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Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to follow the CAH's policies when staff failed: to provide a medical screening examination for 3 of 30 sampled Emergency Department (ED) patients (Patients #1, 2, and 3); failed to provide appropriate stabilizing treatment to 1 of 30 ED patients (Patient #4); and delayed stabilizing treatment in the ED to obtain authorization from the patient's primary physician as required by Medipass for 2 of 30 ED patients (Patients #2 and 3).

The CAH's staff reported furnishing services to an average of 216 patients per month in the ED at the CAH.

Failure to follow the CAH's policies resulted in the ED staff failing to provide a medical screening examination for 3 patients, failed to provide adequate pain control for 1 patient, and delayed a medical screening examination and stabilizing treatment for 2 patients related to insurance requirements for an approval from the patients' primary physician who declined to authorize the ED visit.

Findings include:

The policy "Emergency Examination and Transfer Policy," effective 1/2010, revealed in part, "Medical Screening Examination (MSE): An examination within the capability of the Hospital's Emergency Department ... to determine with reasonable clinical confidence whether an [Emergency Medical Condition] exists... For individuals brought to the Hospital by law enforcement personnel for examination prior to incarceration, the Hospital's obligation is to provide an appropriate MSE."
"Hospital personnel may not seek ... authorization from the individual's insurance company for screening or stabilization services to be furnished ... to an individual until after the hospital has provided [an] appropriate [medical screening exam] ..." "Stabilize. To provide such medical treatment of the condition as may be necessary to assure ... no material deterioration of the condition is likely to result from, or occur during [transfer or discharge.]"

"The objective of the MSE is to determine whether an [emergency medical condition] exists.... Triage is not equivalent to the MSE; triage determines the order in which individuals will be provided a MSE."

Review of the policy "TRANSFER TO A PHYSICIAN'S OFFICE," reviewed 3/2009, revealed in part, "Those patients in the Non-Urgent classification may be transferred to the office of a local physician under the following circumstances: ... Emergency medical screening has been provided."

1. Patient #1's medical revealed the patient presented to the ED on 10/6/14 at 6:37 PM following an interaction with law enforcement officials. Documentation revealed the law enforcement officials used a Tazer three times to subdue the patient and drew their gun during the process. Patient #1 requested that the law enforcement officials shoot him with the firearm. Patient #1 denied suicidal thoughts while in the ED.

During an interview on 10/22/14 at 9:20 AM, ARNP A stated he was not aware Patient #1 made suicidal statements and gestures prior to arrival at the ED. ARNP A reported if he had known Patient #1 made the statements, he would have arranged for Patient #1 to receive inpatient mental health care.

2. Patient #2's medical record revealed the patient presented to the ED on 7/16/14 at 9:37 AM and was sent to the clinic at the request of ARNP A at 9:50 AM. Registered Nurse (RN) C documented contacting Patient #2's primary care physician to obtain preauthorization for the ED visit. Patient #2's primary care physician's office declined the preauthorization and instructed the RN to send the patient to ARNP A's clinic in the CAH. The documentation does not indicate patient #2 received a medical screening examination in the ED prior to transferring to the clinic.

During an interview on 10/22/14 at 9:20 AM, ARNP A stated RN C's triage exam qualified as the medical screening exam for Patient #2. ARNP A stated he did not examine Patient #2 in the ED.

3. Patient #3's medical record revealed Patient #3 presented to the ED on 8/27/14 at 4:34 PM and was sent to the clinic in the CAH at 4:45 PM. RN D documented Patient #3 presented to the ED complaining of a toothache. RN D documented she contacted Patient #3's primary care physician to obtain preauthorization for the ED visit. Patient #3's primary care physician's office initially authorized the ED visit. Later, ARNP A declined the preauthorization and asked RN D to send Patient #3 to the clinic in the CAH. The documentation showed Patient #3 did not receive a medical screening examination prior to leaving the ED.

During an interview on 10/22/14 at 9:20 AM, ARNP A stated RN D's triage exam qualified as the medical screening exam for Patient #3. ARNP A stated he did not examine Patient #3 in the ED.

