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Based on document review and medical record review the Critical Access Hospital (CAH) failed to follow their policies and procedures to provide an appropriate medical screening examination (MSE) within the hospital's capabilities to determine whether or not an emergency medical condition (EMC) existed for one of 20 records reviewed (Patient 5).

Failure of the CAH to conduct an appropriate MSE for all individuals who come to the Emergency Department (ED) seeking assistance has the potential for persons to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition including death.

Findings Include:

Document review of the CAH's undated, "Medical Staff Rules and Regulations," showed ...all persons who come to the CAH for treatment shall be afforded a medical screening examination to determine whether or not an emergency medical condition exists ...based upon this medical screening examination if it is determined the patient has an emergency medical condition, the Hospital will provide treatment to stabilize the medical condition within the capacity and capabilities of the staff and facilities or will arrange for a certified transfer of the individual to an appropriate medical facility ...this includes the use of ancillary services routinely available to patient in the ED to assist in determining whether or not an emergency medical condition exists.

Document review of the CAH's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) - Definitions," dated 07/20/17, showed ... "Medical Screening Examination means the process that is required to reach the determination within a reasonable degree of clinical confidence, as to whether the patient has an emergency medical condition. A medical screening examination typically begins with a nursing assessment and is a spectrum ranging from a very simple to a more complex process. It may consist of as little as brief history and physical to the full use of ancillary services depending on the situation. It is an ongoing process, not an isolated event. This screening must be universally applied to all patients complaining of the same condition."

Document review of the CAH's policy titled, "EMTALA - Medical Screening Examination," dated 07/20/17, Number 7, showed ... "It is the policy of the Stanton County Hospital (SCH) to provide an appropriate Medical Screening Examination (MSE) to individuals presenting at its Emergency Department (ED) requesting examination for or treatment of a medical condition, and to individuals presenting on SCH property requesting examination or treatment of an emergency medical condition (EMC) ...7. The extent of the medical screening examination varies by presenting symptoms: a. The MSE may vary depending on the individual's signs and symptoms. An appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) ...CT scans and other diagnostic tests and procedures. "EMTALA DEFINES AN EMERGENCY MEDICAL CONDITION (EMC) FOR NON-PREGNANT PATIENTS AS: a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to ...result in serious impairment to bodily functions; or result in the serious dysfunction of any bodily organ or part... "Sufficient Severity" includes severe pain ...the process may include ...diagnostic imaging ...the individual shall be continuously monitored according to the individuals needs until it is determined whether the individual has an emergency medical condition ...if the individual does have an emergency medical condition, he/she must be stabilized, admitted or transferred."

Document review of "Exhibit 286, Hospital/CAH Database Worksheet", completed by Staff A, Chief Executive Officer (CEO) on 06/24/20 in conjunction with the surveyor showed that services provided at the CAH included a CT Scanner, an Emergency Department, Diagnostic Radiology Services, and a Clinical Laboratory. Further review showed that the CAH did not provide Orthopedic Surgery Services.

Document review of the CAH's Call Schedule for the Month of April 2020 showed Staff J, Medical Doctor (MD) on call for the ED and Staff V, Radiology Technician on call for radiology services including diagnostic X-rays and CT Scanner the night of April 7, 2020.

Review of Patient 5's medical record showed that he presented to the CAH's ED by ambulance on 04/07/20 at 10:57 PM complaining of pain to his left side after a fall at home. Staff J, MD ordered X-rays of the left elbow, left wrist, left knee, and left hip. At 12:01 AM on 04/08/20 Staff J documented that patient 5 complained of pain with extension of his left wrist, elbow and knee, as well as pain in his left hip with abduction (moving the leg away from the body). Staff J documented that he did not see any fractures after reviewing the imaging results for the wrist, elbow, knee or left hip and determined patient 5's pain could be treated with Tylenol 500 mg every six hours as needed and ordered discharge at 12:12 AM prior to receiving the radiology results from the contracted radiology group's radiologist.

