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Based on record review, interview, document review and policy review the Critical Access Hospital (CAH) failed to ensure emergency medical treatment and labor act (EMTALA) requirements were met by failing to ensure the emergency department (ED) log accurately identified the disposition of each patient and failed to ensure each patient received an appropriate medical screening exam (MSE) to determine if the patient had an emergency medical condition (EMC). These deficient practices had the potential to affect all patients who presented to the ED for emergency medical treatment.


Findings Include:


1. Review of the hospital policy titled, "Central Log Policy: EMTALA [emergency medical treatment and labor act] Interpretive Guidelines 489.24(b) & [and] 489.20 (3)," revised 07/12/18, indicated "Policy: All individuals who present to the Emergency Department requesting exam or treatment of a medical condition must be recorded in a central log. This log identifies the person seeking assistance; whether he or she refused treatment or was refused treatment; or was transferred, admitted and treated, stabilized and transferred, or discharged. . .Procedure: 1. [name of hospital] maintains an electronic log of emergency room patients via the electronic health record. . . 2. Every patient who presents to the emergency room will have an Emergency Room visit created in the electronic health record, recording the visit within the electronic Emergency Room log. . ."

The Critical Access Hospital (CAH) failed to ensure the emergency department (ED) log was accurate and indicated whether the patient refused treatment (left without being seen or left against medical advice), or whether the patient was admitted and treated, stabilized and transferred, or discharged. (Refer to tag 2405).


2. Review of the hospital policy titled, "Medical Screening Exam," revised 08/15/18, indicated the hospital would "provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and will never refuse to examine or treat individuals with an emergency medical condition . . . 3. A qualified medical provider . . . shall assess every patient entering the emergency system in a timely manner. 4. Every patient that presents to the ER [emergency room] will be triaged by an RN [registered nurse] . . . 5. Registered nurse will then complete an initial focused nursing assessment reflective of the patient's complaint . . . This assessment will include, at a minimum: a. Initial vital signs . . . 10. Documentation is key in determining whether an appropriate MSE was performed. All [initials of hospital name] staff should ensure that patient care is clearly and accurately documented in the EHR [electronic health record] . . ."

3. Review of the policy titled "Admission to the Emergency Room," revised 03/13/08, indicated ". . . If a patient refused treatment for any reason the refusal will be documented on the "Refusal for Treatment or Leaving Against Medical Advice" form, and the patient will sign where indicated. If the patient refuses to sign, that is to be documented on the form."

4. Review of the policy titled "EMTALA [emergency medical treatment and labor act] Policy For Registration /Financial [sic] Information For Emergency Services," revised 04/11/08, indicated ". . . Voluntary withdrawal: If a hospital is aware that an individual intends to leave prior to the screening examination, it should take the following steps: (1) Offer the individual further medical examination and treatment within the capabilities of the hospital as may be required to identify and stabilize an emergency medical condition. (2) Inform the individual of the benefits of such exam and treatment. (3) Take all reasonable steps to secure the individual's written informed consent to refuse such exam and treatment. . ."

5. Review of the "Hospital Database Worksheet" updated on 07/27/22 showed the CAH provides "Psychiatric Services - Emergency" by arrangement or agreement.


The Critical Access Hospital (CAH) failed to ensure each patient received an appropriate medical screening exam (MSE) to determine if the patient had an emergency medical condition. (Refer to C2406).

Based on document reviews, policy review, and interviews, the Critical Access Hospital (CAH) failed to ensure the emergency department (ED) log was accurate and indicated whether the patient refused treatment (left without being seen or left against medical advice), or whether the patient was admitted and treated, stabilized and transferred, or discharged for 11 patients (Patient (P) 2, P4, P5, P8, P9, P10, P12, P13, P16, P18) of 22 patient ED records reviewed (two of the 20 patients had two separate presentations to the ED). This deficient practice had the potential to affect all patients who present to the hospital's ED for medical services.


Findings Include:


1. Review of P2's EMR indicated P2 presented to the ED on 05/19/22 at 7:04 PM and left against medical advice (AMA) on 05/19/22 at 9:50 PM. Review of the ED Log, printed by Chief Nursing Officer (CNO), indicated P2's disposition was "Discharged ED" instead of left AMA as indicated in the medical record.

2. Review of P4's EMR indicated P4 presented to the ED on 01/28/22 at 8:50 AM. Review of P4's "Triage Note," located under the "Notes" tab, indicated Registered Nurse (RN) 3 documented, "The nurse went to check on patient in waiting room. No one there. Paperwork gone and clipboard on table." Review of the ED Log indicated P4's disposition was "Discharged ED" rather than left without being seen.

