HospitalInspections.org

Based on document review, observation, and staff and patient interviews, the Critical Access Hospital (CAH) failed to ensure the Emergency Department (ED) staff followed hospital policy which resulted in 1 of 20 sampled patients (patient #3) not being registered in the ED log or appropriately transferred, 5 of 20 emergency patients reviewed (patients #3, #5, #8, #12, and #14) not receiving an appropriate medical screening exam (MSE) and/or stabilizing treatment after presenting to the ED requesting medical care.

Failure to maintain a complete log may result in the hospital's inability to track the care provided to each individual who comes to the ED and may also create an expectation among hospital staff that some individuals who come to the ED may not need to be provided an appropriate MSE.
Failure to provide an appropriate MSE and/or stabilizing treatment or an appropriate transfer places patients at immediate risk for deterioration of their health and wellbeing as a result of unidentified and/or untreated emergency medical conditions and creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur.

Findings include:

1. Review of the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations revealed in part, Section "4 Medical Records A. Attending Physician Duties. The attending physician (and when applicable, other attending practitioners) shall be held responsible for the preparation of a complete medical record for each patient. This record shall include ... physical examination, practitioner order ..." Section "10. Emergency Care, B. Medical Screenings of Patient Seeking Emergency Care. All patients seeking emergency medical care at a dedicated emergency department will have a medical screening exam by a qualified medical personnel. The list of qualified medical personnel will be maintained by the organization." The Medical Staff Rules and Regulations did not designate staff qualified to perform medical screening examinations on individuals who come to the emergency department (ED) requesting medical care.

2. Review of the policy number 14606336 "Emergency Medical Treatment and Labor Act (EMTALA)," Last Revised 06/2004, revealed in part:
" ...All individuals seeking emergency care from this facility will be screened to determine if they have an emergency medical condition, using any resources routinely available to the ED, including ancillary services ...Individuals with emergency medical conditions must be stabilized ... A central log will be maintained noting each individual who presents him/herself to the ED and the disposition of each case ...Neither the initial medical screening nor any needed stabilizing treatment may be delayed by inquiries about payment, insurance status ...Emergency medical condition in a pregnant woman in labor exists ... A woman experiencing contractions is in true labor unless a physician certifies that after a reasonable time of observation, the woman is in false labor. A registered nurse qualified in obstetrics may score the patient according to procedure ... Neither advanced registered nurse practitioners (ARNPs) nor physician assistants (PAs) can certify false labor ..."

Section "VII. MEDICAL SCREENING EXAMINATION, D. Personnel requirements for medical screening: 1. Registered nurse and/or paramedic in consultation with physician, 2. Physician's Assistant (PA), 3. Nurse Practitioner (ARNP), 4. Physician, 5. Physician, Nurse Practitioner, or Physician's Assistant along with ancillary services. 6. In some cases the registered nurse and/or paramedic, PA, or ARNP may deem it necessary to consult with the on-call physician after assessing the patient to determine if an emergency condition exists. When the physician makes treatment or transfer decisions by telephone, the physician remains liable for such decisions ... H. Documentation on the Emergency Room Record: 1. History, physical exam 2. Assessment of whether the individual had an emergency medical condition. 3. Actions taken to determine condition and interventions provided. 4. Results of any diagnostic testing and narrative describing QMP or physician findings, conclusions and plan of care. 5. Discharge/transfer vitals. 6. Entries should be timed and signed with identified initials or actual signatures indicating level of licensure."

Section "VIII. DEFINITION OF EMERGENCY MEDICAL CONDITION: C. Psychiatric emergency medical conditions exists when an individual presents an immediate threat to him/herself or others, for example, if the individual has attempted suicide or is violent. Other psychiatric disturbances covered under this regulation include ... a dissociative state, and inability to comprehend danger or to care for one's self ...psychiatric patients who have an emergency condition would also have to be stabilized using the appropriate therapeutic measures, i.e., medication, seclusion, or restraint under medical supervision, so that the immediate threat to the individual's health or to the safety of others would be removed, even if the underlying psychiatric problem were not addressed ..." " ...Symptoms of substance abuse - these patients are viewed as medically unstable under the law and have been given some special considerations under the law. Because symptoms of substance abuse can mask other medical conditions, physicians and hospital staff need to provide an intense screening exam and provide documentation in the medical records of the caregiver's thought processes that led them to deem the patient stable/unstable ... If the patient leaves, a Leaving Against Medical Advice (AMA) form should be filled out and signed by the patient, if the staff member documents sufficient observation to support a conclusion that the patient understands the implications of the risks and benefits. If the patient refuses to sign, documentation of the attempt made by hospital personnel to secure such signature should be documented on the form ..."

Section "X. STABILIZATION OF EMERGENCY MEDICAL CONDITIONS A. General Definition - an individual who presents themselves to the Emergency Department is assessed as having an emergency medical condition must be provided with treatment as may be required to stabilize the individual's condition within the staffing capabilities and facilities available at the hospital or, if the medical benefits of transfer outweigh the risks, take actions to assure the appropriateness of the transfer. To stabilize is defined to mean that no material deterioration of the condition is likely within reasonable medical probability to result from or occur during a transfer."

Section "XI. APPROPRIATE TRANSFER OF AN INDIVIDUAL TO ANOTHER MEDICAL FACILITY C. Conditions to be Met Prior to Transfer 1. This facility must provide the medical treatment within its capacity which minimizes the risks to the individual's health and, or a woman in labor, to the unborn child. 2. The receiving facility has available space and qualified personnel for the treatment of the individual. 3. The receiving facility has agreed to accept the transfer and to provide appropriate medical treatment. Documentation of the receiving physician should also be made."

3. Review of the policy number 14728070 "Mental Health Evaluation in Emergency Department," Last Reviewed 12/1/22, revealed in part:
Section "V. Guidelines, A. Triage and Medical Screening Exam, 4. The physician will perform and document ongoing assessments of the patient regarding interventions and orders with any change in patient status. 5. Nursing will reassess the patient every 15-30 minutes based on the patient's condition. Frequency of checks will occur consistent with the level of risk. ...
C. Implementing Behavioral Management Precautions-If patient displays any high-risk behaviors, then: If the patient's behavior warrants it, the patient may be placed on behavioral management precautions (encompassing suicide precautions), which may necessitate restraints (chemical or physical), a sitter, and/or seclusion ... Chemical restraints that may be used, but not limited to are: Haldol, Zyprexa, Valium and Ativan [brand names of common psychiatric medications]. ...
E. Determining the Plan of Care in the Emergency Department, 3. If no outside placement is immediately available for the patient, the patient will be admitted to the Med/Surg unit with all necessary behavior management precautions that were implemented in ED.
F. Care of Pediatric Patients with High-Risk Behavior ... 4. Risk Assessments will be performed hourly using age-appropriate language during questioning of the pediatric patient."

4. Review of the policy number 14720649 "Obstetrical Triage and Assessment," Last Revised 1/22, revealed in part:
Section "V. Procedure, 2.a. If an individual is prior to 20 weeks pregnant, they will be evaluated by the provider, with consultation of appropriate local PCP and/or OB/GYN if necessary."
The policy continued at 2.b. "If an individual is greater than 20 weeks pregnant and complains of obstetrical complaints or has an obstetrical emergency, evaluation will be done by the ED provider along with a consult with an OB/GYN specialist for a determination regarding the treatment plan and/or transfer" ... At B. 2. The policy revealed in part, "The assessment according to the patient's gestational age and chief complaint documented in the medical record may include, but not limited to the following: Evaluation of fetal heart tones by Doppler equipment. Regularity and duration of uterine contractions. Fetal position and station. Cervical dilation. Status of the membranes. Vital signs (VS) of the pregnant individual. Consultation with an OB/GYN ..."