When the radiologist's report arrived, documentation showed that Patient 5's daughter was attempting to get her father into her vehicle in the CAH's parking lot. Staff U, Registered Nurse (RN) documented she relayed the radiologist's suspicion of a left hip fracture and recommendation for a CT scan (special type of x-ray) to confirm whether an emergency medical condition existed. Staff U, RN also documented that ED physician J said that the daughter could either take patient 5 to another ED to have a CT scan performed or she could take him to Hospital B (an acute care hospital approximately 88 miles away) later in the day to see an Orthopedic Surgeon.

The medical record did not contain evidence that ED physician J ordered a CT scan or returned to the ED to provide further examination to determine whether an emergency medical condition existed, or to discuss further medical and/or surgical management with Patient 5 and his daughter.

Review of a second medical record showed that patient 5 presented to CAH B (located approximately 53 miles away) on 04/08/20 at 1:06 AM. CAH B provided patient 5 with an examination, including a CT scan of the left hip and arranged transfer to Hospital C to receive stabilizing treatment for his emergency medical condition.

Review of a third medical record showed that patient 5 was flown by helicopter to an acute care hospital (Hospital C - approximately 131 miles away) on 04/08/20 and arrived at approximately 3:30 PM. Further documentation showed that patient 5 received further examination and treatment to stabilize his emergency medical condition.

Based on interview, document review, medical record review, and policy review, the Critical Access Hospital (CAH) failed to provide an appropriate medical screening examination (MSE) within the hospital's capabilities to determine whether or not an emergency medical condition (EMC) existed for one of 20 records reviewed (Patient 5).

Failure of the CAH to provide an appropriate MSE for all individuals who come to the Emergency Department (ED) seeking assistance has the potential for persons to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition including death.

Findings Include:

During an interview on 06/29/20 at 10:45 AM, Patient 5's daughter, (F1) stated that she is a registered nurse (RN). She explained that her father was at home when he fell from his wheelchair, hitting his head and landing on his left side. She stated that she assessed him for injuries and his left leg was shortened, rotated out and he was unable to straighten it. "It seemed to me that it was broken." She called a neighbor who was an off-duty emergency medical services (EMS) worker who also assessed the injury and felt that Patient 5 should be transported by EMS to the ED. F1 called the EMS service and they transferred her father to Stanton County Hospital's ED. F1 stated she believed patient 5 would be admitted so she stayed at the house and gathered his medications and belongings and then drove to the hospital. When F1 arrived at the hospital, she was met by the Staff U, RN who told her Staff J, Medical Doctor (MD) was going to discharge her father to home and then Staff U gave her discharge instructions. F1 stated that Staff J never spoke with her.

Review of Patient 5's medical record showed he presented to the ED on 04/07/20 at 10:57 PM via EMS with a complaint of a fall resulting in hip and arm pain. Staff U, RN assessed the patient on 04/07/20 at 10:57 PM and noted no grimacing, frowning, or eyebrow knit and that the patient was unable to verbalize his pain. Staff U noted a skin tear to the left elbow with no bleeding and no apparent injuries to the lower extremities. Vital signs (VS) upon admission showed his blood pressure (BP) was high 175/104 (Normal Systolic 90 - 140 and Diastolic 50 - 90).

Staff J, MD saw Patient 5 on 04/07/20 at 11:20 PM and noted trauma to the left side of his body due to a fall at home, with no impairment, and Staff J ordered STAT (immediate) X-rays of the left elbow, left wrist, left knee, and left hip. Staff J's note showed, "Extremities: There is pain on left wrist extension, left elbow extension, left knee extension and left hip abduction. X-rays [sic] of left hip, knee, elbow and wrist: No fractures seen."

Review of the "Patient Chart Report" signed and dated on 04/08/20 at 1:24 AM, by Staff U, RN, showed, Patient 5 was taken to X-Ray at 11:38 PM on 04/07/20. At 12:08 AM on 04/08/20, Staff J, MD, reported that not fractures were seen, and Patient 5 could be discharged home. At 12:14 AM, Staff J, MD, left the hospital ED.