3. Review of P5's EMR indicated P5 was born in the ED on 01/31/22 at 11:53 PM and was transferred to another healthcare institution on 02/01/22 at 2:56 AM. Review of the ED Log indicated P5's disposition was "Discharged ED" and not transferred.

4. Review of P8's EMR indicated P8 presented to the ED on 03/14/22 at 2:39 PM and left without being seen on 03/14/22 at 2:50 PM. Review of the ED Log indicated P8's disposition was "Discharged ED" rather than left without being seen.

5. Review of P9's EMR indicated P9 presented to the ED on 03/27/22 at 10:56 AM and left AMA on 03/27/22 at 12:23 PM. Review of the ED Log indicated P9's disposition was "Discharged ED" rather than left AMA.

6. Review of P10's EMR indicated P10 presented to the ED on 04/30/22 at 9:21 AM and left AMA on 04/30/22 at 10:06 AM. Review of the ED Log indicated P10's disposition was "Discharged ED" rather than left AMA.

7. Review of P12's EMR indicated P12 presented to the ED on 06/06/22 at 1:49 AM and left AMA on 06/06/22 at 3:20 AM. Review of the ED Log indicated P12's disposition was "Discharged ED" rather than left AMA.

8. Review of P13's EMR indicated P13 presented to the ED on 06/13/22 at 3:25 PM and was transferred to another healthcare institution on 06/13/22 at 8:39 PM. Review of the ED Log indicated P13's disposition was "Discharged ED" rather than transferred.

9. Review of P16's EMR indicated P16 presented to the ED on 07/03/22 at 4:28 PM and left AMA on 07/03/22 at 7:13 PM. Review of the ED Log indicated P16's disposition was "Discharged ED" rather than left AMA.

10. Review of P18's EMR indicated P18 presented to the ED on 07/08/22 at 6:44 PM and was transferred to another healthcare institution on 07/09/22 at 12:04 AM. Review of the ED Log indicated P18's disposition was "Discharged ED" rather than transferred.

11. Review of P20's EMR indicated P20 presented to the ED on 07/22/22 at 10:01 PM and was transferred to another healthcare institution on 07/23/22 at 2:50 AM. Review of the ED Log indicated P20's disposition was "Discharged ED" rather than transferred.

During an interview on 07/26/22 at 11:28 AM, Risk Manager (RM) confirmed the above-listed EMR dates of service for each patient and the disposition for each patient on the ED Log.

During an interview on 07/26/22 at 12:58 PM with Clinical Services Manager (CSM), (CNO), and Director of Nursing (DON) present, CSM stated that they admit the patient into ED and put a provider's name when they check in the patient. CSM stated that the provider has to enter a discharge order, and once the order is completed, the disposition is included. CSM stated the disposition is "not free text but a drop-down menu." CSM stated that disposition choices include AMA, elopement, discharge to home, discharge to nursing home facility, and discharge to higher level of care. CSM stated that in the hospital's electronic health record documentation system, a transfer is considered a transfer to another department within the facility. CNO stated that they discovered after the surveyor reviewed the ED log that the discharge disposition detail (such as AMA, transfer, elopement, and such) was not being pulled into the ED log from the electronic health record documentation system. CNO stated that explains why the ED log only shows "Discharged ED" or "admitted to med/surg" [medical/surgical].

Based on record reviews, policy review, and interview, the Critical Access Hospital (CAH) failed to ensure each patient received an appropriate medical screening exam (MSE) to determine if the patient had an emergency medical condition (EMC) for 3 (Patient (P)3, P8, and P10) of 20 patient records reviewed. This deficient practice had the potential to affect any patient presenting to the emergency department (ED).


Findings Include:


Patient 3

Review of P3's EMR, showed P3 presented to the ED on 05/19/22 at 6:54 PM with a chief complaint of hypoglycemia (low blood sugar). Review of Nurse Practitioner (NP) 3's documentation dated 05/19/22 at 8:00 PM indicated P3 "is currently residing at [name of] nursing home . . . [He/she] is on hospice care for cancer. The nurse at the nursing facility inadvertently gave [him/her] someone elses [sic] insulin at 1500 [3:00 PM] this afternoon. They have been monitoring blood sugars. [He/she] received 2 [two] doses of glucagon [increases the blood sugar level and prevents it from dropping too low] and some pudding. Blood sugars continued to fall from 240 down to 100 when they called the ambulance at about 1900 [7:00 PM]. They were advised by hospice doctor to send [him/her] in here because they did not feel they could manage [his/her] blood sugars continuing to fall. [P3] is diabetic but [he/she] does not usually get insulin. [He/she] was given 20 units 70/30 insulin [combination isophane/regular insulin is used with a proper diet and exercise program to control high blood sugar in people with diabetes]. [He/she] is normally somewhat lethargic but they felt [he/she] was becoming more so. Daughter is also concerned that [he/she] may be retaining urine. [He/she] has been constipated and belly has been distended. [He/she] did get suppository today and had some stool since being here. They just want to know if it is constipation or [his/her] bladder disted [sic]. Apparently, NH [nursing home] staff was advised to put foley [urinary indwelling catheter] in but they had not gotten the chance yet."

