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Based on record review, review of policies/procedures, review of credential files, review of the emergency room call schedule, and interview, the Critical Access Hospital (CAH) failed to enforce policies and procedures to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 on 2 of 2 days of on-site survey (August 18-19, 2014).

Hospitals are required to adopt and enforce policies and procedures to ensure compliance with the requirements of ?489.24. Failure of the CAH to develop, adopt, and enforce their policies and procedures relating to the Emergency Medical Treatment and Labor Act placed patients at risk of increased anxiety, suffering, distress, and pain related to their reasons for seeking assistance.

Findings include:

The CAH failed to ensure the availability of effective and consistent policies and procedures (Refer to C2404); failed to ensure emergency department medical providers had approved obstetrical privileges for emergency spontaneous delivery (Refer to C2404); and failed to provide evidence a medical provider completed a medical screening examination, determined a medical emergency existed, and provided necessary treatment prior to transfer to another hospital (Refer to C2406).

1. Based on review of policies/procedures and staff interviews, the facility failed to ensure emergency staff had available effective and consistent policies and procedures on 2 of 2 days of survey (August 18-19, 2014). Failure to ensure staff have readily available current and effective policies/procedures placed individuals presenting in active labor at avoidable risk for complications/harm in the event staff needed to deliver the unborn child in an emergency situation.

Findings include:

-Review of undated emergency department policies and procedures occurred on the afternoon of 08/18/14 in the presence of two management level staff members (#2 and #4). The staff members indicated the facility had both a hard copy policy/procedure manual available for use in the department, and staff could also access policies/procedures online/electronically.

The staff members provided copies of three polices/procedures available to staff either through the hard copy manual or online/electronically. The three available policies/procedures were not consistent. The staff members indicated the policy/procedure located in the hard copy manual was no longer effective, and the two online/electronic policies/procedures were both effective. However, these two policies/procedures were not the same, and did not provide a consistent guideline for staff to follow (including the location and contents of the "OB Tool Kit") in the event staff needed to deliver a baby in an emergency situation.

2. Based on review of policies/procedures, review of credential files, review of emergency room call schedule, and staff interviews, the facility failed to ensure 4 of 7 medical providers (#8, #9, #12, and #13), assigned for emergency department coverage, had approved obstetrical (OB) privileges for emergency spontaneous delivery. Failure to ensure all medical practitioners providing emergency department coverage had approved privileges for emergency obstetrical spontaneous delivery placed individuals who present at the emergency room in active labor at risk for harm and the facility at risk for resulting liability.

Findings include:

- An interview occurred on the afternoon of 08/18/14, and again on the afternoon of 08/19/14, with an administrative staff member (#1). The staff member indicated the facility did not provide inpatient obstetrical services, but had provisions for emergency deliveries, and required all medical practitioners providing coverage of the emergency department have emergency spontaneous delivery obstetrical privileges.

The administrative staff member also indicated the facility utilized members of their active medical staff for weekday/night coverage, and contracted with an agency to provide practitioners for most weekend coverage.

Review of the credentialing files on 08/19/14 showed the following:
*Practitioner #8 and Practitioner #13 - both physician assistants, requested, and the medical staff /governing board approved privileges "to assist the supervising physician at surgery or emergency obstetrical delivery." Review of the call schedule showed these practitioners did not have timely access to a physician who would be available at the facility to provide emergency obstetrical services during the dates the physician assistants provided emergency room coverage.
*Practitioner #9 - a physician, did not request, nor did the medical staff and governing board approve privileges for emergency spontaneous delivery.
*Practitioner #12 - a physician, requested and received approval for "non-emergency OB delivery."

Based on review of emergency room records, the facility failed to provide evidence a medical provider completed a medical screening examination (MSE), determined a medical emergency existed, and provided necessary treatment prior to transfer to another hospital for 2 of 20 emergency room records (Patient #5 and Patient #6) reviewed. Failure to complete an appropriate MSE prior to transfer did not ensure the necessity for transfer, the patient received the necessary stabilizing treatment prior to transfer, and the receiving hospital received all necessary information relevant to the continuum of care.

Findings include:

Review of emergency room records occurred on August 18-19, 2014 and showed the following:

*Patient #5 presented to the emergency room on 11/07/13 with an identified diagnosis/chief complaint of "suicidal ideation." The record showed the facility transferred the patient via law enforcement to a psychiatric hospital. The record lacked a documented MSE from the medical provider attending to the patient in the emergency room until 11/14/13, seven days later.

*Patient #6 presented to the emergency room on 11/14/13 as "unresponsive." The record showed emergency room staff transferred the patient via "life flight" to another hospital. The emergency room record of Patient #6 lacked documentation of the MSE by the medical provider attending the patient until 11/18/13, four days later.