5. Review of patient #3's medical record revealed:

a. On 2/9/24 at 3:45 AM, patient #3, a 28-week pregnant patient, presented to the ED for symptoms consistent with contractions and preterm labor. The medical record face sheet (includes patient demographic information) identified Physician F as the Attending Physician. Staff B, registered nurse (RN) documented in the medical record "Upon arrival, patient is leaning over, moaning, taking deep breaths and holding her back." ..." RN asks patient how many minutes pass in between each episode of pain. She states she is unsure, but she thinks around 4-5 minutes. She says this is her first pregnancy ... She states her OB doctor is in Sioux City, RN informs patients that we do not have OB or external fetal monitoring. RN speaks to ED provider, Dr. [physician F] about patient's situation. Dr. [physician F] states, if patient is comfortable with it, she feels it is in the patient's and baby's best interest for the patient to call her OB and drive to Sioux City as her symptoms are consistent with contractions." The CAH failed to complete any assessment, obtain vital signs, complete an appropriate MSE, provide patient #3 with stabilizing treatment or arrange an appropriate transfer after presenting with symptoms of preterm labor (labor that occurred after 20 weeks of gestation and prior to 37 weeks). ED staff failed to have patient #3 evaluated by a physician or QMP, consult with an OB/GYN, or follow hospital policy number 14720649 "Obstetrical Triage and Assessment" for an evaluation which may include, but not limited to "evaluation of fetal heart tones by Doppler equipment, regularity and duration of uterine contractions, fetal position and station, cervical dilation, status of the membranes, vital signs of the pregnant individual, and consultation with an OB/GYN" to confirm whether patient # 3 was in labor and treatment or transfer plans. (Cross refer C2406, C2407 and C2409.)

b. During an interview on 3/4/24 at 1:00 PM, Physician F recalled patient #3 came into the ED, and Staff B, ED RN, reported a 28-week pregnant patient presented with episodes of back pain. Physician F recalled asking Staff B if patient #3 contacted their OB provider. Physician F recalled coming out of the call room, and Staff B reported they told patient #3 to contact their OB provider to see what they recommended. Physician F denied ever talking to patient #3 while they were at the ED. Physician F said they felt patient #3 was "non-emergent." Physician F said they felt the most expedient thing for patient #3 would be for them to consult their OB provider, because the CAH didn't have the ability to monitor for contractions. Physician F acknowledged patient #3 didn't receive an appropriate MSE after presenting to the ED and requesting medical care. Physician F's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

c. During an interview on 2/21/24 at 1:00 PM, Physician E reported anytime a woman comes to the ED with abdominal pain, and is known to be pregnant, it warrants medical attention and "should be seen by a provider, and not a RN or paramedic." When asked about the assessment to determine a patient is in labor, Physician E said she would "check maternal vital signs, check fetal heart tones, assess the cervix, check for ruptured membranes, check the abdomen for contractions, I can palpate the contractions, and figure out how far along the patient is by measuring from the pubic bone to the top of the uterine fundus. 20 weeks would be 20 cm, 30 weeks would be 30 cm if you have an average size kid." Physician E said "we don't have continuous electronic fetal heart monitoring here. We do have a doppler, but we cannot do continuous fetal heart monitoring in the ED, or tocometry" (a pressure-sensitive contraction transducer used to record the frequency and duration of uterine contractions).

d. During an interview on 3/6/24 at 3:48 PM, patient #3 recalled going to the ED on 2/9/24 for medical care. Patient #3 reported having extreme pain in the upper back and upper right abdominal area, and crying in pain. Patient #3 reported ED staff told them it sounded like "back labor, and recommended patient #3 go to their OB". Patient #3 recalled being told the CAH "didn't have the ability for ultrasound, and they didn't want patient #3 to pay for an ED visit at the CAH." Patient #3 reported they left the ED and drove 45 minutes (40 miles) to another town. Patient #3 denied being offered an MSE or treatment. Patient #3 reported they felt like "once ED staff heard they were pregnant, they said they could not help" patient #3.

e. Review of a second medical record revealed patient # 3 presented to Hospital B on 2/9/24 at 4:41 AM complaining of sharp, stabbing pain to the middle of the back that began the night before. Patient # 3 was examined by obstetrical physician T who determined the patient was not in labor.

f. During an interview on 3/7/24 at 3:00 PM Hospital B's advanced registered nurse practitioner (ARNP) U recalled Patient #3 came to Hospital B with complaints of right upper abdominal pain, was cleared by obstetrics first and then came to the ED where the patient was further examined, and an ultrasound confirmed she had gallstones.

g. The ED central log, dated 2/9/24, lacked documentation of patient #3's name and reason for coming to the ED. (Cross refer C2405.)

6. Review of patient #14's medical record revealed:

a. Patient # 14 presented to the ED on Saturday 8/26/23 at 11:12 PM. The medical record face sheet identified Physician D as the Attending Physician. Staff J, critical care paramedic (CCP) documented in a late entry note (8/27/23 at 3:55 AM) that the patient stated "she is concerned she is having a miscarriage", that she was told yesterday by a physician in [name of town] that she was 4-6 weeks pregnant, that she has had "cramping for the last two days as well as nausea" and that she believed she was having a miscarriage "as she has had 3 in the past." Staff J, CCP documented that patient # 14 was discharged on 8/26/23 at 11:12 PM and in a "Miscellaneous Nursing Note" documented the patient and mother of boyfriend are not content after Dr. [physician D] "informs then that we do not have ultrasound this evening. They ask to leave so they are allowed to leave non-emergent and state they will be going to Sioux City." (Cross refer C206 and C2407).

b. Patient # 14's medical record lacked of evidence of an appropriate medical screening examination, or any type of diagnostic testing or evaluation within the CAH's capability, such as consideration by a physician or QMP of the possibility of ectopic pregnancy (a fetus implanted and growing outside the uterus) and history, examination, monitoring, and available laboratory test to evaluate other potential emergency medical conditions, such as, but not limited to, miscarriage with severe hemorrhage, infection, hemodynamic compromise (such as low blood pressure due to bleeding), hemorrhagic shock, coagulopathy, and trauma, which could have resulted in placing the health of patient # 14 in serious jeopardy, serious impairment to bodily functions, and/or serious dysfunction of any bodily organ or part. ED staff failed to conduct the evaluation required by hospital policy, including consultation with an OB/GYN on patient # 14's condition as specified by hospital policy number 14720649 "Obstetrical Triage and Assessment."

c. During an interview on 3/12/24 at 9:33 AM, patient #14 reported being pregnant, and going to the ED for concerns of a miscarriage, because of bleeding. Patient #14 asked for an ultrasound, but Physician D said they didn't have ultrasound available at that time and could not do it. Patient #14 reported they left the ED, and drove 45 minutes to another hospital, and recalled being given Morphine (pain medication) for their cramps. Patient # 14 reported she could not remember the name of the hospital and confirmed that she miscarried the pregnancy.

d. During an interview on 3/4/24 at 3:15 PM, Physician D indicated their policy for a patient presenting to the ED for a possible miscarriage would be to "examine the patient and do a pregnancy test to check for pregnancy, we would do labs on the patient, we would check her pregnancy levels." Physician D indicated they would typically obtain an ultrasound and if an ultrasound was not available, they would contact the patient's OB provider, or transfer the patient to another facility if needed." "If they are 'stable', we can discharge them and scheduled them to come back in the morning for the ultrasound. Sometimes we have kept them in the ED and watched them until morning when we can get an ultrasound." Physician D added "We may give them fluids if needed. It depends on how 'stable' the patient is. We would check their blood pressure to see what that is doing. Most of the time the patient is 'stable' and we can go from there." When asked why patient # 14 was not seen by a provider, Physician D said "I did see this patient for like 30 minutes. I examined her and when they found out we did not have ultrasound available at that time the mother-in-law got upset and they wanted to leave." Physician D said, "we were told when we started the 'non-emergent process' we still had to go in and see the patient but with 'non-emergent patients' we will let the nurse know the patient is 'non-emergent' and the nurse documents the patient was seen by the provider and they were stable. We do not do a full ED provider note on the patient." Physician D's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

e. On 5/8/24 PM during a follow up interview Physician D clarified he examined patient # 14's abdomen, lungs, heart and oral cavity but did not document his examination.