Review of P3's vital signs on 05/19/22 at 6:56 PM showed P3's blood pressure was 135/63 (Normal 120/80), pulse 104 (Normal 60-100), respirations 16 (Normal 12-20), temperature 98.4 (Normal 98.6) Fahrenheit, and oxygen saturation 98% (per cent) (normal 97-100%) on room air. Review of P3's vital signs at 9:50 PM, prior to discharge, indicated P3's blood pressure was 124/58, pulse 96, respirations 22, and oxygen saturation 96% on room air.

Review of P3's blood glucose (Normal 99 mg/dl (milligrams per deciliter) or below) results were as follows:

05/19/22 at 7:17 PM - 84 mg/dl;
05/19/22 at 7:44 PM - 119 mg/dl;
05/19/22 at 8:25 PM - 128 mg/dl; and
05/19/22 at 9:41 PM - 95 mg/dl.

Documentation dated 05/19/22 at 8:13 PM by NP3 indicated "Monitor blood sugars. Readings every 30 minutes so far were 84 and then 119. 70/30 has a half-life of 8 hours and has hit its peak. Will do another blood sugar at 2030 [8:30 PM]. If continuing to improve, will check again in one hour and if still looking ok, will send back to NH. Will also do bladder scan to make sure [he/she] is not retaining urine."

Documentation dated 05/19/22 at 9:13 PM by NP3 indicated "Care turned over to [NP4] but will be discharging if next blood sugar in 20 minutes continues to stay stable. [He/she] is past the peak level of the insulin."

Review of P3's "Nursing Order' indicated an order dated 05/19/22 at 8:13 PM for a bladder scan and on 05/19/22 at 8:37 PM to "insert foley catheter ongoing leave in place when sending back to NH now."

Review of P3's EMR indicated P3 was discharged on 05/19/22 at 10:07 PM back to the NH.

Review of P3's entire EMR failed to show an appropriate MSE was completed as the providers did not check laboratory tests or provide supplemental methods of boosting the patient's glucose and there was no documentation that a bladder scan was performed, that an indwelling foley catheter was inserted and left in place at discharge, and there was no documentation in the EMR by NP4.


Review of documentation of a second presentation to the ED indicated P3 returned to the ED by ambulance on 05/19/22 at 11:40 PM with a chief complaint of hypoglycemia and hypotension (EMR has presentation time of 11:40 PM with provider assessment documented at 11:30 PM). NP4 documented on 05/19/22 at 11:30 PM "This is [his/her] second ER [emergency room] admission this evening for same complaint . . . Shortly after [he/she] arrived back they checked [his/her] blood sugar and it was 58. They called the hospice company who recommended [he/she] go back to the ER. They gave [him/her] a dose of glucagon and then [he/she] was transported here ..."


During an interview on 07/26/22 at 10:56 AM, Registered Nurse (RN) 2 stated that a bladder scan was done, and an indwelling 16 French catheter was inserted. After reviewing the nursing documentation, RN2 confirmed RN2 didn't document performing the bladder scan and the insertion of the catheter.

During an interview on 07/26/22 at 12:45 PM, NP3 stated that when the care was turned over to NP4, NP3 "reported that [P3's] blood sugar would be checked in another hour, which would be 9:30 PM, and if it was okay, it would be at [NP4's] discretion regarding discharge." After reviewing the EMR, NP3 stated he/she entered discharge instructions at 9:14 PM, but the ED staff would have still needed to report the last blood sugar result to NP4 before discharge. NP3 stated, "don't see any nursing notes actually," that indicated the nurse notified NP4 of the last blood sugar result. NP3 confirmed he/she didn't see any documentation from NP4 in P3's EMR.

During a telephone interview on 07/26/22 at 6:23 PM, NP4 stated that P3's blood sugar was 95, the nurse reported it to her, and NP3 had done the discharge. NP4 stated that NP4 told the nurse it was okay to discharge P3. NP4 stated he/she normally would receive the patient from the provider handing over the patient, and NP4 would document a progress note saying NP4 assumed care and what the blood sugar was. NP4 stated he/she "apparently didn't do that."


