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Based on document and medical record review the Critical Access Hospital (CAH) failed to follow its policies and did not provide 2 (# 1 and 21) of 22 sampled patients who presented to the emergency department (ED) from November 2018 - August 2019 with a medical screening examination sufficient to determine whether an emergency medical condition existed. The CAH also failed to provide within its capabilities, stabilizing treatment prior to discharging one patient (# 10) with an emergency medical condition. Additionally, the CAH failed to arrange an appropriate transfer when patient # 10 returned to the ED with an un-stabilized emergency.

These failures may cause patients to leave the ED with an undiagnosed and/or untreated emergency, placing them at risk for delays in care which could lead to complications and deterioration in their health, up to and including death. Failing to weigh the medical benefits of transfer when arranging appropriate transfers has the potential to place a patient with an unstabilized emergency at risk for an unsafe transport which could lead to further deterioration in their health or death.

Findings Include:

Review of the CAH's policy titled, "EMTALA" dated 02/18/19 showed in part, "All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic. Hospital may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. Medical Screening exams should include at a minimum the following and will be completed by a combination of provider and nursing assessments: Emergency Department Log entry including the disposition of the patient, Patient's triage record, vital signs, history if known, physical exam of the affected systems and potentially affected systems, exam of known chronic conditions, necessary testing to rule out emergency medical conditions, notification and use of on-call personnel to complete previously mentioned guidelines, notifications and use of on-call physicians to diagnose and/or stabilize the patient as necessary, vital signs upon discharge or transfer, and complete documentation of the medical screening exam.

Review of a closed medical record showed that patient # 1 presented to the emergency department (ED) by ambulance on 8/1/19 at 6:40 PM. The ambulance pre-hospital trip report indicated patient # 1 stated she was recently released from an area care facility to live by herself and that she had consumed a 1/2 liter of vodka because "she is upset." "The patient asked multiple times if we were going to help her." Further documentation showed that the patient stated she was "drunk and wants to die."

Upon arrival to the ED, the triage nurse documented the patient's clinical signs of intoxication included "confusion/disorientation, nausea", "slurred" speech, was "stuporous" and that the patient "started drinking today after 2 years of sobriety." The mid-level practitioner A examined patient # 1 at 6:50 PM and documented the patient reported "drinking too much alcohol today and is now nauseated." Further documentation showed that the patient "drifted in and out of sleep" and that she did not feel safe to go home due to the presence of alcohol. Eleven minutes later at 7:11 PM the mid-level practitioner documented orders for patient # 1 to be discharged back home. The medical record did not contain evidence that the CAH provided patient # 1 with a medical screening examination sufficient to determine whether or not an emergency medical condition existed. Refer to tag C2406 for further details.

Review of a closed medical record showed that patient # 21 presented to the ED seeking care on 8/7/19 at 5:47 PM. Documentation showed that mid-level practitioner A examined the patient at 6:10 PM. "The patient presents with difficulty breathing and wheezing." At 6:09 PM the patient received an intravenous (IV) dose of methylprednisolone 125 mg (steriodal anti-inflammatory) The mid-level practitioner A documented he diagnosed the patient with exacerbation of chronic obstructive pulmonary disease, high dependence on smoking, and non-compliance with medical treatment. Further documentation showed "patient stating there is no need for prescriptions because he will not fill them - he has money for smoking but states he has no money to get medication." At 6:18 PM the ED nurse documented patient # 21 showed signs of respiratory distress which included labored breathing, grunting and sitting in the tripod position (leaning forward with hands on knees in order to breathe easier). At 6:43 PM the ED nurse documented the patient's respiratory rate was 26 breaths per minute (normal resting respiratory rate is 12-20). At 6:47 PM mid-level practitioner A discharged patient # 21. The medical record did not contain evidence that mid-level practitioner A re-assessed or re-examined the patient prior to discharge to determine whether he had an emergency medical condition. Refer to tag C2406 for further details.