7. Review of patient #8's medical record revealed:

a. On 8/23/23 at 10:39 AM, patient #8, who had a history of opioid use disorder (OUD), presented to the ED for a complaint of opioid withdrawal. Documentation in the medical record showed patient #8 reported stomach cramps, nausea, vomiting, diarrhea, general aches, and back pain of 8 out of 10 (0 being no pain, and 10 being the worst possible pain), and chills. CCP C documented "Patient and family with him are looking for resources and are happy to take him somewhere else for treatment today. They noted they didn't know where to start." CCP C documented contact with a recovery center and noted "they do have a walk in assessment clinic but they cannot do inpatient 'detox.'" "[Advanced Registered Nurse Practitioner (ARNP) P] and I discuss this with the patient and the patient gets up and notes that he would like to go to Sioux City instead." ARNP P documented "Patient was brought back from Des Moines reports withdrawing from heroin and fentanyl. Patient has started withdrawal symptoms of fatigue and jitteriness. Family reports they know he does not need to be here they just not sure where to go. Educated family that we do not have specialized care for that 'detox' here [name of hospital] in Sioux City would have those facilities. [Name of facility] in Sioux City will work with him after 'detox' has been done. At this time patient got up and left prior to filling out discharge paperwork to get specialist care." ED staff documented patient #8 got up and left the ED on 8/23/23 at 11:23 AM with a disposition of "AMA (against medical advice)." (Cross refer C2406 and C2407.)

b. The medical record lacked evidence the CAH provided patient #8, within its capabilities, an appropriate MSE for his presenting signs and symptoms and stabilizing treatment for acute opioid withdrawal, of which it documented actual knowledge. ED staff did not provide or offer within its capabilities, lab testing (by way of example, creatine kinase (CK) for rhabdomyolysis, a serious medical condition that can be fatal or result in permanent disability, when damaged muscle tissue releases its proteins and electrolytes into the blood, or for electrolyte disturbances or dehydration to determine the need for IV fluids), or to assess for any psychiatric disturbances associated with drug withdrawal such as suicidal or homicidal thoughts, or determine if the patient was withdrawing from alcohol or other drugs (such as benzodiazepines) which can be life-threatening, or determine if the patient required medication to control the patient's pain and vomiting. ED staff failed to explain the medical risks of leaving and failed to try and get the patient to stay for further examination and treatment. ED staff failed to follow hospital policy number 14606336 "Emergency Medical Treatment and Labor Act (EMTALA)" and to explain the medical risks of leaving prior to receiving an MSE and failed to document the discussion in patient #8's medical record prior to his AMA departure.

c. During an interview on 3/5/24 at 9:00 AM, ARNP P reported if a patient with active withdrawal symptoms presented to the ED, and verbalized they "wanted to detox," she would make sure the patient was "stable" first. ARNP P reported she would "obtain labs and contact the on-call provider to see if the patient could be admitted to inpatient." ARNP P reported the CAH didn't have specialized treatment for things such as fentanyl withdrawal. ARNP P reported they would "assist with finding placement at an inpatient or outpatient setting, but patient #8 got up while she was talking to them and left". ARNP P reported she didn't have an opportunity to offer other services to patient #8.

d. During an interview on 2/22/24 at 10:00 AM, Staff C, Critical Care Paramedic (CCP) reported "if a patient wanted to leave AMA, they would find out why the patient wanted to leave and explain why they should stay." "They would inform the ED provider the patient wanted to leave, and the ED provider would talk with the patient." Staff C reported if the patient refused to sign the AMA form, they would "document what happened, and that the patient refused to sign the AMA form."

8. Review of patient #12's medical record revealed:

a. On 8/31/23 at 3:47 PM, patient #12 presented to the ED for a complaint of "known kidney stones since December of 2022." The medical record face sheet identified Physician Assistant, Certified (PA-C) V as the "Attending Physician." Patient #12 reported they previously had a nephrostomy tube (to allow urine to drain from the kidney through an opening in the skin on the back), which was removed on 8/7/23. Notes referred to patient #12 having recently had a baby 8/25/23 in another state and had a ureteral stent (small tube placed inside the ureter to help urine pass from a kidney into the bladder) placed on 8/25/23 as well as bleeding when she wiped ... "unsure if it is from her urine or from her period." ED staff CCP C documented that patient #12 had an elevated heart rate (tachycardia) and reviewed the patient's "vital signs and the signs and symptoms associated with [patient #12's] chief complaint" with an unnamed ED "provider" and that the "ER Provider has deemed that this patient is 'non-emergent' according to the medical screening exam." (Cross refer C2406 and C2407.)

b. The medical record did not contain evidence of medical decision making by the Attending Physician or that patient #12 received an appropriate MSE or stabilizing treatment for an emergency medical condition (bleeding of unknown origin and an elevated heart rate) known to the CAH. The CAH provided disparate cae and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and its Amended February 9, 2022 Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

c. During an interview on 2/22/24 at 11:45 AM, ARNP G did not recall Patient #12, but reported that a patient with similar symptoms and medical history would be a patient they would work-up in the ED to rule out an emergency medical condition (EMC). ARNP G's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

d. Review of the August 2023 ED on-call schedule revealed the on-call provider included PA-C V and Physician W were available to the ED to provide a medical screening examination and necessary stabilizing treatment at the time patient #12 came to the ED.

9. Review of patient #5's medical record revealed:

a. On 1/3/24 at 2:05 PM, patient #5, a teenager, presented to the ED for a behavioral health (BH) court committal with a judicially-identified risk to themselves or others and documentation on court paperwork available to the hospital and provided as part of the medical record that he "wants to put a bullet in his head." At 2:25 PM, Staff A, CCP documented the guardian "believes that he is a flight risk. I notified that if he does run, we will call law enforcement as he is a danger to himself and others and is on court hold." Documentation showed laboratory testing completed on patient #5 at 4:01 PM showed an elevated white blood cell count of 18.4 (hospital reference range 4.8 to 10.8) and a positive drug screen for benzodiazepines and cannabinoids (marijuana). The medical record did not include evidence that staff obtained the patient's vital signs including respiratory rate, heart rate, blood pressure or temperature. At 7:38 PM (5 1/2 hours after arriving at the ED), Staff A documented patient #5 "pushed his Grandmother [sic] to the side and ran out the back door" prior to being provided an appropriate medical screening examination and stabilizing treatment. The disposition was listed as "AMA." (Cross refer C2406 and C2407.)

b. The medical record lacked evidence that ED staff provided the patient with an appropriate medical screening examination including ongoing assessments of the patient regarding interventions and orders with any change in patient status. The patient did not receive stabilizing treatment for his known mental health emergency including hourly risk assessments for a patient demonstrating high-risk behaviors as required by hospital policy number 14728070 "Mental Health Evaluation in the ED." ED staff also failed to monitor patient #5 or have them evaluated by a physician for appropriate use of physical or chemical restraints to decrease their risk of elopement.

c. During an interview on 3/4/24 at 3:15 PM, Physician D recalled patient #5 eloped from the ED shortly after their shift started. Physician D reported hospital staff contacted law enforcement. Physician D reported they didn't see patient #5 and couldn't speak to whether they attempted medication with patient #5 prior to their elopement. Physician D's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

Based on document review and staff interviews, the Critical Access Hospital (CAH) failed to maintain a complete ED log for at least one individual who came to the ED (patient #3) seeking medical care. Failure to maintain a complete log may result in the hospital's inability to track the care provided to each individual who comes to the ED seeking care for a potential emergency medical condition (EMC).