During an interview on 07/27/22 at 11:43 AM, Medical Doctor (MD) 1 stated that P3 was discharged after the first visit with a normal blood sugar. When asked if MD1 thought P3 should have been monitored longer when going from a blood sugar of 128 to 95, MD1 stated "no, [P3] had a normal blood sugar, and it was still higher than when [P3] came in." MD1 stated he/she thought it was appropriate to discharge P3 with a blood sugar of 95, because that was within normal limits. MD1 stated that he/she recalled telling NP4 to "admit the patient for observation, because they would probably be getting calls all night long."



Patient 8

Review of P8's electronic medical record (EMR), indicated P8 presented to the ED on 03/14/22 at 2:39 PM with a chief complaint of "low oxygen."

Review of P8's "Nursing Assessment," indicated RN3 documented on 03/14/22 at 2:47 PM, "Chief complaint: chief complaint: (this nurse went to waiting room to bring patient back; personal SpO2 [equipment used to monitor a patient oxygen saturation] monitor was on patient and [he/she] states [he/she] got [his/her] oxygen tank to work and [his/her] SpO2 is now 95% [normal 95-100%]; states [he/she] will just go home and connect to [his/her] concentrator there) Airway: patent"

Review of P8's entire EMR failed to show an appropriate MSE was completed as there was no documentation of an assessment of P8's vital signs by RN3, and no MSE was performed.

Furthermore, the CAH failed to follow policy and offer P8 further medical examination and treatment within their capabilities as required to identify and stabilize an emergency medical condition. Failed to inform P8 of the benefits of such exam and treatment and of the risks of leaving prior to receiving such examination and treatment or to take all reasonable steps to secure the individual's written informed consent to refuse such exam and treatment.

During an interview on 07/25/22 at 3:30 PM, RM confirmed there was no documentation of vital signs assessed by RN3 and no documentation of an MSE.

During a telephone interview on 07/26/22 at 9:27 AM, RN3 stated "if I recall, I thought there was a triage done and paperwork done. I would have to go back and look in there. I honestly don't remember a lot of that patient." After the surveyor read the triage note to RN3, RN3 stated "it sounds like vitals were obtained, and the patient was seen by me. I'm not exactly sure if [he/she] was assessed by me, but it doesn't sound like [he/she] was assessed by a provider." RN3 stated [he/she] was aware that a patient was supposed to have a MSE when they present to the ED.

During an interview on 07/26/22 at 9:38 AM, RM confirmed there was no provider who saw P8 (no MSE). RM confirmed there were no vital signs documented in P8's EMR.



Patient 10

Review of P10's EMR indicated P10 presented to the ED on 04/30/22 at 9:21 AM and left AMA on 04/30/22 at 10:06 AM. Review of P10's "ED Provider Assessment" documented by PA2 on 04/30/22 at 9:29 AM indicated "Patient presents to the emergency department via ambulance after being picked up at the casino. Per EMS report [he/she] was involved in an altercation and stated that [he/she] was having an anxiety attack. [He/She] is very difficult to get information from as [he/she] has scattered thought process and unable to stay on task. . . When asked regarding review of systems questions [he/she] goes off on a tangent with [his/her] thought process. When asked if [he/she] is suicidal or homicidal [he/she] reports "f..k no" to suicidal and that [he/she] could kill me and not remember anything. . ."

Review of documentation by PA2 dated 04/30/22 at 9:53 AM indicated "Attempted to discuss with the patient [his/her] exam and that we would need to draw labs and would have [him/her] screened by [name of mental health screening company]. [He/She stated that was a "good F..king idea". [sic] [He/She] thinks [he/she] needs to be monitored because of [his/her] brain device. Nursing informed me that [he/she] is refusing labs- when they discussed the reason for labs [he/she] was becoming very loud and not cooperative. They informed [him/her] that they would call PD [police department] if [he/she] did not settle down. Pt [patient] left AMA at that time on foot."

Review of P10's entire EMR failed to show an appropriate MSE was completed prior to P10 leaving. P10's evaluation showed P10 admitted to using methamphetamine's, was having active hallucinations, demonstrated scattered speech and had the inability focus or stay on task. The medical record failed to show psychiatric emergency services or that a mental health evaluation was provided for P10 within the CAHs capability.

Review of P10's EMR indicated there was no "Refusal of Services and/or Treatment" form that included what treatment was refused, the risks and benefits of such refusal, the signature of a witness, or documentation that P10 refused to sign the form. There was no documentation in the EMR to show discussion of the risks of leaving.

During an interview on 07/25/22 at 3:19 PM, Risk Manager (RM) confirmed there was no "Refusal of Services and/or Treatment" form in P10's EMR.

During an interview on 07/26/22 at 1:26 PM, Chief Nursing Officer (CNO) stated Registered Nurse (RN) 1 was on vacation and not available to be interviewed regarding RN1's communication to PA2 regarding P10's refusal of lab work and P10's leaving AMA.