Patient 5's medical record failed to show documentation of any pain (verbal or faces) scale assessment. There was no documented evidence to show Patient 5 was given any pain medications or treatment to the left elbow laceration. There was no documented evidence of Patient 5's past medical history that included a non-operable meningioma (brain tumor), expressive aphasia (difficulty communicating to others what the person knows and wants to say) and cognitive impairment (loss of mental function).

Review of Patient 5's radiology report showed the report was faxed to the CAH on 04/08/20 at 12:19 AM and indicated that the left hip showed suspected impact left femoral neck subcapital [sic] fracture (a fracture of the head and neck of the thighbone that requires surgical repair to stabilize and prevent ongoing pain and debility), recommend CT Scan (radiology test that uses a combination of X-rays and a computer to create pictures of your organs, bones, and other tissues. The CT scan can reveal anatomic details that cannot be seen in conventional X-rays).

Further review of the "Patient Chart Report" signed and dated on 04/08/20 at 1:24 AM, by Staff U, RN, showed that at 12:35 AM, "after difficulty in transferring Patient 5 into the vehicle, staff brought the x-ray report from the radiologist [out to the car], that recommended a CT scan of the pelvis. Staff J, MD was informed by telephone and he said that the family could take the patient to [Hospital C - an acute care hospital located approximately 88 miles away] later that day."

Patient 5 was discharged into the care of his daughter at 12:39 AM. Discharge instructions included: a printed handout on falls and contusions, apply ice to left hip, elbow, knee as needed, follow up with primary care physician as needed and can take Tylenol 500 mg, every 4-6 hours for pain as needed.

Staff J failed to order the CT scan of the pelvis per the recommendations of the radiologist before Patient 5 was discharged. Staff J, MD did not return to provide further examination to determine whether an emergency medical condition existed, or provide treatment to stabilize Patient 5's severe pain, or to discuss further medical and/or surgical management with Patient 5 and his daughter.

During an interview on 06/24/20 at 4:48 PM, Staff V, Radiology Tech stated that she remembered coming to the CAH to perform X-rays for Patient 5 the night of 04/07/20. She verified that the CAH has the capability to perform a CT scan and she could have easily come back in that night to complete a CT scan.

During an interview on 06/29/20 at 6:48 PM, Staff T, Certified Nurse Assistant (CNA) stated that she remembered when Patient 5 arrived in the ED that he was in a lot of pain. She also recalled that when the X-ray report came back it showed the patient had a fractured femur; Staff J wanted him to go to a larger hospital for follow up the next day.

During an interview on 06/29/20 at 6:30 PM, Staff S, RN stated that she remembered that Staff U, RN was the nurse for Patient 5 the night of his ED visit on 04/07/20. Staff S explained that she took the X-ray results for Patient 5 off the fax machine, gave them to Staff U who then made a phone call to Staff J, MD at his home and he instructed Staff U to send the patient home and have them follow up at Hospital C later that day.

During a telephone interview on 06/30/20 at 1:15 PM, Staff U, RN stated that she remembered Staff J, MD left the CAH prior to Patient 5's discharge and prior to receipt of the radiology report. She stated that Staff J reviewed the X-ray and stated the patient was ok to dismiss to home (no fractures). Staff U stated that as she was assisting the transfer of Patient 5 into the car, Staff S, RN presented the printed X-ray report from the radiologist which recommended a CT scan for further determination of a possible break of the left leg. Staff U stated that although the results and recommendation was read to Staff J, he did not order a CT scan. She stated that she relayed the information, from Staff J to the daughter, that she could take him to Hospital C and have a CT performed later that day. Staff U explained it is more common to transfer patients when there is confirmation of a bone break than it is to discharge them. She further stated that the EMS stayed on site at the CAH because they thought he would be transferred.