Findings include:
1. Review of patient #3's medical record revealed:
a. On 2/9/24 at 3:45 AM, patient #3, a 28-week pregnant patient, presented to the ED for symptoms consistent with contractions and preterm labor. The medical record face sheet (includes patient demographic information) identified Physician F as the Attending Physician. Staff B, registered nurse (RN) documented in the medical record "Upon arrival, patient is leaning over, moaning, taking deep breaths and holding her back." ..." RN asks patient how many minutes pass in between each episode of pain. She states she is unsure, but she thinks around 4-5 minutes. She says this is her first pregnancy ... She states her OB doctor is in Sioux City, RN informs patients that we do not have OB or external fetal monitoring. RN speaks to ED provider, Dr. [physician F] about patient's situation. Dr. [physician F] states, if patient is comfortable with it, she feels it is in the patient's and baby's best interest for the patient to call her OB and drive to Sioux City as her symptoms are consistent with contractions." The CAH failed to complete any assessment, obtain vital signs, complete an appropriate MSE, provide patient #3 with stabilizing treatment or arrange an appropriate transfer after presenting with symptoms of preterm labor (labor that occurred after 20 weeks of gestation and prior to 37 weeks). ED staff failed to have patient #3 evaluated by a physician or QMP, consult with an OB/GYN, or follow hospital policy number 14720649 "Obstetrical Triage and Assessment" for an evaluation which may include, but not limited to "evaluation of fetal heart tones by Doppler equipment, regularity and duration of uterine contractions, fetal position and station, cervical dilation, status of the membranes, vital signs of the pregnant individual, and consultation with an OB/GYN" to confirm whether patient # 3 was in labor and treatment or transfer plans. (Cross refer C2406, C2407 and C2409.)

2. Review of the 2/9/24 ED log between 12:00 AM to 6:30 AM revealed staff did not enter patient # 3 in the ED log.

3. During an interview on 2/21/24 at 4:00 PM Staff B ED registered nurse (RN) confirmed patient # 3 presented to the ED on 2/9/24. "I was working that night. She came in through the front doors of the ER. She was holding her back and said this was her first pregnancy. I asked how far along she was, and she said she was 28 weeks pregnant." "I went back into the ED, talked with the provider, and decided that it was possible back contractions. She was never brought back into the ED. The provider recommended that she call her OB and go to Sioux City." Staff B confirmed ED physician F was in the ED but did not see or speak to patient # 3 when she presented seeking medical care. Staff B said that patient # 3 "never got checked into the ED."

4. During an interview on 3/5/24 at 10:30 AM, the Director of Emergency and Inpatient Services confirmed Patient #3 presented to the ED on 2/9/24, and didn't get admitted to the ED or recorded on the ED log,

Based on document review, and staff and patient interviews, the Critical Access Hospital (CAH) failed to provide 5 of 20 emergency patients reviewed (patients #3, #5, #8, #12, and #14) with an appropriate medical screening examination (MSE) when they presented to the hospital's dedicated ED requesting examination or treatment for a medical condition. Failure to provide an appropriate MSE places current and future patients at immediate risk for deterioration of their health and wellbeing as a result of unidentified and/or untreated emergency medical conditions and creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur. The cumulative effect of these deficient practices resulted in the hospital's inability to ensure the safe and effective delivery of care to all patients and places current and future patients at immediate risk for deterioration of their health and wellbeing as a result of unidentified and/or untreated emergency medical conditions and creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur.

Findings include:
1. Review of patient #3's medical record revealed:

a. On 2/9/24 at 3:45 AM, patient #3, a 28-week pregnant patient, presented to the ED for symptoms consistent with contractions and preterm labor. The medical record face sheet (includes patient demographic information) identified Physician F as the Attending Physician. Staff B, registered nurse (RN) documented in the medical record "Upon arrival, patient is leaning over, moaning, taking deep breaths and holding her back." ..." RN asks patient how many minutes pass in between each episode of pain. She states she is unsure, but she thinks around 4-5 minutes. She says this is her first pregnancy ... She states her OB doctor is in Sioux City, RN informs patients that we do not have OB or external fetal monitoring. RN speaks to ED provider, Dr. [physician F] about patient's situation. Dr. [physician F] states, if patient is comfortable with it, she feels it is in the patient's and baby's best interest for the patient to call her OB and drive to Sioux City as her symptoms are consistent with contractions." The CAH failed to complete any assessment, obtain vital signs, complete an appropriate MSE, provide patient #3 with stabilizing treatment or arrange an appropriate transfer after presenting with symptoms of preterm labor (labor that occurred after 20 weeks of gestation and prior to 37 weeks). ED staff failed to have patient #3 evaluated by a physician or QMP, consult with an OB/GYN, or follow hospital policy number 14720649 "Obstetrical Triage and Assessment" for an evaluation which may include, but not limited to "evaluation of fetal heart tones by Doppler equipment, regularity and duration of uterine contractions, fetal position and station, cervical dilation, status of the membranes, vital signs of the pregnant individual, and consultation with an OB/GYN" to confirm whether patient # 3 was in labor and treatment or transfer plans. (Cross refer C2407 and C2409.)

b. During an interview on 3/4/24 at 1:00 PM, Physician F recalled patient #3 came into the ED, and Staff B, ED RN, reported a 28-week pregnant patient presented with episodes of back pain. Physician F recalled asking Staff B if patient #3 contacted their OB provider. Physician F recalled coming out of the call room, and Staff B reported they told patient #3 to contact their OB provider to see what they recommended. Physician F denied ever talking to patient #3 while they were at the ED. Physician F said they felt patient #3 was "non-emergent." Physician F said they felt the most expedient thing for patient #3 would be for them to consult their OB provider, because the CAH didn't have the ability to monitor for contractions. Physician F acknowledged patient #3 didn't receive an appropriate MSE after presenting to the ED and requesting medical care. Physician F's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

c. During an interview on 2/21/24 at 1:00 PM, Physician E reported anytime a woman comes to the ED with abdominal pain, and is known to be pregnant, it warrants medical attention and "should be seen by a provider, and not a RN or paramedic." When asked about the assessment to determine a patient is in labor, Physician E said she would "check maternal vital signs, check fetal heart tones, assess the cervix, check for ruptured membranes, check the abdomen for contractions, I can palpate the contractions, and figure out how far along the patient is by measuring from the pubic bone to the top of the uterine fundus. 20 weeks would be 20 cm, 30 weeks would be 30 cm if you have an average size kid." Physician E said "we don't have continuous electronic fetal heart monitoring here. We do have a doppler, but we cannot do continuous fetal heart monitoring in the ED, or tocometry" (a pressure-sensitive contraction transducer used to record the frequency and duration of uterine contractions).

d. During an interview on 3/6/24 at 3:48 PM, patient #3 recalled going to the ED on 2/9/24 for medical care. Patient #3 reported having extreme pain in the upper back and upper right abdominal area, and crying in pain. Patient #3 reported ED staff told them it sounded like "back labor, and recommended patient #3 go to their OB". Patient #3 recalled being told the CAH "didn't have the ability for ultrasound, and they didn't want patient #3 to pay for an ED visit at the CAH." Patient #3 reported they left the ED and drove 45 minutes (40 miles) to another town. Patient #3 denied being offered an MSE or treatment. Patient #3 reported they felt like "once ED staff heard they were pregnant, they said they could not help" patient #3.

e. Review of a second medical record revealed patient # 3 presented to Hospital B on 2/9/24 at 4:41 AM complaining of sharp, stabbing pain to the middle of the back that began the night before. Patient # 3 was examined by obstetrical physician T who determined the patient was not in labor.

f. During an interview on 3/7/24 at 3:00 PM Hospital B's advanced registered nurse practitioner (ARNP) U recalled Patient #3 came to Hospital B with complaints of right upper abdominal pain, was cleared by obstetrics first and then came to the ED where the patient was further examined, and an ultrasound confirmed she had gallstones.

g. The ED central log, dated 2/9/24, lacked documentation of patient #3's name and reason for coming to the ED. (Cross refer C2405.)

