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Based on record review, interview, document review and policy review the Critical Access Hospital (CAH) failed to follow policy and ensure emergency medical treatment and labor act (EMTALA) requirements were met by failing to ensure each patient received an appropriate medical screening exam (MSE) to determine if the patient had an emergency medical condition (EMC) and failed to ensure an appropriate transfer of patients with an Emergent Medical Condition (EMC). This deficient practice has the potential to place patients at risk for deterioration in health and condition up to and including death and puts them at risk during an unsafe transfer.

Findings Include:


1. The Critical Access Hospital (CAH) failed to ensure an appropriate Medical Screening Exam (MSE) was conducted to determine if an Emergent Medical Condition (EMC) existed for 3 of 22 patients (Patient 2, 21, and 22) seeking treatment at the hospital's emergency department. (Refer to tag C-2406)

2. The Critical Access Hospital (CAH) failed to ensure an appropriate transfer of a patient with an Emergent Medical Condition (EMC) for 1 of 9 patients (Patient 10) transferred. (Refer to tag C-2409)

Based on record review, policy review, document review and interview the Critical Access Hospital (CAH) failed to ensure an appropriate Medical Screening Exam (MSE) was conducted to determine if an Emergent Medical Condition (EMC) existed for 3 of 22 patients (Patient 2, 21, and 22) seeking treatment at the hospital's emergency department. Failure to complete an appropriate MSE has the potential to place patients at risk for deterioration of an EMC up to and including death.


Findings Include:

Review of a policy titled, "EMTALA-medical screening exam & stabilization policy," dated 07/25/22, showed " ...the elements of an appropriate medical screening examination should include the following elements at a minimum: a. log entry with disposition: b. triage record c. ongoing recording of vital signs: d. oral history: e. physical exam: f. use of all available/necessary testing resources: g. discharge or transfer vital signs: and h. adequate documentation of all of the above ..."


Review of a policy titled, "EMTALA Compliance policy," dated 07/25/22, showed "the purpose of this policy is to provide a summary of the responsibilities that [The Hospital] has and what treatments and services must be provided in order to be in compliance with the provisions of the Emergency Medical Treatment and Active Labor Act ('EMTALA'). DEFINITIONS: 1. Appropriate Medical Screening Examination. "Appropriate Medical Screening Examination" is defined as 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. An Appropriate Medical Screening Examination is not an isolated event; it is an ongoing process that begins, but does not end, with triage..."

Patient 2

Review of Patient 2's medical record showed the patient arrived at the emergency department (ED) on 08/16/22 at 7:00 PM with a diagnosis of abdominal pain, nausea, and vomiting, accompanied by his step-mother and half-brother. The ER Note showed Patient 2 was "extremely distraught, crying for his mother "I just want my mom" he states again and again." "Step-mother appears slightly distant to child and does not console him in any way." The record showed staff were unable to start an IV or draw blood after multiple attempts.

Patient 2's medical record failed to show an appropriate MSE to determine if an emergency medical condition existed prior to allowing the patient to transfer by private vehicle.

Review of Patient 2's transfer certification form showed the reason for transfer as "Medically Indicated" with the benefit of Lab/IVF (intravenous fluids) with the risk of deterioration related to transport and deterioration of condition. Further review of the transfer certificate showed Patient 2 was transferred on 8/16/22 at 9:35 PM, by private vehicle.

Review of Patient 2's H3 ED medical record showed, he presented on 08/16/22 and was seen by the provider at 11:42 PM, the record showed an appropriate MSE was completed that included lab and x-ray.


Patient 21

Review of Patient 21's emergency medical services (EMS) transport report dated 08/16/22 at 5:54 PM showed, " ... 1900 (7:00 PM) ...Dispatch advised that [Hospital 1] was trying to contact A6 (ambulance number). Per dispatch, [Hospital 1] does not have surgical and A6 would need to defer. A6 advised dispatch that we were less than a mile from [Hospital 1]. 1901 (7:01 PM) A6 arrives at [Hospital 1]. 1902 (7:02 PM) A6 personnel opened back door and is met by Staff K, APRN, and informed that we would need to (sic) Hospital 2. Advised Staff K about PTS. (patient) pain level. [Hospital 1] personnel [Staff K] talks with PT's wife regarding situation. ...1950 (7:50 PM) contact [H2] ER by cell phone 1959 (7:59) A6 arrives at [H2]