During an interview on 06/30/20 at 9:45 AM, Staff J, MD, CAH Medical Director stated that he does prefer to send all patients with fractures to Hospital C because he knows the orthopedic specialists. Staff J was asked what his treatment protocol would be for a patient presenting to the ED with elevated blood pressure (BP) of 178/104, 178/88, 177/97 and in pain and he stated he would treat any underlying cause and attempt to medicate to lower the BP. Staff J then was asked to review Patient 5's medical record with the above listed elevated BP and presentation of pain and he verified he did not treat either one. Staff J remembers Patient 5 presented to the ED by ambulance, was grimacing with movement, and he was non-verbal. He noted a bruise on the patient's leg which was turned to the inside a little, and when touched it was painful. He stated the daughter arrived several minutes later and he spoke with daughter who gave a history of the fall and brought him to the ED to verify a fracture. Staff J stated that determining the level of pain and ordering pain medication was difficult because the patient had a seizure disorder and Alzheimer's. Staff J verified both diagnoses were not documented in the medical record and he clarified that he assumed those were the diagnosis the patient had based on the medication he was taking, Levetiracetam (seizure medication) and Aricept (for treatment of Alzheimer's). Based on the medications the patient was taking Staff J chose not to give pain medications, and he further stated he could have ordered Tylenol. Staff J explained he visually looked at the hip X-rays right after they were taken and determined there was no fracture, so the patient was discharged by private vehicle home with instructions to follow up with an orthopedist at Hospital C if the family wanted to, and Staff J left to go home. Staff J stated that after he was home, the ED nurse called to tell him the written report came back from the radiologist recommending a CT scan of the hip. Staff J determined since the patient was discharged, the CT could be performed when the patient had his orthopedic follow up. Staff J stated that he was unaware the patient was in so much pain when they transferred him from the wheelchair to the car at the time of discharge. He further stated that he did not talk with the daughter about the X-ray report after he received if from the radiologist. Staff J shared that had he been aware of the recommendation for the CT before he left, he would have ordered it to be performed at this CAH, however he was concerned about exposing the patient to excess radiation. He further stated he usually stays for the radiology report to be completed but did not during that visit.

During an interview on 06/30/20 at 1:25 PM, Staff A, Chief Executive Officer (CEO) stated that providers are not to make decisions regarding X-ray results or other radiology tests until they receive the radiologist's report, even if the provider looks at the X-ray results. Staff A explained there is too much room for error in those cases.

During an interview on 06/29/20 at 10:45 AM, F1, Patient 5's daughter further stated that it required four or five people to transfer her father into the car and it was very painful for her father, and F1 shared her father was not given any pain medication during the ED visit. The CAH staff asked F1 during the transfer into the car if her father could stand and F1 knew by that question it was evident the staff had not attempted to move him or have him stand while in the ED. Once they had him in the car, a nurse brought the X-ray report to F1 to review, which showed it identified a possible fracture of the hip and would need to be clarified by CT. F1 stated that a CT scan was not done prior to his discharge. When F1 questioned the X-ray report, the nurse took the report back into the ED and called Staff J, MD who told her there was no fracture and to send the patient home, and the family could choose to take him to another ED or orthopedic physician at another hospital the next day if they wanted. F1 told the facility staff she did not think she would be able to transfer him again out of the car into the house, especially since it took so many to get him into the car. F1 stated that she immediately drove her father to another CAH where he was assessed, given pain medication, and a CT was performed confirming the fracture to the hip. The patient was admitted and then air transported to another hospital for surgery the next day.

Review of a second medical record showed the daughter drove Patient 5 directly to another CAH B about 53 minutes away where he was seen in the ED. Patient 5 had a high BP (148/99) and an elevated Pulse (heart rate) 107 (Normal 60 - 100). Patient 5 had swelling and tenderness to the left side, his leg was shortened and externally rotated. Patient 5 received Fentanyl (narcotic pain medication) and he had a CT scan which showed a nondisplaced femoral neck fracture, with edema (fluid under the skin). The facility admitted Patient 5 for further management and discussion of surgical repair of the fracture versus no repair. The family chose surgical repair of the fracture and the patient was air lifted to another hospital (Hospital C) with the capabilities for orthopedic surgery that same morning. Patient 5 had surgical repair of the fracture there and then went to another hospital after discharge for rehabilitation and ultimately was discharged back to his home.