2. Review of patient #14's medical record revealed:

a. Patient # 14 presented to the ED on Saturday 8/26/23 at 11:12 PM. The medical record face sheet identified Physician D as the Attending Physician. Staff J, critical care paramedic (CCP) documented in a late entry note (8/27/23 at 3:55 AM) that the patient stated "she is concerned she is having a miscarriage", that she was told yesterday by a physician in [name of town] that she was 4-6 weeks pregnant, that she has had "cramping for the last two days as well as nausea" and that she believed she was having a miscarriage "as she has had 3 in the past." Staff J, CCP documented that patient # 14 was discharged on 8/26/23 at 11:12 PM and in a "Miscellaneous Nursing Note" documented the patient and mother of boyfriend are not content after Dr. [physician D] "informs then that we do not have ultrasound this evening. They ask to leave so they are allowed to leave non-emergent and state they will be going to Sioux City." (Cross refer C2407).

b. Patient # 14's medical record lacked of evidence of an appropriate medical screening examination, or any type of diagnostic testing or evaluation within the CAH's capability, such as consideration by a physician or QMP of the possibility of ectopic pregnancy (a fetus implanted and growing outside the uterus) and history, examination, monitoring, and available laboratory test to evaluate other potential emergency medical conditions, such as, but not limited to, miscarriage with severe hemorrhage, infection, hemodynamic compromise (such as low blood pressure due to bleeding), hemorrhagic shock, coagulopathy, and trauma, which could have resulted in placing the health of patient # 14 in serious jeopardy, serious impairment to bodily functions, and/or serious dysfunction of any bodily organ or part. ED staff failed to conduct the evaluation required by hospital policy, including consultation with an OB/GYN on patient # 14's condition as specified by hospital policy number 14720649 "Obstetrical Triage and Assessment."

c. During an interview on 3/12/24 at 9:33 AM, patient #14 reported being pregnant, and going to the ED for concerns of a miscarriage, because of bleeding. Patient #14 asked for an ultrasound, but Physician D said they didn't have ultrasound available at that time and could not do it. Patient #14 reported they left the ED, and drove 45 minutes to another hospital, and recalled being given Morphine (pain medication) for their cramps. Patient # 14 reported she could not remember the name of the hospital and confirmed that she miscarried the pregnancy.

d. During an interview on 3/4/24 at 3:15 PM, Physician D indicated their policy for a patient presenting to the ED for a possible miscarriage would be to "examine the patient and do a pregnancy test to check for pregnancy, we would do labs on the patient, we would check her pregnancy levels." Physician D indicated they would typically obtain an ultrasound and if an ultrasound was not available, they would contact the patient's OB provider, or transfer the patient to another facility if needed." "If they are 'stable', we can discharge them and scheduled them to come back in the morning for the ultrasound. Sometimes we have kept them in the ED and watched them until morning when we can get an ultrasound." Physician D added "We may give them fluids if needed. It depends on how 'stable' the patient is. We would check their blood pressure to see what that is doing. Most of the time the patient is 'stable' and we can go from there." When asked why patient # 14 was not seen by a provider, Physician D said "I did see this patient for like 30 minutes. I examined her and when they found out we did not have ultrasound available at that time the mother-in-law got upset and they wanted to leave." Physician D said, "we were told when we started the 'non-emergent process' we still had to go in and see the patient but with 'non-emergent patients' we will let the nurse know the patient is 'non-emergent' and the nurse documents the patient was seen by the provider and they were stable. We do not do a full ED provider note on the patient." Physician D's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

e. On 5/8/24 PM during a follow up interview Physician D clarified he examined patient # 14's abdomen, lungs, heart and oral cavity but did not document his examination.

3. Review of patient #8's medical record revealed:

a. On 8/23/23 at 10:39 AM, patient #8, who had a history of opioid use disorder (OUD), presented to the ED for a complaint of opioid withdrawal. Documentation in the medical record showed patient #8 reported stomach cramps, nausea, vomiting, diarrhea, general aches, and back pain of 8 out of 10 (0 being no pain, and 10 being the worst possible pain), and chills. CCP C documented "Patient and family with him are looking for resources and are happy to take him somewhere else for treatment today. They noted they didn't know where to start." CCP C documented contact with a recovery center and noted "they do have a walk in assessment clinic but they cannot do inpatient 'detox.'" "[Advanced Registered Nurse Practitioner (ARNP) P] and I discuss this with the patient and the patient gets up and notes that he would like to go to Sioux City instead." ARNP P documented "Patient was brought back from Des Moines reports withdrawing from heroin and fentanyl. Patient has started withdrawal symptoms of fatigue and jitteriness. Family reports they know he does not need to be here they just not sure where to go. Educated family that we do not have specialized care for that 'detox' here [name of hospital] in Sioux City would have those facilities. [Name of facility] in Sioux City will work with him after 'detox' has been done. At this time patient got up and left prior to filling out discharge paperwork to get specialist care." ED staff documented patient #8 got up and left the ED on 8/23/23 at 11:23 AM with a disposition of "AMA (against medical advice)." (Cross refer C2407.)

b. The medical record lacked evidence the CAH provided patient #8, within its capabilities, an appropriate MSE for his presenting signs and symptoms and stabilizing treatment for acute opioid withdrawal, of which it documented actual knowledge. ED staff did not provide or offer within its capabilities, lab testing (by way of example, creatine kinase (CK) for rhabdomyolysis, a serious medical condition that can be fatal or result in permanent disability, when damaged muscle tissue releases its proteins and electrolytes into the blood, or for electrolyte disturbances or dehydration to determine the need for IV fluids), or to assess for any psychiatric disturbances associated with drug withdrawal such as suicidal or homicidal thoughts, or determine if the patient was withdrawing from alcohol or other drugs (such as benzodiazepines) which can be life-threatening, or determine if the patient required medication to control the patient's pain and vomiting. ED staff failed to explain the medical risks of leaving and failed to try and get the patient to stay for further examination and treatment. ED staff failed to follow hospital policy number 14606336 "Emergency Medical Treatment and Labor Act (EMTALA)" and to explain the medical risks of leaving prior to receiving an MSE and failed to document the discussion in patient #8's medical record prior to his AMA departure.

c. During an interview on 3/5/24 at 9:00 AM, ARNP P reported if a patient with active withdrawal symptoms presented to the ED, and verbalized they "wanted to detox," she would make sure the patient was "stable" first. ARNP P reported she would "obtain labs and contact the on-call provider to see if the patient could be admitted to inpatient." ARNP P reported the CAH didn't have specialized treatment for things such as fentanyl withdrawal. ARNP P reported they would "assist with finding placement at an inpatient or outpatient setting, but patient #8 got up while she was talking to them and left". ARNP P reported she didn't have an opportunity to offer other services to patient #8.

d. During an interview on 2/22/24 at 10:00 AM, Staff C, Critical Care Paramedic (CCP) reported "if a patient wanted to leave AMA, they would find out why the patient wanted to leave and explain why they should stay." "They would inform the ED provider the patient wanted to leave, and the ED provider would talk with the patient." Staff C reported if the patient refused to sign the AMA form, they would "document what happened, and that the patient refused to sign the AMA form."

4. Review of patient #12's medical record revealed:

a. On 8/31/23 at 3:47 PM, patient #12 presented to the ED for a complaint of "known kidney stones since December of 2022." The medical record face sheet identified Physician Assistant, Certified (PA-C) V as the "Attending Physician." Patient #12 reported they previously had a nephrostomy tube (to allow urine to drain from the kidney through an opening in the skin on the back), which was removed on 8/7/23. Notes referred to patient #12 having recently had a baby 8/25/23 in another state and had a ureteral stent (small tube placed inside the ureter to help urine pass from a kidney into the bladder) placed on 8/25/23 as well as bleeding when she wiped ... "unsure if it is from her urine or from her period." ED staff CCP C documented that patient #12 had an elevated heart rate (tachycardia) and reviewed the patient's "vital signs and the signs and symptoms associated with [patient #12's] chief complaint" with an unnamed ED "provider" and that the "ER Provider has deemed that this patient is 'non-emergent' according to the medical screening exam." (Cross refer C2407.)

b. The medical record did not contain evidence of medical decision making by the Attending Physician or that patient #12 received an appropriate MSE or stabilizing treatment for an emergency medical condition (bleeding of unknown origin and an elevated heart rate) known to the CAH. The CAH provided disparate cae and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and its Amended February 9, 2022 Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

c. During an interview on 2/22/24 at 11:45 AM, ARNP G did not recall Patient #12, but reported that a patient with similar symptoms and medical history would be a patient they would work-up in the ED to rule out an emergency medical condition (EMC). ARNP G's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

d. Review of the August 2023 ED on-call schedule revealed the on-call provider included PA-C V and Physician W were available to the ED to provide a medical screening examination and necessary stabilizing treatment at the time patient #12 came to the ED.

