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Based on interviews, record review, and review of the Critical Access Hospital's (CAH) policy, the facility failed to maintain records related to one of 20 patients (P) (P1) transferred to another hospital.

Findings include:

Interview on 12/01/20 at 9:30 AM, the hospital's Chief Executive Officer (CEO) stated that on 11/11/20 at 11:38 PM, Registered Nurse (RN)1 received a telephone call from the Emergency Medical Services (EMS) who informed RN1 they were transporting P1 to the Emergency Department (ED) due to chest pain and confusion. RN1 placed a telephone call to the EMS and learned that the EMS had already arrived on the hospital grounds and that the EMS had transported P1 in the hospital's ED hallway. After discussion with the hospital's security guard, the CEO stated that the EMS placed P1 back into the ambulance after being informed the hospital ED was on diversion. Before RN2 could reach the ambulance, the ambulance drove away from the hospital. The CEO stated that P1 was taken to another hospital approximately 20 miles away. The CEO stated the hospital had not identified the identity of P1.

Interview on 12/02/20 at 8:00 AM, RN2 who stated that he/she was attending a patient in the ED Trauma Bay when P1 arrived on the ED grounds. RN2 stated the hospital's Security Guard informed him/her that the EMS had arrived and stated the EMS brought P1 into the hospital's ED hallway after being informed the ED was on diversion. RN2 further stated P1 was never seen by the ED'sMedical Doctor (MD) or a nurse because the EMS placed P1 back in the ambulance and left the hospital property. RN2 stated he/she did not initiate any medical record documentation, because the EMS did not provide any information about P1prior to leaving the hospital's ED.

Interview on 12/02/20 at 11:45 AM, the ED Manager stated that the 11/11/20 incident was immediately reported to him/her and the Director of Nursing (DON). The ED Manager further confirmed that the ED's MD was not aware P1 was brought to the hospital's ED hallway. The ED manager confirmed that a medical record was not initiated for P1 regarding the incident on 11/11/20.

On 12/02/20 at 12:30 PM, a telephone interview was conducted with the MD on duty at the time of the incident that occurred on 11/11/20. The MD stated he/she was not aware P1 was brought to the hospital ED on 11/11/20.

On 12/20/20 a review of the emergency room log indicates that the transfer of P1 was not documented.

A review of the CAH's policy titled, "Emergency Policy" dated 11/19/30, indicated," ...Upon notification of an ambulance call and/or after an individual presents to the ER [Emergency Room] ...the provider will document on the ER record the screening exam findings and sign and date the record."

This deficiency was cited based on complaint# MN00067358

Based on interviews, record review and review of Critical Access Hospital (CAH) policy, the facility failed to ensure the Emergency Department's (ED) central log was maintained by logging the arrival of one of 20 patients (P) (P1) to the hospital's ED.

Findings include:

Interview on 12/01/20 at 9:30 AM, the hospital's Chief Executive Officer (CEO) stated that Registered Nurse (RN) 1 was working in the ED on 11/11/20 and received a telephone call from the Emergency Medical Service (EMS) informing the hospital's ED staff of the transport of P1 to the ED for evaluation. The CEO stated the EMS was informed that the hospital's ED was on diversion but had already arrived at the ED and transported P1 into the ED hallway. The CEO stated that the EMS placed P1 back in the ambulance after being informed the hospital's ED was on diversion. The CEO confirmed that the hospital did not know the identity of P1 and that P1 was not logged in the ED's central log.

Interview on 12/02/20 at 9:00 AM, the Quality Manager (QM) stated that he/she had spoken to the Emergency Medical Service (EMS) and the receiving hospital on 12/02/20 and identified P1. The QM stated the facility did not document in the ED's log regarding P1's arrival at the hospital's ED on 11/11/20.

Review of the EMS transport "Patient Care Report" dated 11/11/20, indicated the EMS provide transport of P1 to Cass Lake Indian Services Hospital's ED for evaluation. The report further indicated the EMS personnel were informed this hospital's ED was on diversion and the EMS personnel took P1 to another hospital.

Interview on 12/02/20 at 8:10 AM, RN1 stated P1 was brought to the hospital's ED, but the patient was not logged into the hospital's ED log on 11/11/20.

Interview on 12/02/20 at 8:00 AM, RN2 stated P1 was not logged in the hospital's ED log because the EMS did not provide any identifying information about the patient prior to leaving the hospital's property.

On 12/02/20 at 11:45 AM, the ED Manager confirmed that the hospital's ED central log did not have documentation on 11/11/20 of P1's ED visit.

Review of the CAH's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", dated 08/10/18 indicated, "Under the Emergency Medical Treatment and Labor Act (EMTALA), every Medicare-participating hospital that has an emergency department (ED) ...Maintaining a central log that tracks persons requesting emergency services."

This deficiency was cited based on complaint #MN00067358

Based on interviews, record review and review of the Critical Access Hospital's (CAH) policy, the facility failed to ensure one of 20 patients (P) (P1) was provided an appropriate Medical Screening Exam (MSE) after presenting to the hospital's Emergency Department (ED).

Findings include:

Interview on 12/01/20 at 9:30 AM, the hospital's Chief Executive Officer (CEO) stated that Registered Nurse (RN) 1 received a telephone call from the Emergency Medical Service (EMS) informing the hospital's ED staff of the transport of P1 to the ED for evaluation. The CEO stated the EMS arrived at the hospital's ED and transported P1 into the ED hallway. The CEO stated the EMS placed P1 back in the ambulance after being informed the hospital's ED was on diversion. The CEO confirmed that P1 was not examined by the ED's nurse or Medical Doctor (MD) prior to EMS transporting P1 to another hospital.

Interview on 12/02/20 at 9:00 AM, the Quality Manager (QM) confirmed that P1 did not receive an MSE prior to being transported to another hospital's ED.

Review of P1's ED medical record from the other hospital indicated that on 11/12/20 at 12:07 AM, P1 presented with weakness and a questionable unresponsive episode, complained of chest pain and lump in the breast area. Laboratory and radiological tests were conducted. P1's blood alcohol level indicated the patient's level of ethanol was 269.6. The ED medical record documented the diagnoses of alcoholic intoxication without complication and left-side weakness.

Review of the EMS transport "Patient Care Report" dated 11/11/20, indicated the EMS responded to P1's home and that P1 was having trouble breathing. The report indicated P1 requested the EMS provide transport to the Cass Lake Indian Health Services Hospital's ED. The report indicated the EMS personnel were informed after arrival to the ED, that the hospital was on diversion and the EMS personnel took P1 to the receiving hospital without P1 being seen by Cass Lake Indiana Health Services Hospital's ED nurse or MD.

Interview on 12/02/20 at 8:00 AM, RN2 confirmed that P1 was never seen by the hospital's ED nurse or MD because the EMS placed P1 back in the ambulance after they arrived and left the hospital's property.

Interview on 12/02/20 at 11:45 AM, the ED Manager stated that P1 was not examined by the ED's MD or a nurse prior to the EMS transporting P1 to another hospital's ED.

Review of the CAH's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", dated 08/10/18 indicated, "Under the Emergency Medical Treatment and Labor Act (EMTALA), every Medicare-participating hospital that has an emergency department (ED) must provide an appropriate medical screening exam to every individual who presents to the emergency department, regardless of ...status."

This deficiency was cited based on complaint #MN00067358