During an interview on 11/07/22 at 1:32 PM Staff K APRN stated she remembered Patient 21. Staff K stated that she attempted to defer the patient prior to arrival at the hospital. She stated although she attempted to defer the patient EMS arrived at the hospital and she declined an MSE stating that the patient is a post-surgical patient having surgical complications and the hospital has no surgical interventions available. She stated her concern that if she accepted the patient and the patient needed emergent care that the hospital could not provide the patient would be in mortal danger due to lack of transport availability. Staff K stated the hospital does have the availability to perform laboratory services, Computed Tomography (imagining technique used to obtain detailed internal images of the body) (CT), X-ray (digital image of internal body composition) that can be used in a MSE to determine if an EMC exists.

Review of Patient 21's Hospital 2's (H2) emergency department medical record dated 08/16/22, showed Patient 21 arrived at 8:02 PM by EMS. The History of Present Illness (HPI) in Patient 21's record showed " ...EMS was enroute to [H1] and they refused, rather than take patient north to his hospital where his surgeon was, EMS decided to take patient to [H2] for evaluation and treatment ..."


Patient 22

Review of Patient 22's EMS transport report dated, 01/15/21 at 7:12 AM showed, " ... this morning, staff stated [a physician] requested the pt (patient) be transported [Hospital 1 (H1)] for ACUTE RESPIRATORY FAILURE, due to the pt (patient) needing O2 (oxygen) when not previously prescribed O2 ... questioned pt (patient) if she agreed to be transported to [H1], pt (patient) stated "I am just doing what they tell me." ...cell phone report given to [H1]. Noted report given to [Staff K] APRN. Arrived at [H1] with no interventions needed noting [Staff K] met the unit at the ambulance bay. [Staff K] reported the COVID 19 bed was currently occupied, and she would not accept the pt (patient) and place the other current pts of the hospital at risk. (Staff Q EMS interim director) advised [Staff K] again of pt (patient) status and suggested the pt (patient) be examined and discharged back to the nursing facility with supportive O2 as needed. [Staff K] again denied acceptance and suggested transporting the patient to [H2]. Staff Q advised [Staff K] the pt (patient) does not warrant that level of care and would not transport to [H2]. Crew of A5 elected [Hospital 3 (H3)] in [town name] would be the next appropriate facility ...

Review of Patient 22's H3 emergency department medical record dated 01/15/21 showed Patient 22 arrived at 8:00 AM by EMS. The record showed " ...EMS reports pt (patient) sat 96% on RA this AM at time of transport, taken to [H1], diverted here by APRN due to no COVID beds ..."


During an interview on 11/07/22 at 1:32 PM Staff K APRN stated that people that come into the ED must have MSE and go from there to see if there is an EMC. MSE is dependent on what's wrong. Certainly vitals, lab, X-ray before anything else because that's the most pressing.

Based on record review, policy review, document review and interview the Critical Access Hospital (CAH) failed to ensure an appropriate transfer of a patient with an Emergent Medical Condition (EMC) for 1 of 9 patients (Patient 10) transferred. Failure to ensure an appropriate transfer places patients at risk for an unsafe transfer and deterioration of an EMC.


Findings Include:

Review of a policy titled, "EMTALA-transfer policy," dated 07/25/22, showed ... if an individual "or individuals designated representative" comes to [the Hospital] emergency department requesting (or prudent layperson observer would assume the individual would be requesting) medical care and EMC is identified, the hospital must provide an appropriate medical screening examination("MSE") and either: ...a transfer to another more appropriate or specialized facility after provision of treatment necessary to minimize the risks to the health of the individual ...authority to transfer: only the ED physician or QMP (Qualified Medical Professional) are authorized to transfer a patient. The ED physician or QMP shall be responsible for determining the appropriate mode, equipment and attendance for the transfer in such a manner as to be able to effectively manage any reasonably foreseeable deterioration of the patient's condition that could arise during transfer ...requirements for all transfers for individuals who are not medically stabilized ...the following requirements must be met: 1. Minimize the risk. Before any transfer may occur, the hospital must first provide, to the limits of its capacity and capability, medical treatment to minimize the risks to the health of the individual or unborn child. 2. Individuals request or QMP/physician order. Any transfer to another medical facility must be initiated either by written request by the individual or the legally responsible person acting on the individual's behalf or by a physician or QMP order with the appropriate physician certification as required by EMTALA. ...7. Physician/QMP Certification of Risks and Benefits. The ED physician or QMP, subject to hospital policy and the applicable provisions of EMTALA, must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred (see attached transfer form). Additional requirements for transfers REQUESTED by individuals who are not medically stabilized. In addition to the above transfer requirements for medically indicated transfers of individuals who are not medically stabilized, if a medically unstable individual, or the legally responsible person, requests a transfer to another hospital that is not medically indicated, the individual or the legally responsible person must first be fully informed of the risks of the transfer: the alternatives (if any) to the transfer: and the hospitals obligations to provide further examination and treatment sufficient to stabilize the individuals EMC. If a request is made and a certification is provided, the individual or legally responsible person must still be informed of the risks verses benefits. Components of an appropriate risk for transfer. The transfer is appropriate only when the request meets all of the following requirements: the request is in writing and contains the reasons for the request: it contains a statement of the hospitals obligations under EMTALA and the benefits and risks that were outlined to the person signing the request: the request indicated that the individual is aware of the risks and the benefits of the transfer: the request becomes part of the individual's medical record with a copy being sent to the receiving facility; and the request is not obtained thru coercion or misrepresentation ..."


Review of a policy titled, "EMTALA Compliance policy," dated 07/25/22, showed, "...5. Transfer. "Transfer" means the movement (including the discharge or movement of the patient to another facility) of an individual from the Hospital at the direction of any physician or QMP employed by the hospital but does not include the movement of a patient that (i) has been declared dead; (ii) leaves the Hospital without permission; or (iii) signs out against medical advice. POLICY: The Hospital shall maintain a robust EMTALA compliance program which shall include the following elements with specific policies to support each of those individual elements: The Hospital must provide an appropriate MSE to all individuals seeking emergency services to determine the presence or absence of an EMC, either by physician or other qualified medical personnel, as specified in the Hospital's medical staff bylaws and Hospital board resolution. The Hospital must stabilize the EMC of the individual, with in the capabilities of the staff, facilities and modalities of the Hospital, prior to transfer or discharge. An unstable patient cannot be transferred unless the patient (or a person acting on his or her behalf, preferably a guardian, spouse or person who has been assigned such a role by way of a Durable power of Attorney) requests the transfer, the transfer benefits outweigh the risks, and the transfer is in the best medical interest of the patient. In the event a transfer is required, the Hospital must: 1) Stabilize the patient within the Hospital's capabilities to minimize the risks associated with a transfer; 2) Obtain the acceptance of the receiving hospital; 3) Send all pertinent medical records available at the time of the transfer to receiving hospital with the understanding that any test results or other information not available at the time of transfer will be provided as soon as such tests and/or information is available; and 4) Effect the transfer through qualified persons and transportation equipment (including life support measures) ..."

Patient 10

Review of Patient 10's medical record showed the patient arrived at the ED on 07/04/22 at 12:45 AM with a complaint of a left foot laceration. Review of the hospitals transfer certification form showed that Staff K, APRN transferred Patient 10 to a higher level of care with a diagnosis of an ankle laceration with an arterial bleed on 07/04/22 at 2:30 AM.

Review of Patient 10's medical record "ED Course" showed ...2) Silver Nitrate (used to stop bleeding) utilized for attempts at hemostasis (stopping the bleeding) and unsuccessful. 3) tourniquet placed and suturing initiated. Multiple uninterrupted stitches placed, however wound starts bleeding profusely and will not stop despite tourniquet and pressure point and direct pressure."


Further review of the medical record failed to show evidence that Staff K, APRN notified the on-call attending physician prior to transfer of a patient with an EMC. In addition, Patient 10 was allowed to transfer via private vehicle even though attempts to stop the bleeding failed.


During an interview 11/07/22 at 1:32 PM, Staff K APRN stated it is a requirement to notify the supervising physician prior to any transfer and stated that documentation would be located in their narrative note.

During an interview on 11/08/22 at 12:00 PM, Staff V MD stated that the on-call physician doesn't necessarily have to come into the hospital for a patient transfer but must be notified of the transfer. She also stated that when transferring a patient to a higher level of the physician must counter sign the transfer certification form within 24 hours.