5. Review of patient #5's medical record revealed:

a. On 1/3/24 at 2:05 PM, patient #5, a teenager, presented to the ED for a behavioral health (BH) court committal with a judicially-identified risk to themselves or others and documentation on court paperwork available to the hospital and provided as part of the medical record that he "wants to put a bullet in his head." At 2:25 PM, Staff A, CCP documented the guardian "believes that he is a flight risk. I notified that if he does run, we will call law enforcement as he is a danger to himself and others and is on court hold." Documentation showed laboratory testing completed on patient #5 at 4:01 PM showed an elevated white blood cell count of 18.4 (hospital reference range 4.8 to 10.8) and a positive drug screen for benzodiazepines and cannabinoids (marijuana). The medical record did not include evidence that staff obtained the patient's vital signs including respiratory rate, heart rate, blood pressure or temperature. At 7:38 PM (5 1/2 hours after arriving at the ED), Staff A documented patient #5 "pushed his Grandmother [sic] to the side and ran out the back door" prior to being provided an appropriate medical screening examination and stabilizing treatment. The disposition was listed as "AMA." (Cross refer C2407.)

b. The medical record lacked evidence that ED staff provided the patient with an appropriate medical screening examination including ongoing assessments of the patient regarding interventions and orders with any change in patient status. The patient did not receive stabilizing treatment for his known mental health emergency including hourly risk assessments for a patient demonstrating high-risk behaviors as required by hospital policy number 14728070 "Mental Health Evaluation in the ED." ED staff also failed to monitor patient #5 or have them evaluated by a physician for appropriate use of physical or chemical restraints to decrease their risk of elopement.

c. During an interview on 3/4/24 at 3:15 PM, Physician D recalled patient #5 eloped from the ED shortly after their shift started. Physician D reported hospital staff contacted law enforcement. Physician D reported they didn't see patient #5 and couldn't speak to whether they attempted medication with patient #5 prior to their elopement. Physician D's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

Based on document review and staff and patient interviews, the Critical Access Hospital (CAH) failed to provide 5 of 20 emergency patients reviewed (patients #3, #5, #8, #12, and #14) with the appropriate stabilizing treatment when they presented to the hospital's dedicated ED seeking emergency medical care. Failure to provide appropriate stabilizing treatment places current and future patients at immediate risk for deterioration of their health and wellbeing as a result of unidentified and/or untreated emergency medical conditions and creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur. The cumulative effect of these deficient practices resulted in the hospital's inability to ensure the safe and effective delivery of care to all patients and places current and future patients at immediate risk for deterioration of their health and wellbeing as a result of unidentified and/or untreated emergency medical conditions and creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur.

Findings include:

1. Review of patient #3's medical record revealed:

a. On 2/9/24 at 3:45 AM, patient #3, a 28-week pregnant patient, presented to the ED for symptoms consistent with contractions and preterm labor. The medical record face sheet (includes patient demographic information) identified Physician F as the Attending Physician. Staff B, registered nurse (RN) documented in the medical record "Upon arrival, patient is leaning over, moaning, taking deep breaths and holding her back." ..." RN asks patient how many minutes pass in between each episode of pain. She states she is unsure, but she thinks around 4-5 minutes. She says this is her first pregnancy ... She states her OB doctor is in Sioux City, RN informs patients that we do not have OB or external fetal monitoring. RN speaks to ED provider, Dr. [physician F] about patient's situation. Dr. [physician F] states, if patient is comfortable with it, she feels it is in the patient's and baby's best interest for the patient to call her OB and drive to Sioux City as her symptoms are consistent with contractions." The CAH failed to complete any assessment, obtain vital signs, complete an appropriate MSE, provide patient #3 with stabilizing treatment or arrange an appropriate transfer after presenting with symptoms of preterm labor (labor that occurred after 20 weeks of gestation and prior to 37 weeks). ED staff failed to have patient #3 evaluated by a physician or QMP, consult with an OB/GYN, or follow hospital policy number 14720649 "Obstetrical Triage and Assessment" for an evaluation which may include, but not limited to "evaluation of fetal heart tones by Doppler equipment, regularity and duration of uterine contractions, fetal position and station, cervical dilation, status of the membranes, vital signs of the pregnant individual, and consultation with an OB/GYN" to confirm whether patient # 3 was in labor and treatment or transfer plans. (Cross refer C2409.)

b. During an interview on 3/4/24 at 1:00 PM, Physician F recalled patient #3 came into the ED, and Staff B, ED RN, reported a 28-week pregnant patient presented with episodes of back pain. Physician F recalled asking Staff B if patient #3 contacted their OB provider. Physician F recalled coming out of the call room, and Staff B reported they told patient #3 to contact their OB provider to see what they recommended. Physician F denied ever talking to patient #3 while they were at the ED. Physician F said they felt patient #3 was "non-emergent." Physician F said they felt the most expedient thing for patient #3 would be for them to consult their OB provider, because the CAH didn't have the ability to monitor for contractions. Physician F acknowledged patient #3 didn't receive an appropriate MSE after presenting to the ED and requesting medical care. Physician F's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

c. During an interview on 2/21/24 at 1:00 PM, Physician E reported anytime a woman comes to the ED with abdominal pain, and is known to be pregnant, it warrants medical attention and "should be seen by a provider, and not a RN or paramedic." When asked about the assessment to determine a patient is in labor, Physician E said she would "check maternal vital signs, check fetal heart tones, assess the cervix, check for ruptured membranes, check the abdomen for contractions, I can palpate the contractions, and figure out how far along the patient is by measuring from the pubic bone to the top of the uterine fundus. 20 weeks would be 20 cm, 30 weeks would be 30 cm if you have an average size kid." Physician E said "we don't have continuous electronic fetal heart monitoring here. We do have a doppler, but we cannot do continuous fetal heart monitoring in the ED, or tocometry" (a pressure-sensitive contraction transducer used to record the frequency and duration of uterine contractions).

d. During an interview on 3/6/24 at 3:48 PM, patient #3 recalled going to the ED on 2/9/24 for medical care. Patient #3 reported having extreme pain in the upper back and upper right abdominal area and crying in pain. Patient #3 reported ED staff told them it sounded like "back labor, and recommended patient #3 go to their OB". Patient #3 recalled being told the CAH "didn't have the ability for ultrasound, and they didn't want patient #3 to pay for an ED visit at the CAH." Patient #3 reported they left the ED and drove 45 minutes (40 miles) to another town. Patient #3 denied being offered an MSE or treatment. Patient #3 reported they felt like "once ED staff heard they were pregnant, they said they could not help" patient #3.

e. Review of a second medical record revealed patient # 3 presented to Hospital B on 2/9/24 at 4:41 AM complaining of sharp, stabbing pain to the middle of the back that began the night before. Patient # 3 was examined by obstetrical physician T who determined the patient was not in labor.

f. During an interview on 3/7/24 at 3:00 PM Hospital B's advanced registered nurse practitioner (ARNP) U recalled Patient #3 came to Hospital B with complaints of right upper abdominal pain, was cleared by obstetrics first and then came to the ED where the patient was further examined, and an ultrasound confirmed she had gallstones.

g. The ED central log, dated 2/9/24, lacked documentation of patient #3's name and reason for coming to the ED.