4. Patient #4's medical record revealed the patient presented to the ED on 4/1/14 at 10:24 PM complaining of lower abdominal pain. Physician E documented the patient's abdominal pain as a 9-10. Physician E documented Patient #4 did not appear in any distress. The medical record did not indicate the patient was offered any medication for the pain.

During an interview on 10/22/14 at 10:05 AM, Physician E stated he felt Patient #4 did not present with a significant amount of pain, despite the patient's report of pain. Physician E felt Patient #4's demeanor did not fit with Patient #4's rating of the pain.

Based on document review and staff interview, the Critical Access Hospital (CAH) staff failed to provide a medical screening examination for 3 of 30 sampled Emergency Department (ED) patients (Patients #1, 2, and 3). The CAH's staff identified an average of 216 patients per month who sought emergency medical care at the CAH.

Failure to provide an appropriate medical screening exam may result in the ED staff failing to diagnose a patient's emergency medical condition.

Findings include:

1. The medical record for Patient #1 revealed the patient presented to the ED on 10/6/14 at 6:37 PM following an interaction with law enforcement officials. Advanced Registered Nurse Practitioner (ARNP) A documented the law enforcement official drew a gun and used a Tazer to subdue Patient #1. In the ED, the patient denied suicidal thoughts. Patient #1's medical record showed ARNP A documented "No acute medical or psychiatric illness appreciable. No need for labs, radiology."

During an interview on 10/22/14 at 12:10 PM Sheriff's Deputy B stated he took the patient to the ED instead of the jail due to the patient's suicidal statements.

During an interview on 10/22/14 at 9:20 AM, ARNP A stated he did not know Patient #1 made suicidal statements and gestures prior to Patient #1's arrival at the ED. ARNP A stated if he knew Patient #1 made the statements, ARNP A would have arranged for Patient #1 to receive inpatient mental health care.

2. Patient #2's medical record revealed the patient presented to the ED on 7/16/14 at 9:37 AM. Patient #2's mother stated the child threw up every time she took a liquid antibiotic. Registered Nurse (RN) C documented she contacted the patient's primary care physician to obtain preauthorization for the ED visit. The primary care physician's office declined the preauthorization and instructed RN C to send the patient to ARNP A's clinic, located within the CAH. The patient's ED documentation did not indicate the patient received a medical screening examination prior to transferring to ARNP A's clinic at 9:50 AM. The clinic medical record revealed the patient presented to the clinic 20 minutes after leaving the ED.

During an interview on 10/22/14 at 11:40 AM, RN C verified ARNP A told RN C to send Patient #2 to ARNP A's clinic at the CAH on 7/16/14.

During an interview on 10/22/14 at 9:20 AM, ARNP A stated he provided coverage for ED patients on 7/16/14 while working in the clinic. He spoke with RN C regarding Patient #2 and instructed RN C to send the patient to the clinic in the CAH. ARNP A verified he did not examine the patient in the ED. ARNP A added he believed RN C's triage examination qualified as the medical screening examination.

3. Patient #3's medical record revealed Patient #3 presented to the ED on 8/27/14 at 4:34 PM. RN D documented Patient #3 complained of a toothache. Patient #3 rated the pain at 8 on a 0 to 10 scale. RN D documented contacting the patient's primary care physician's office to obtain preauthorization for the ED visit. The patient's primary care physician's office initially authorized the ED visit but later ARNP A denied the preauthorization and instructed RN D to send the patient to the clinic in the CAH. Patient #3 did not receive a medical screening examination before leaving the ED at 4:45 PM. The clinic medical record revealed the patient presented to the clinic 14 minutes after leaving the ED.

During an interview on 10/21/14 at 11:20 AM, RN D stated when she called Patient #3's primary care physician's office for insurance pre-approval of the ED visit, the receptionist initially approved Patient #3's ED visit. However, ARNP A heard the patient was in the ED and requested to see the patient in the clinic. Patient #3 was tearful with pain when RN D examined Patient #3. RN D stated she knew Patient #3 required a medical screening examination prior to leaving the ED but did not receive one.