Review of a closed medical record showed that patient # 10 presented to the ED on 5/23/19 at 4:50 PM complaining of vomiting and abdominal pain. The triage nurse documented the patient stated her upper abdominal pain was constant, that it "hurts whole lot" and that she rated it "8" on a scale of 1 - 10, 10 being the most severe pain. At 5:00 PM mid-level practitioner A documented he examined patient # 10 and that the patient presented with nausea and vomiting that began 12 hours prior, her symptoms were constant and exacerbated by eating and drinking, and that the patient had been exposed to others with gastroenteritis (stomach flu). Further documentation showed the patient had mild abdominal tenderness. At 5:16 PM the ED nurse gave patient # 10 a 4 mg tablet of Zofran (medication to control nausea). At 5:26 PM mid-level practitioner A determined patient # 10 could be discharged home. The medical record did not contain evidence that patient # 10 received further examination including administration of fluids to ensure that she did not continue to vomit and would be able to maintain adequate hydration at home. Without further examination, it could not be determined that patient # 10 would not deteriorate after discharge. Refer to tag C 2407 for further details.

Review of the CAH's policy titled, "Transfer of Patient to Another Facility" dated 02/18/19 showed in part, ..."The following standards will be followed: i. Patients must need treatment that is not offered at SCH [Stafford County Hospital]. If the patient is unstable and is found to have an emergency medical condition, and the benefit of the transfer must outweigh the risks. ii. Access is provided to all resources of the hospital to determine if a patient has a potentially harmful condition. iii. Patients may not be transferred if they remain at risk of deteriorating due to or during the transfer to another facility; unless the needs of the patient cannot be met at SCH. iv. Patients may not be transferred if they remain at risk of deteriorating due to or during the transfer; unless a provider has certified in writing that the risks are justified by the benefits to be obtained at receiving facility.

Review of a closed medical record showed that patient # 10 presented to the ED by ambulance on 5/24/19 at 8:19 PM, approximately 24 hours after discharge on 5/23/19. At 8:30 PM mid-level practitioner A examined patient # 10 and documented the patient had severe right lower abdominal pain. At 9:46 PM a CT scan (special type of x-ray) showed that patient # 10 had acute appendicitis (infection of the appendix). Further documentation showed the patient had symptoms of sepsis (potentially life threatening condition caused by the body's response to an infection) and required administration of IV fluids and an antibiotic. The medical record did not contain evidence that the CAH administered an antibiotic to treat patient # 10's infection prior to transferring her to a higher level of care for emergency surgery or that the on-call physician certified that the medical benefits of transfer outweighed the risks. Documentation on the transfer form specified that a "PHYSICIAN MUST COUNTERSIGN WITHIN 24 HOURS", however the space on the transfer form for the physician's signature was blank. Refer to tag C 2409 for further details.

Based on interview, record review, and document review the Critical Access Hospital (CAH) failed to provide an appropriated medical screening exam (MSE) for two (Patient 1 and 21) of 22 sampled patients who came to the emergency department (ED) seeking treatment.

Failure of the CAH to perform an appropriate MSE for every patient presenting to the ED has the potential to allow an emergency medical condition (EMC) to be unidentified which could place patients at risk and could potentially lead to further complications or death.

Findings Include:

Review of Patient 1's closed medical record showed the patient presented to the ED by ambulance on 08/01/19 at 6:40 PM with a chief complaint of alcohol intoxication and nausea. Review of the pre-hospital ambulance trip report showed that patient 1 stated she was recently released from a local care facility to live by herself. Further documentation showed the patient stated she had "consumed a 1/2 liter of vodka because she is upset." "[name of patient 1] asks numerous times if we are going to help her." "[name of patient 1] states she is just drunk and wants to die."

Upon arrival to the ED, Registered Nurse (RN) B documented the patient's clinical signs of intoxication included "confusion/disorientation, nausea", "slurred" speech, was "stuporous" and that the patient "started drinking today after 2 years of sobriety." RN B documented Patient 1 was unable to sign the CAH's consent to treat form and signed "implied consent" (an assumption that an unconscious patient would consent to emergency care if the patient were conscious and able to consent) on the form for Patient 1. Documentation showed patient # 1's blood pressure was low at 92/52 (normal range 120/80 - 140/90).

Physician Assistant (PA) A examined patient 1 at 6:50 PM and ordered Zofran 8 milligrams (a medication used to treat nausea). Further documentation showed the patient "drifted in and out of sleep" and that she did not feel safe to go home due to the presence of alcohol. Eleven minutes later at 7:11 PM the PA A documented orders for patient 1 to be discharged back home.

