff E stated that she was standing in the ED hallway with Patient 1 and her mother when she told them they needed to go to Hospital AA. Staff E stated that Patient 1 left the ED without being seen by a physician/provider in the ED.

Review of Patient 1's medical record from Hospital AA dated 07/07/21, showed Patient 1, 2 years old, presented to their ED at 11:58 AM on 7/07/21. The ED triage assessment showed Patient 1's mother reported that the patient fell down steps last night at home, hit her head, vomited two times yesterday (07/06/21) and two times today. The assessment showed the mother denied Patient 1 had treatment prior to arrival.

During an interview on 07/21/21 at 2:26 PM, Staff C, RN, Director of Nursing (DON), stated that she was not aware that Patient 1 presented to the ED and was told to go to Hospital AA until after the fact. She stated that the mother was told to take Patient 1 to the ED by a clinic provider, Staff F, APRN and when she arrived at the ED she was told to go to Hospital AA. Staff C stated that the CT scanner does not work all the times, and they don't always get clear pictures. She stated that radiology staff are to inform her, the providers, clinic, and nearby hospitals when the CT scanner is down. She stated that she notifies the nursing staff, Emergency Medical Service (EMS) and the providers on call.

During an interview on 07/22/21 at 8:47 AM Staff C, RN, DON stated that if a patient comes to the ED, they can't turn them away, the patient has to be seen and assessed. She stated that no formal training has been provided as a result of Patient 1 not being seen in the ED. She stated that she has provided 1:1 training with staff until they have a formal meeting.

During an interview on 07/20/21 at 11:30 PM Staff B, RN, Director of Risk Manager stated that Staff F, APRN works in the clinic, she does not work in the ED. Staff B stated that she was made aware of the incident when Hospital AA, called last week and informed them that they had an "EMTALA violation." Staff B had Staff E, RN fill out an incident report. She stated that her investigation showed, Patient 1's mother called the clinic to be seen, Staff F told the receptionist at the front desk that Patient 1 needed to be seen in the ED. She stated that Staff F didn't know the CT scanner was down. The mother brought Patient 1 to the ED and Staff E, RN called Staff F, and Patient 1's mother was told to take her to Hospital AA for a CT scan.

During an interview on 07/21/21 at 3:57 PM, Staff L, Director of Radiology, stated that the CT scanner has occasional problems. She stated that sometimes there will be streaking on the images. Staff L stated that when the CT scanner is not working, she will call the doctors in the clinic, the doctor on call and lets the DON know and stated that she also lets the surrounding hospitals know so that they are prepared for an influx of patient's needing a CT scans. Before she leaves for the day, she will let the nurses know if it is working. Staff L stated that they are getting a new CT scanner.