During an interview on 10/22/14 at 9:20 AM, ARNP A stated RN D's triage exam qualified as the medical screening exam for patient #3. ARNP A verified he did not examine Patient #3 in the ED.

4. During an interview on 10/22/14 at 12:01 PM, the Director of Nursing stated the administrative and medical staff determined registered nurses could not perform a sufficiently detailed examination to qualify as a Medical Screening Exam on 9/25/14. The Director of Nursing stated the administrative staff changed the policy to reflect the determination but the Board of Trustees had not provided final approval to the policy so the policy was not in place.

Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to provide appropriate pain control for 1 of 30 sampled Emergency Department (ED) patients (Patient #4). The CAH's staff identified an average of 216 patients per month who sought emergency medical care in the ED at the CAH.

Failure to provide appropriate pain control resulted in a patient suffering avoidable pain and discomfort.

Findings include:

The medical record for Patient #4 revealed the patient presented to the ED on 4/1/14 at 10:24 PM. Patient #4 complained of lower abdominal pain. Physician E documented Patient #4 had abdominal pain that the patient rated at 9-10 on a 0 - 10 scale. Physician E documented Patient #4 did not appear in any distress. The medical record did not indicate Physician E ordered or discussed any medication for the severe pain with the patient.

During an interview on 10/21/14 at 4:05 PM, Registered Nurse (RN) F could not remember providing anything for pain relief to Patient #4. RN F stated "I can't imagine we wouldn't do something if the patient's pain was a 10. I don't see any documentation we gave the patient anything. There isn't any further documentation regarding the patient's pain. I don't even know the patient's discharge pain level."

During an interview on 10/22/14 at 10:30 AM, RN G stated Patient #4 rated the pain as 10 on a scale of 0-10 but did not appear in obvious pain. Patient #4 was calm and did not appear in distress. RN G wondered if patient #4 understood the pain scale.

During an interview on 10/22/14 at 10:05 AM, Physician E stated Patient #4 did not present with a significant amount of pain, despite Patient #4 rating the pain as a 10. Physician E felt Patient #4's demeanor did not fit with Patient #4's rating of their pain.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure staff did not delay the medical screening examination while waiting for approval from the patient's primary physician as required by the patients' insurance for 2 of 30 sampled Emergency Department (ED) patients (Patients #2 and 3). The CAH's administrative staff identified an average of 216 patients per month who sought emergency medical care at the CAH.

Failure to conduct a medical screening examination while in the ED could potentially result in the ED staff failing to identify an emergency medical condition and delay any needed stabilization.

Findings include:

1. Patient #2's medical record revealed the patient presented to the ED on 7/16/14 at 9:37 AM. Registered Nurse (RN) C documented contacting the patient's physician's office for authorization to see the patient in the ED as required by the patient's insurance. RN C documented ARNP A declined to authorize Patient #2's evaluation in the ED and instructed the RN to send the patient to ARNP A's clinic located in the CAH. Patient #2 did not receive a medical screening examination in the ED.

During an interview on 10/22/14 at 11:40 AM, RN C stated Patient #2 had Medipass insurance. Medipass insurance required the ED staff to obtain prior authorization for any patient's visit to the ED from the patient's primary physician. RN C contacted the patient's primary care physician's office and spoke with ARNP A. ARNP A denied the pre-approval for Patient #2's ED visit and instructed RN C to send Patient #2 to ARNP A's clinic in the CAH. RN C reported the patient only received a nursing assessment in the ED and did not receive a medical screening examination in the ED prior to leaving for ARNP A's clinic.

2. Review of Patient #3's medical record revealed the patient presented to the ED on 8/27/14 at 4:34 PM. Patient #3 had Medipass insurance. RN D documented contacting the physician's office for authorization to see the patient in the ED. Documentation shows the physician's office did not authorize the ED visit for the patient. RN D sent Patient #3 to the physician's clinic at the CAH. ARNP A documented "...seen in clinic Medipass denied" on Patient #3's ED medical record.

During an interview on 10/21/14 at 11:20 AM, RN D verified Patient #3 did not receive a medical screening examination in the ED prior to leaving for ARNP A's clinic.