2. Review of patient #14's medical record revealed:

a. Patient # 14 presented to the ED on Saturday 8/26/23 at 11:12 PM. The medical record face sheet identified Physician D as the Attending Physician. Staff J, critical care paramedic (CCP) documented in a late entry note (8/27/23 at 3:55 AM) that the patient stated "she is concerned she is having a miscarriage", that she was told yesterday by a physician in [name of town] that she was 4-6 weeks pregnant, that she has had "cramping for the last two days as well as nausea" and that she believed she was having a miscarriage "as she has had 3 in the past." Staff J, CCP documented that patient # 14 was discharged on 8/26/23 at 11:12 PM and in a "Miscellaneous Nursing Note" documented the patient and mother of boyfriend are not content after Dr. [physician D] "informs then that we do not have ultrasound this evening. They ask to leave so they are allowed to leave non-emergent and state they will be going to Sioux City."

b. Patient # 14's medical record lacked of evidence of an appropriate medical screening examination, or any type of diagnostic testing or evaluation within the CAH's capability, such as consideration by a physician or QMP of the possibility of ectopic pregnancy (a fetus implanted and growing outside the uterus) and history, examination, monitoring, and available laboratory test to evaluate other potential emergency medical conditions, such as, but not limited to, miscarriage with severe hemorrhage, infection, hemodynamic compromise (such as low blood pressure due to bleeding), hemorrhagic shock, coagulopathy, and trauma, which could have resulted in placing the health of patient # 14 in serious jeopardy, serious impairment to bodily functions, and/or serious dysfunction of any bodily organ or part. ED staff failed to conduct the evaluation required by hospital policy, including consultation with an OB/GYN on patient # 14's condition as specified by hospital policy number 14720649 "Obstetrical Triage and Assessment."

c. During an interview on 3/12/24 at 9:33 AM, patient #14 reported being pregnant, and going to the ED for concerns of a miscarriage, because of bleeding. Patient #14 asked for an ultrasound, but Physician D said they didn't have ultrasound available at that time and could not do it. Patient #14 reported they left the ED, and drove 45 minutes to another hospital, and recalled being given Morphine (pain medication) for their cramps. Patient # 14 reported she could not remember the name of the hospital and confirmed that she miscarried the pregnancy.

d. During an interview on 3/4/24 at 3:15 PM, Physician D indicated their policy for a patient presenting to the ED for a possible miscarriage would be to "examine the patient and do a pregnancy test to check for pregnancy, we would do labs on the patient, we would check her pregnancy levels." Physician D indicated they would typically obtain an ultrasound and if an ultrasound was not available, they would contact the patient's OB provider, or transfer the patient to another facility if needed." "If they are 'stable', we can discharge them and scheduled them to come back in the morning for the ultrasound. Sometimes we have kept them in the ED and watched them until morning when we can get an ultrasound." Physician D added "We may give them fluids if needed. It depends on how 'stable' the patient is. We would check their blood pressure to see what that is doing. Most of the time the patient is 'stable' and we can go from there." When asked why patient # 14 was not seen by a provider, Physician D said "I did see this patient for like 30 minutes. I examined her and when they found out we did not have ultrasound available at that time the mother-in-law got upset and they wanted to leave." Physician D said, "we were told when we started the 'non-emergent process' we still had to go in and see the patient but with 'non-emergent patients' we will let the nurse know the patient is 'non-emergent' and the nurse documents the patient was seen by the provider and they were stable. We do not do a full ED provider note on the patient." Physician D's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

e. On 5/8/24 PM during a follow up interview Physician D clarified he examined patient # 14's abdomen, lungs, heart and oral cavity but did not document his examination.

3. Review of patient #8's medical record revealed:

a. On 8/23/23 at 10:39 AM, patient #8, who had a history of opioid use disorder (OUD), presented to the ED for a complaint of opioid withdrawal. Documentation in the medical record showed patient #8 reported stomach cramps, nausea, vomiting, diarrhea, general aches, and back pain of 8 out of 10 (0 being no pain, and 10 being the worst possible pain), and chills. CCP C documented "Patient and family with him are looking for resources and are happy to take him somewhere else for treatment today. They noted they didn't know where to start." CCP C documented contact with a recovery center and noted "they do have a walk in assessment clinic but they cannot do inpatient 'detox.'" "[Advanced Registered Nurse Practitioner (ARNP) P] and I discuss this with the patient and the patient gets up and notes that he would like to go to Sioux City instead." ARNP P documented "Patient was brought back from Des Moines reports withdrawing from heroin and fentanyl. Patient has started withdrawal symptoms of fatigue and jitteriness. Family reports they know he does not need to be here they just not sure where to go. Educated family that we do not have specialized care for that 'detox' here [name of hospital] in Sioux City would have those facilities. [Name of facility] in Sioux City will work with him after 'detox' has been done. At this time patient got up and left prior to filling out discharge paperwork to get specialist care." ED staff documented patient #8 got up and left the ED on 8/23/23 at 11:23 AM with a disposition of "AMA (against medical advice)."

b. The medical record lacked evidence the CAH provided patient #8, within its capabilities, an appropriate MSE for his presenting signs and symptoms and stabilizing treatment for acute opioid withdrawal, of which it documented actual knowledge. ED staff did not provide or offer within its capabilities, lab testing (by way of example, creatine kinase (CK) for rhabdomyolysis, a serious medical condition that can be fatal or result in permanent disability, when damaged muscle tissue releases its proteins and electrolytes into the blood, or for electrolyte disturbances or dehydration to determine the need for IV fluids), or to assess for any psychiatric disturbances associated with drug withdrawal such as suicidal or homicidal thoughts, or determine if the patient was withdrawing from alcohol or other drugs (such as benzodiazepines) which can be life-threatening, or determine if the patient required medication to control the patient's pain and vomiting. ED staff failed to explain the medical risks of leaving and failed to try and get the patient to stay for further examination and treatment. ED staff failed to follow hospital policy number 14606336 "Emergency Medical Treatment and Labor Act (EMTALA)" and to explain the medical risks of leaving prior to receiving an MSE and failed to document the discussion in patient #8's medical record prior to his AMA departure.

c. During an interview on 3/5/24 at 9:00 AM, ARNP P reported if a patient with active withdrawal symptoms presented to the ED, and verbalized they "wanted to detox," she would make sure the patient was "stable" first. ARNP P reported she would "obtain labs and contact the on-call provider to see if the patient could be admitted to inpatient." ARNP P reported the CAH didn't have specialized treatment for things such as fentanyl withdrawal. ARNP P reported they would "assist with finding placement at an inpatient or outpatient setting, but patient #8 got up while she was talking to them and left". ARNP P reported she didn't have an opportunity to offer other services to patient #8.

d. During an interview on 2/22/24 at 10:00 AM, Staff C, Critical Care Paramedic (CCP) reported "if a patient wanted to leave AMA, they would find out why the patient wanted to leave and explain why they should stay." "They would inform the ED provider the patient wanted to leave, and the ED provider would talk with the patient." Staff C reported if the patient refused to sign the AMA form, they would "document what happened, and that the patient refused to sign the AMA form."

4. Review of patient #12's medical record revealed:

a. On 8/31/23 at 3:47 PM, patient #12 presented to the ED for a complaint of "known kidney stones since December of 2022." The medical record face sheet identified Physician Assistant, Certified (PA-C) V as the "Attending Physician." Patient #12 reported they previously had a nephrostomy tube (to allow urine to drain from the kidney through an opening in the skin on the back), which was removed on 8/7/23. Notes referred to patient #12 having recently had a baby 8/25/23 in another state and had a ureteral stent (small tube placed inside the ureter to help urine pass from a kidney into the bladder) placed on 8/25/23 as well as bleeding when she wiped ... "unsure if it is from her urine or from her period." ED staff CCP C documented that patient #12 had an elevated heart rate (tachycardia) and reviewed the patient's "vital signs and the signs and symptoms associated with [patient #12's] chief complaint" with an unnamed ED "provider" and that the "ER Provider has deemed that this patient is 'non-emergent' according to the medical screening exam."

b. The medical record did not contain evidence of medical decision making by the Attending Physician or that patient #12 received an appropriate MSE or stabilizing treatment for an emergency medical condition (bleeding of unknown origin and an elevated heart rate) known to the CAH. The CAH provided disparate cae and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and its Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

c. During an interview on 2/22/24 at 11:45 AM, ARNP G did not recall Patient #12, but reported that a patient with similar symptoms and medical history would be a patient they would work-up in the ED to rule out an emergency medical condition (EMC). ARNP G's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

d. Review of the August 2023 ED on-call schedule revealed the on-call provider included PA-C V and Physician W were available to the ED to provide a medical screening examination and necessary stabilizing treatment at the time patient #12 came to the ED.

