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Based on information from the complainant, observation, review of the central emergency log, policy review, and staff interview, the Critical Access Hospital (CAH) failed to enforce policies and procedures to ensure compliance with Section 42 CFR 489.20(1) of the Provider's Agreement requiring participating hospitals comply with 42 CFR 489.24, Special Responsibilities of Medicare hospitals in emergency cases on 2 of 2 days of survey (July 26-27, 2018). The CAH failed to conspicuously post signs specifying the patients' rights to receive an examination and treatment of emergency medical conditions and notice of the hospitals participation in both the Medicare and Medicaid programs (Refer to C2402); failed to maintain a complete and accurate central emergency department log (Refer to C2405); and failed to provide an appropriate Medical Screening Examination (MSE) and stabilizing treatment to any individual who comes to the emergency department requesting/seeking emergency services (Refer to C2406). Failure of the CAH to enforce their policies and procedures relating to the Emergency Medical Treatment and Labor Act placed patients at risk for improper screening and treatment.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to conspicuously post in the emergency department and in places likely to be noticed by individuals entering the emergency department and individuals waiting for examination and treatment a sign specifying the rights of individuals to receive examination and treatment on 1 of 1 day of observation (07/26/18). Failure to conspicuously post signs in waiting areas, triage rooms, and examination/treatment rooms limited the opportunity of individuals presenting to the emergency department to obtain notice of their right to receive an examination and notice of whether the hospital participates in the Medicare and Medicaid programs.

Findings include:

Observation of the signage located in the desk area of the lobby on the afternoon of 07/26/18 showed an 8.5 inch x 11 inch sign. The sign contained various script types and letter sizes. The sign did not address the CAH's participation in the Medicaid program or include information regarding how/where the patient may report problems/concerns. The sign was not conspicuous for individuals waiting in the lobby area or for individuals with impaired vision.

During interview on the morning of 07/26/18, an administrative/management staff member (#4) stated individuals presenting for emergency services may enter through the main entrance, report to the lobby desk, and be escorted to a triage room by staff or individuals may enter directly into one of the nine examination/treatment rooms. The administrative/management staff member (#4) stated the triage and examination rooms did not have the required signage.

Based on information from the complainant, review of the central emergency log, policy review, and staff interview, the Critical Access Hospital (CAH) failed to maintain an accurate and complete emergency log representing each individual presenting to the emergency department (ED) seeking emergency assistance for 1 of 1 sampled patient (Patient #8) and at least 1 additional unknown patient identified by staff. Failure to maintain a central log listing each individual seeking assistance and the patient's disposition limited the CAH's ability to track the care provided to emergency department patients.

Findings include:

Reviewed on 07/26/18, the complainant information indicated Patient #8 presented to the ED on 07/07/18 at approximately 3:30 p.m. The complainant information indicated Patient #8 was pregnant and had started bleeding.

Reviewed on 07/26/18, the CAH's undated policy titled "Transfer and Acceptance of Patients," stated, "ALL patients must also be entered in the mandated patient log."

Reviewed on 07/26/18, the central emergency log lacked evidence of an entry on 07/07/18 for Patient #8.

During interview on 07/27/18 at 2:00 p.m., an ED staff nurse (#5), who had attended to Patient #8 on 07/07/18, stated staff did not enter Patient #8 in the ED log and did not create an ED record for Patient #8. This nurse indicated not everyone who comes to the ED is entered into the central emergency log or has an ED record established. When asked for other examples, this nurse recalled a patient presenting with a chief complaint of "high blood pressure." The nurse stated, "I checked the patient's blood pressure, and told her she did not have high blood pressure, and sent her home."

Based on information from the complainant, staff interview, policy review, and review of the Critical Access Hospital's (CAH's) central emergency log, the CAH failed to provide an appropriate medical screening examination (MSE) for 1 of 1 sampled patients (Patient #8) who presented to the emergency department (ED). Failure to provide patients who present to the emergency department with an appropriate medical screening examination limited the CAH's ability to determine if the patient had an emergency medical condition.

Findings include:

Reviewed on 07/26/18, information from the complainant indicated Patient #8 presented to the ED on 07/07/18 at approximately 3:30 p.m. The complainant information indicated Patient #8 was pregnant and bleeding and the patient did not get examined by a physician.

Reviewed on 07/26/18, the CAH's undated policy titled "Pregnant Patients Presenting to the ED, Assessment of" stated, "Guidelines - 1. Pregnant patients less than 20 weeks gestational age that present to the Emergency Department will be registered as an Emergency Department patient and evaluated by the Emergency Department physician."

During an interview on 07/26/18 at 9:50 a.m., administrative/management staff members (#1, #2, #3, and #4) stated the ED process/routine for all patients who present to the ED always includes an examination by a physician who provides/obtains necessary medical procedures and stabilizing treatment. The physician determines appropriate disposition of the patient, home with instructions, admit, transfer, etc.

Reviewed on 07/26/18, the CAH's central emergency log lacked evidence Patient #8 had presented to the ED on 07/07/18 or at any time during the month of July 2018. Upon request, CAH administrative/management staff (#1, #2, #3, and #4) failed to provide an ED record for Patient #8 from 07/07/18.

On 07/26/18, CAH administrative/management staff (#1, #2, #3, and #4) provided information that Patient #8 had come to the ED on 07/07/18 from an "Appointment Desk" entry stating, "Encounter date - 07/07/18 Sat [Saturday], Time 3:10p, Department Rm [room]: Triage Bed 1, Provider - EMERGENCY DEPARTMENT, Visit Type - Emergency Department." Staff (#2, #3, and #4) confirmed the CAH could not provide a record showing a physician had completed a MSE for Patient #8.

During interview on the morning of 07/26/18, an administrative nursing staff member (#2) stated she had visited with the physician on duty (#6) in the ED on the afternoon of 07/07/18 in regard to the alleged complaint of a physician not seeing Patient #8 and not receiving a MSE. The physician (#6) had responded, "I told the nurse I would see her (Patient #8) if she (Patient #8) wanted me to see her."

A telephone interview occurred on the afternoon of 07/27/18 with the RN (#5) who had seen Patient #8 in the ED on 07/07/18. The RN provided the following information:
*The afternoon of 07/07/18 was an "average day" in the ED. The CAH staffs the ED with three RNs and a physician physically present in the ED.
* She told Patient #8 "She was having a miscarriage and there was not much more they could do."
* She told Patient #8 they would "probably not do an ultrasound or any lab work."
* She did not know how long or how much Patient #8 had been bleeding.
* Patient #8 remained in the triage room throughout the time spent in ED.
* She did not conduct any type of nursing assessment/exam.
* She told Patient #8 she "could see the doctor if she wanted to."
* Patient #8 "repeatedly told nurse she did not want to see the doctor."
* She communicated with the physician (#6) regarding Patient #8, and the physician (#6) did not say he needed to see/examine the patient.
* She did not maintain a written record of Patient #8's ED visit.
* She stated "Not everyone who comes the ED are seen by the doctor." When asked to provide an example, she said, "A patient came into ED complaining of high blood pressure. I took her blood pressure and told her she did not have high blood pressure and told her she should go home."