The medical record did not contain evidence that the CAH provided patient 1 with a medical screening examination sufficient to determine whether or not an emergency medical condition existed. There was no documentation of a psychiatric/substance abuse assessment, re-assessment of the patient's blood pressure, fall risk, or whether her nauesa had resolved and she was able to tolerate fluids for adequate hydration.

During an interview on 08/20/19 at 4:30 PM, Patient 1 stated that she went to the hospital after drinking a lot of alcohol. She stated she had been sober for two years and had just left the nursing home to live independently. Patient 1 stated that when she got to the hospital she was embarrassed and ashamed of herself and felt she should go home. Patient 1 stated a male provider told her that if she wanted to go home she should, "just go home, we don't want you here" and "you are a waste of time and money." Patient 1 stated that she was afraid to go home because she had come to the realization that she couldn't live independently and needed to go back to the nursing home. Patient 1 stated that she did not refuse anything and doesn't remember anyone asking her to sign a consent form.

During an interview on 08/21/19 at 8:30 AM Staff C, Emergency Medical Technician (EMT), stated that when they arrived at the hospital with Patient 1 a nurse, Staff B, RN, and the physician's assistant Staff A, came in to the room and Patient 1 stated she wanted to go home. Staff A then told the patient "good go home, we don't want you here" and then he told her that she was "a waste of time and money." Staff C stated that he was concerned because he felt the patient was possible dehydrated because she had been drinking alcohol all day and had not eaten or drank anything else and when they tried to get an IV started they were unsuccessful. Staff C stated that they did not do anything for the patient just told her to "go home and sleep it off." Staff C stated that the nurse, Staff B, came down the hall and asked them if they would take Patient 1 home. Staff C stated that Patient 1 didn't want to go home because there was alcohol in the house and she was afraid she would drink more. Staff C stated that Staff A would not let the patient stay at the hospital. Staff C stated that his partner stayed with the patient until arrangements could be made for her.

During an interview on 08/21/19 at 9:30 AM, Staff H, Paramedic, stated that her and her partner Staff C, EMT, were called to assist Patient 1 who had a chief complaint of alcohol intoxication. Staff H stated that Patient 1 was a little hypotensive (low blood pressure) and they tried to start IV three times but were unsuccessful because the patient's veins were "flat." Staff H stated that hypotension and difficulty establishing an IV indicated to her that the patient was potentially dehydrated and would benefit from IV fluids. Staff H stated the patient also reported nausea but without an IV they were unable to give her any. Staff H stated that when they arrived at the hospital Staff A, PA, came in to the room and Patient 1 stated she wanted to go home. Staff A then told the patient "good go home, we don't want you here" and then he told her that she was "a waste of time and money". Staff H stated that after Staff A said that to the patient she would no longer make eye contact and looked "depressed". Staff H stated Staff A discharged the patient without attempting any laboratory studies or providing her any treatments. Staff H stated that Staff B, RN, asked them to take her home so she could "sleep it off."

During an interview on 08/20/19 at 10:15 AM, Staff A, PA, stated that when Patient 1 first arrived via EMS she stated that she wanted to go home. Staff A, confirmed that he might have told the patient "then go home, we don't want you here" but doesn't recall telling her that she was "a waste of time and money". Staff A, stated that Patient 1 was alert and oriented and only complained of nausea.

During an interview on 08/20/19 at 7:45 PM, Staff B, RN, stated that the patient was stuporous, confused, and she couldn't assess the patients gait because she was just lying there in the bed when she first arrived. Staff B, stated that she did not hear Staff, A, PA, tell the patient that "we don't want you here" or "you're a waste of time and money." Staff B, stated that the patient only complained of nausea and was given Zofran for that. Staff B, stated that she thought she had gotten the discharge vital signs but must have forgotten to document it.

During an interview on 08/20/19 at 9:45 AM, Staff F, Medical Director, stated that when an intoxicated patient comes into the ED he expects that the provider would draw laboratory studies for at least electrolytes and possibly administer some intravenous fluids.

Review of Patient 21's closed medical record showed that he presented to the ED on 08/07/19 at 5:47 PM with a chief complaint of Chronic Obstructive Pulmonary Disease (COPD) exacerbation. Patient 21 was given 150 milligrams of solumedrol (a steroid medication used to treat inflammation), Atrovent nebulized breathing treatment, and a Duoneb nebulized breathing treatment. No laboratory studies were performed to rule out an emergency medical condition.