5. Review of patient #5's medical record revealed:

a. On 1/3/24 at 2:05 PM, patient #5, a teenager, presented to the ED for a behavioral health (BH) court committal with a judicially-identified risk to themselves or others and documentation on court paperwork available to the hospital and provided as part of the medical record that he "wants to put a bullet in his head." At 2:25 PM, Staff A, CCP documented the guardian "believes that he is a flight risk. I notified that if he does run, we will call law enforcement as he is a danger to himself and others and is on court hold." Documentation showed laboratory testing completed on patient #5 at 4:01 PM showed an elevated white blood cell count of 18.4 (hospital reference range 4.8 to 10.8) and a positive drug screen for benzodiazepines and cannabinoids (marijuana). The medical record did not include evidence that staff obtained the patient's vital signs including respiratory rate, heart rate, blood pressure or temperature. At 7:38 PM (5 1/2 hours after arriving at the ED), Staff A documented patient #5 "pushed his Grandmother [sic] to the side and ran out the back door" prior to being provided an appropriate medical screening examination and stabilizing treatment. The disposition was listed as "AMA."

b. The medical record lacked evidence that ED staff provided the patient with an appropriate medical screening examination including ongoing assessments of the patient regarding interventions and orders with any change in patient status. The patient did not receive stabilizing treatment for his known mental health emergency including hourly risk assessments for a patient demonstrating high-risk behaviors as required by hospital policy number 14728070 "Mental Health Evaluation in the ED." ED staff also failed to monitor patient #5 or have them evaluated by a physician for appropriate use of physical or chemical restraints to decrease their risk of elopement.

c. During an interview on 3/4/24 at 3:15 PM, Physician D recalled patient #5 eloped from the ED shortly after their shift started. Physician D reported hospital staff contacted law enforcement. Physician D reported they didn't see patient #5 and couldn't speak to whether they attempted medication with patient #5 prior to their elopement. Physician D's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

Based on document review, and staff interview, the Critical Access Hospital (CAH) failed to arrange an appropriate transfer for patient (# 3) of 20 emergency department (ED) records reviewed, when the patient presented to the ED seeking care for symptoms of pre-term labor. Failure to arrange an appropriate transfer placed the patient and future patients at immediate risk for deterioration of their health and wellbeing as a result of delaying transfer to another hospital with the necessary capabilities and capacity for treating their unstabilized emergency medical condition and creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur.

Findings include:

1. Review of Patient #3 ' s medical record revealed:

a. On 2/9/24 at 3:45 AM, patient #3, a 28-week pregnant patient, presented to the ED for symptoms consistent with contractions and preterm labor. The medical record face sheet (includes patient demographic information) identified Physician F as the Attending Physician. Staff B, registered nurse (RN) documented in the medical record "Upon arrival, patient is leaning over, moaning, taking deep breaths and holding her back." ..." RN asks patient how many minutes pass in between each episode of pain. She states she is unsure, but she thinks around 4-5 minutes. She says this is her first pregnancy ... She states her OB doctor is in Sioux City, RN informs patients that we do not have OB or external fetal monitoring. RN speaks to ED provider, Dr. [physician F] about patient's situation. Dr. [physician F] states, if patient is comfortable with it, she feels it is in the patient's and baby's best interest for the patient to call her OB and drive to Sioux City as her symptoms are consistent with contractions." The CAH failed to complete any assessment, obtain vital signs, complete an appropriate MSE, provide patient #3 with stabilizing treatment or arrange an appropriate transfer after presenting with symptoms of preterm labor (labor that occurred after 20 weeks of gestation and prior to 37 weeks). ED staff failed to have patient #3 evaluated by a physician or QMP, consult with an OB/GYN, or follow hospital policy number 14720649 "Obstetrical Triage and Assessment" for an evaluation which may include, but not limited to "evaluation of fetal heart tones by Doppler equipment, regularity and duration of uterine contractions, fetal position and station, cervical dilation, status of the membranes, vital signs of the pregnant individual, and consultation with an OB/GYN" to confirm whether patient # 3 was in labor and treatment or transfer plans.

b. During an interview on 3/4/24 at 1:00 PM, Physician F recalled patient #3 came into the ED, and Staff B, ED RN, reported a 28-week pregnant patient presented with episodes of back pain. Physician F recalled asking Staff B if patient #3 contacted their OB provider. Physician F recalled coming out of the call room, and Staff B reported they told patient #3 to contact their OB provider to see what they recommended. Physician F denied ever talking to patient #3 while they were at the ED. Physician F said they felt patient #3 was "non-emergent." Physician F said they felt the most expedient thing for patient #3 would be for them to consult their OB provider, because the CAH didn't have the ability to monitor for contractions. Physician F acknowledged patient #3 didn't receive an appropriate MSE after presenting to the ED and requesting medical care. Physician F's interview corroborated disparate care and practices inconsistent with the CAH's policy number 14606336 "Emergency Medical Treatment and Active Labor Act (EMTALA)" and the CAH's Amended February 9, 2022, Medical Staff Rules and Regulations pertaining to the Attending Physician's duties.

c. During an interview on 2/21/24 at 1:00 PM, Physician E reported anytime a woman comes to the ED with abdominal pain, and is known to be pregnant, it warrants medical attention and "should be seen by a provider, and not a RN or paramedic." When asked about the assessment to determine a patient is in labor, Physician E said she would "check maternal vital signs, check fetal heart tones, assess the cervix, check for ruptured membranes, check the abdomen for contractions, I can palpate the contractions, and figure out how far along the patient is by measuring from the pubic bone to the top of the uterine fundus. 20 weeks would be 20 cm, 30 weeks would be 30 cm if you have an average size kid." Physician E said "we don't have continuous electronic fetal heart monitoring here. We do have a doppler, but we cannot do continuous fetal heart monitoring in the ED, or tocometry" (a pressure-sensitive contraction transducer used to record the frequency and duration of uterine contractions).

d. During an interview on 3/6/24 at 3:48 PM, patient #3 recalled going to the ED on 2/9/24 for medical care. Patient #3 reported having extreme pain in the upper back and upper right abdominal area and crying in pain. Patient #3 reported ED staff told them it sounded like "back labor, and recommended patient #3 go to their OB". Patient #3 recalled being told the CAH "didn't have the ability for ultrasound, and they didn't want patient #3 to pay for an ED visit at the CAH." Patient #3 reported they left the ED and drove 45 minutes (40 miles) to another town. Patient #3 denied being offered an MSE or treatment. Patient #3 reported they felt like "once ED staff heard they were pregnant, they said they could not help" patient #3.

e. Review of a second medical record revealed patient # 3 presented to Hospital B on 2/9/24 at 4:41 AM complaining of sharp, stabbing pain to the middle of the back that began the night before. Patient # 3 was examined by obstetrical physician T who determined the patient was not in labor.

f. During an interview on 3/7/24 at 3:00 PM Hospital B's advanced registered nurse practitioner (ARNP) U recalled Patient #3 came to Hospital B with complaints of right upper abdominal pain, was cleared by obstetrics first and then came to the ED where the patient was further examined, and an ultrasound confirmed she had gallstones.

g. During an interview on 3/5/24 at 10:30 AM, the Director of Emergency and Inpatient Services revealed that Patient # 3 "should have been brought into the ED and assessed by a provider to the best of our ability to make sure she was not in labor." The Director of Emergency and Inpatient Services said that the provider had "the patient's best interest in mind" and wanted her to go to "another facility where OB was offered" and that "transportation to another hospital by ambulance should have been considered."