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Based on complaint information, policy review, emergency department (ED) central log review, record review, and patient/staff interview, the Critical Access Hospital (CAH) failed to enforce policies to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 for 1 of 1 sampled patient (Patient #1) who presented to the CAH for a blood pressure check.

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements at §489.24. Failure of the CAH to enforce their Emergency Medical Treatment and Labor Act policy limited the CAH's ability to determine if the patient had an emergency medical condition.

Findings include:

The CAH failed to ensure an ED provider conducted an appropriate medical screening examination within the capability of the CAH's ED (Refer to C2406).

Based on complaint information, policy review, emergency department (ED) central log review, record review, and patient/staff interview, the Critical Access Hospital (CAH) failed to ensure a qualified medical person provided a medical screening examination for 1 of 1 sampled patient (Patient #1) who presented to the CAH for a blood pressure check. Failure to provide a medical screening examination limited the CAH's ability to determine if the patient had an emergency medical condition.

Findings include:

Review of complaint information occurred on 10/22/24. The complaint information indicated the patient presented to the hospital in February or March 2023 and was not seen by a medical provider.

Review of the policy "EMTALA Guidelines for Emergency Department Services" occurred on 10/23/24. This policy, revised 09/30/20, stated, "Definitions: . . . Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not. North Dakota has interpreted this statement to mean a MD [medical doctor], DO [doctor of osteopathy], NP [nurse practitioner], or PA [physician assistant]. . . . Policy: . . . All patients presenting to Cavalier County Memorial Hospital's Emergency Department seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. In the absence of an actual request for services, if a 'prudent layperson' observer would believe, based on the individual's appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment. . . . All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capacity of the hospital to reach a diagnosis. . . ."

Review of the 2023-2024 ED central log occurred the afternoon of 10/22/24. The log failed to include an entry for Patient #1 in February-March 2023.

Review of Patient #1's medical record occurred the morning of 10/23/24. The record included the following:
- An ambulance patient care record, dated 03/24/23, stated, ". . . Vitals were taken and the . . . blood pressure remained high during the duration of being in the rig. . . . was continued to be monitored due to blood pressure. . . . refused to be transported by ambulance to the hospital. Due to continued high blood pressure . . . was advised to be seen at the hospital for a follow up. . . . agreed and once he left the rig he drove himself to the hospital for a follow up. . . ."
- A progress note by a nursing staff member (#1), dated 03/31/23 at 21:43, stated, ". . . presents ambulatory stating, 'the ambulance staff said I should come in and get my blood pressure checked because it was really high when they checked it.' . . . house fire . . . was exposed to the smoke. . . . denies shortness of breath and chest pain. . . . was asked to sit for 15 minutes to relax then writer would check it. . . . was in agreement. . . . states he has a 'little headache' and that it's 'probably from the smoke'. . . . denies wanting to be seen in the ED. Blood pressure was 128/98 and pulse was 80. . . . is encouraged to get plenty of fresh air and come back if headache worsens or any other symptoms develop. . . . ." An addendum to the note by an administrative nursing staff member (#2), dated 05/03/23 at 5:16 p.m., stated, ". . . The date of service on the above was 03/24/23. Patient is stating he did not say he refused emergency room. . . ."
- The record failed to include evidence of a medical screening examination by a qualified medical person.

During interview on 10/22/24 at 3:05 p.m., an administrative nursing staff member (#3) stated she has told staff not to do routine blood pressure checks on patients that present for a blood pressure check. If staff does provide just a blood pressure check, they are to chart in [name of electronic record]. If staff had concerns, they would refer the patient to the ED.

During interview on 10/22/24 at 4:12 p.m., Patient #1 stated there was a house fire on 03/24/23. He was seen by ambulance staff on-site and they recommended to have his blood pressure rechecked at the hospital. He said he asked the ambulance staff to call the hospital to let them know he would be coming. He entered the hospital around 8:40 p.m. via the main entrance. An aid called him by name and took him to an observation room by the nurses' station. The nurse checked his blood pressure. The nurse made a comment about his lower number being on the higher side but that it could be because he just came from the incident site and his adrenaline was still high. The nurse told him if he was feeling any problems later to return to the ED. Patient #1 stated he did not remember stating to hospital staff why he presented to the ED as he was recommended to do so by the paramedics at the incident site and they were going to call the hospital. He stated the nurse did not recommend he be seen by a provider.

During interview on 10/23/24 at 8:05 a.m., an administrative ambulance staff member (#4) stated he remembered treatment of Patient #1 in March 2023 after a fire incident. He said ambulance staff did an initial evaluation of Patient #1 in the ambulance, and Patient #1 declined an ambulance transfer to the hospital. He said ambulance staff called the hospital to inform them Patient #1 was on his way to the hospital.

During interview on 10/23/24 at 10:55 a.m., a nursing staff member (#1) stated she recalled the incident with Patient #1 on 03/24/23. She said when Patient #1 came to the hospital he stated his blood pressure was high and was told to get it rechecked. She checked his blood pressure which was a little high. She also checked his oxygen saturation level which was within normal limits. She said she told Patient #1 that if he needed to be seen in the ED for any shortness of breath or anything else that may be related to the fire, the ED was available 24/7. Nursing Staff Member #1 stated she asked Patient #1 multiple times if he wanted to be seen in the ED, but he refused. She stated the ED provider also laid eyes on the patient and offered ED services, but the patient declined.

Upon request on 10/22/24 and 10/23/24, the CAH failed to provide a policy regarding blood pressure checks at the hospital and failed to provide a listing of patients who received blood pressure checks at the hospital.