Staff J, RN, performed an assessment on 08/07/19 at 6:18 PM and documented the following: Respiratory: Grunting, Hyperpnea, Labored, Stridor, Tripod position. Cough: unable to clear secretions, Breath sounds: Lower lobes: Expiratory wheeze, inspiratory wheeze, Upper lobes: Diminished, Expiratory wheeze, inspiratory wheeze.

Staff J, RN, documented vital signs at 6:48 PM to be a pulse of 131 beats per minute (normal range is 60 - 100), Respirations of 26 breaths per minute (normal range is 14 - 20), blood pressure of 149/89 and oxygen saturation of 94% on room air (within normal range)

Staff A, PA, documented, "Patient states there is no need for the prescription because he will not fill them. He has money for smoking but states he has no money to get medication." Further documentation showed Staff A, PA entered orders for discharge at 6:41 PM and that the patient was discharged at 6:47 PM.

Review of a second closed medical record showed that patient 21 presented to Hospital BB by ambulance on 08/07/19 at 10:10 PM, approximately 3 1/2 hours after discharge complaining of shortness of breath. Documentation showed that patient 21 was in respiratory distress (an emergency medical condition) and was admitted as an inpatient for stabilizing treatment.

During an interview on 08/21/19 at 5:30 PM, Patient 21 stated that he received a breathing treatment and some IV medications, and he did feel a little better when he left. Patient 21 stated that his breathing problems got worse shortly after he got home so he called EMS. Patient 21 stated that the ambulance transported him to Hospital BB where he was admitted for a few days.

During an interview on 08/21/19 at 9:30 AM, Staff H, Paramedic, stated that she had concerns about Patient 21 who had called for EMS with a complaint of respiratory distress after being discharged from Hospital AA. Staff H stated, "Patient 21 had an oxygen saturation of 85% on room air when we got to his place. Patient 21 said that he had been treated at Hospital AA by Staff, A, PA. After we gave Patient 21 some breathing treatments he had enough breath to talk and told us that Staff A had the nurse start an IV (a device used to allow access to the veins) and give him some medicine. We transported Patient 21 to Hospital BB where he was admitted for acute COPD exacerbation for 2 days.

During an interview on 08/21/19 at 3:00 PM, Staff J, RN, stated that she gave Patient 21 two breathing treatments and an IV injection of solumedrol (a steroid medication). Staff J stated that after the treatments the patient stated, "that's just what I needed". Staff J stated that she reassessed Patient 21 and he was discharged home.

During an interview on 08/21/19 at 8:45 PM, Staff A, PA, stated that he treated this patient with a steroid and nebulized breathing treatments. Staff A stated the patient still had some wheezing when he was reassessed but was improved and ready for discharge. Staff A stated that Patient 21 was known to him and often comes in for a breathing treatment when his medications have run out and he has not received refills in the mail.

During an interview on 08/21/19 at 6:00 PM, Staff F, Medical Director, stated that he would have liked to have seen more done in this case like laboratory studies and a chest x-ray. Staff F stated that "You don't always have to do labs, but I would have on this patient. I would have liked to have known the underlying cause of the COPD exacerbation".

Based on interview, record review and document review, the Critical Access Hospital (CAH) failed to provide necessary stabilizing treatment, resulting in a delay in treatment of an emergency medical condition (EMC), within the capability of the staff and CAH for one (Patient 10) of 22 sampled patients. Failure of the CAH to provide appropriate stabilizing treatment has the potential to place patients presenting to the emergency department (ED) at risk for worsening of their condition or even death.

Findings Include:

Review of Patient 10's closed medical record showed she presented to the ED on 05/23/19 at 4:50 PM with a chief complaint of vomiting and abdominal pain. Laboratory studies included a urine analysis and a pregnancy test which were both negative.

Staff L, RN, documented vital signs at 5:12 PM as a blood pressure of 157/103 (normal range 120/80 - 140/90), pulse of 86 beats per minute, respirations at 20 breaths per minute, and a temperature of 36.7* Celsius (within normal range). Staff L, RN documented the patient complained she had upper abdominal pain that was constant and "hurts whole lot." Patient 10 rated her pain as an 8/10 on a scale of 0 to 10 (0 being no pain and 10 being severe pain).

Staff A, PA, documented he assessed the patient's abdomen and documented the patient reported mild, generalized tenderness. Staff A documented, "Patient has no fever, or focal tenderness, multiple patients in the area with similar symptoms - likely viral illness."

At 5:06 PM on 05/23/19, Zofran (a medication to treat nausea and vomiting) 4 milligrams (mg) tablet was ordered by the provider and documented as given to Patient 10 at 5:17 PM.

At 5:29 PM Staff A, PA entered an order for discharge in the medical record. At 5:38 PM patient 10 was discharged with a prescription for Zofran to treat her nausea.

The medical record lacked evidence that patient 10's nausea and vomiting had stabilized after receiving a dose of Zofran while in the ED or that she did not continue to vomit and would be able to maintain adequate hydration at home. Without this treatment, the CAH could not be assured the patient would not deteriorate after discharge.

Review of the hospital's ED log showed Patient 10 returned to the ED on 05/24/19 at 8:10 PM (approximately 26 hours after discharge) with a chief complaint of severe right sided abdominal pain and was diagnosed with acute appendicitis and sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death).

During an interview on 08/21/19 at 8:45 PM, Staff A, PA, stated that Patient 10 had no focal tenderness the first time she came in and it is rare to have anything acute without any tenderness. Staff A stated it might have been early for it to show up. Staff A stated that Patient 10's symptoms are almost always viral. Staff A stated, "I always explain to patients with belly pain that it can be a number of things and they should return if anything changes or gets worse".

Based on policy review and record review the Critical Access Hospital (CAH) failed to ensure the physician signed the Transfer Certification form of an unstable patient and failed to document the risk that could occur during the transfer for one (Patient 10) of 22 sampled patients the who came to the emergency department (ED) seeking treatment. Failure to document the risks of a transfer and ensure the physician signs the Transfer Certification form has the potential to place patients at risk for further complications or death.

Findings Include:

Document review of the CAH's policy titled, "Transfer of Patient to Another Facility" dated 02/18/19 showed, ..."The following standards will be followed: iv. Patients may not be transferred if they remain at risk of deteriorating due to or during the transfer; unless a provider has certified in writing that the risks are justified by the benefits to be obtained at receiving facility.

Review of the hospitals ED log showed Patient 10 was seen in the ED on 05/23/19 with a diagnosis of gastroenteritis (inflammation of the stomach and intestines), given medication for nausea and vomiting and discharged home. She returned to the ED on 05/24/19 at 8:10 PM (approximately 26 hours after discharge) with a chief complaint of right sided abdominal pain.

Staff B, RN documented vital signs at 8:19 PM as a pulse of 114 beats per minute (normal range is between 60-100), respirations of 28 (normal range is 14-20), blood pressure of 140/82, temperature of 37.2*Celsius, and an oxygen saturation of 99% on room air (within normal range)

Patient 10 rated her pain at a 10/10 and was given the following medications: Morphine 5 mg, Sodium Chloride 1000 milliliters (ml) and Zofran 4 mg. A CAT (CT) scan was performed and revealed an acute appendicitis. White Blood Cell count showed 22,000 (normal range is 4,500-10,500) and a high bilirubin level of 2.5 mg/dl (normal is less than 0.3 mg/dl) (can be a marker for a perforated appendicitis).

The medical record showed a diagnosis of acute appendicitis and acute sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). Patient 10 was transferred to Hospital CC for surgical intervention.

Review of Patient 10's "Transfer Certificate/Consent for Transfer/Transfer Record" dated 05/24/19 showed, Staff A, PA determined Patient 10 required transfer to Hospital CC which could provide further stabilizing treatment for the patient's surgical emergency. Documentation on the transfer form indicated staff contacted the ambulance at 9:50 PM, the receiving hospital at 10:18 PM and at 10:34 PM the patient departed Stafford County Hospital. The medical benefits noted on the transfer form was "surgery." The medical record did not contain a certification by a physician that the medical benefits of transfer outweighed the risks, or whether transport by a basic life support equipped ambulance was appropriate. The form indicated Staff A, PA, arranged the transfer "on verbal orders from" Dr. M, the on-call physician on 05/24/19. The form specified that a "PHYSICIAN MUST COUNTERSIGN WITHIN 24 HOURS." However, the space on the transfer form for Dr. M's signature was blank.