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Based on interview, medical record and document review, the Critical Access Hospital (CAH) admitted a patient from the CAH's Emergency Department (ED) with an emergency medical condition to the medical surgical unit. The CAH lacked the capability to provide the specialized care the patient required. The deficient practice affected one of twenty patient records sampled from the ED log from January to July 2010.

Findings included:

Review of the medical record revealed patient #1 presented to the ED on 6/18/10 at 1:55 AM with complaints of chest pain. Staff D (Physician Assistant) provided patient # 1 with a Medical Screening Examination. At 2:00 AM a 12 lead EKG (a cardiac test which records the conduction, magnitude and duration of the electrical activity of the heart) demonstrated patient # 1 was experiencing a ST elevated MI (a type of heart attack requiring medication to dissolve a blood clot and time-critical treatment in a cardiac catheterization lab). Staff D documented a description of the ST elevation and determined patient #1 required transfer to Hospital F (specialized capabilities included a cardiac catheterization lab), but the transfer was declined. Staff D phoned Physician C (on call physician) to report the assessment findings and notify him that Hospital F had refused to accept patient # 1 for transfer. Neither Staff D or Physician C arranged transfer to another hospital with specialized capabilities equal to Hospital F. Physician C did not come to the ED to examine patient # 1 and at 3:00 AM provided Staff D with orders for inpatient admission. At 9:56 AM patient # 1 deteriorated and at 10:00 AM the code blue team (medical personnel specially trained to respond to medical emergencies) initiated advanced life support efforts to stabilize patient # 1. At 10:18 AM documentation in the medical record revealed arrangements for transfer to Hospital F had been made and that patient # 1 ' s condition was critical. At 10:34 AM the ambulance crew presented to patient # 1 ' s bedside for emergent transport to Hospital F.

Review of a partially transcribed phone call (provided by Hospital F) revealed Staff D initiated contact with Hospital F ' s on call cardiologist on 6/18/10 because it looked like patient # 1 was " infarcting again " (destruction of heart tissue resulting from obstruction of the blood supply).

According to the statutorily mandated Quality Improvement Organization physician peer review conducted on August 31, 2010, patient # 1 had an emergency medical condition and the cardiac resources necessary to stabilize the patient ' s STEMI (ST elevated MI) were not available at the hospital.

Review of the Hospital/CAH Medicare Database Worksheet completed by Chief Nursing Officer (CNO) on 8/3/10 revealed the CAH does not have the capabilities of a trauma center, an intensive care unit, a cardiac catheterization laboratory or cardiac-thoracic surgery and has an average daily census of 9.34 patients.

Review of the CAH's transfer agreement with Hospital F, "Transfer and Referral Protocols" revealed "IV. Resolution of Transfer Problems, A. In the event that difficulties are encountered in transferring a patient from the CAH to Hospital F, and the problem cannot be resolved by Hospital F Emergency Department Staff, the CAH or the referring physician will contact the "Patient Services Supervisor" at Hospital F. This individual will seek to solve the problem. The policy also states "B. Should the resolution at that level not be satisfactory, either the CAH or referring physician may request to be contacted by the administrative staff member on duty or on call. The administrator should be provided with appropriate information including the patient name, condition, name of the referring physician, name of the individuals contacted at Hospital F, and any other pertinent information. The administrative staff person will follow up immediately."

During an interview on 9/4/10 at 10:45 AM, Staff D reviewed the CAH ' s Network Agreement and indicated he had not seen the Network Agreement before and was unfamiliar with what to do when a request for transfer was denied.

During an interview on 8/3/10 at 4:40 PM, Physician C confirmed he did not come to the ED to examine patient # 1. Physician C stated that Staff D called him twice in the night on 6/18/10 and that Staff D expressed to him the patient required a higher level of care. Physician C stated he concurred.

According to the CAH's bylaws titled "Rules for Emergency Services 10.3" . . "Response time - Physicians on call to the emergency room shall respond as soon as possible but never more than thirty (30 minutes) from the time of being notified." In the CAHs "COBRA/EMTALA Regulations for Emergency Medical Condition and Transfers" it states, "If it has been determined that a patient has an Emergency Medical Condition the physician must come to the hospital to examine the patient."

Review of the CAH's "Rules and Regulations of the Medical Staff" revealed under " The Rules and Regulations include "Admission of any patient is contingent on adequate facilities and personal...". According to the CAH's Rules and Regulations they admit patients they can take care of and all those they can't take care of are transferred. 10.1 . . . "Emergency patients who require services beyond the scope of the hospital to provide must be stabilized and referred to an appropriate institution as soon as possible."

The CAH ' s physician on call did not come to the emergency department to examine patient # 1 as required by its policies and procedures and did not arrange transfer to a hospital with the capabilities to stabilize patient #1's emergency medical condition.

Based on document review and interview, the Critical Access Hospital (CAH) failed to transfer a patient with an Emergency Medical Condition to an acute care hospital with the capabilities to provide specialized cardiac care. The CAH admitted a patient from the Emergency Department (ED) with an emergency medical condition. Admitting a patient to the CAH without the capabilities to provide specialized cardiac care affected one of 20 patient records sampled from the ED log from January to July 2010 (patient #1).

Findings included:

Review of the EMS (emergency medical services) report dated 6/18/10 revealed Patient #1 called EMS from home at approximately 1:10 AM complaining of chest pain. Documentation revealed patient # 1 took nitroglycerine (a medication used to treat episodes of chest pain) before the ambulance arrived. The ambulance crew documented they administered three additional nitroglycerine tablets, initiated 2 liters of oxygen and started an intravenous infusion of normal saline before arriving at the hospital at 1:55 AM.

Upon arrival at the CAH ' s ED, Staff D (Physician Assistant) examined patient #1 and documented that she had recently been discharged from Hospital F after placement of a coronary stent (a tube placed in the coronary arteries that supply the heart to keep the arteries open) and that she now presented with new onset chest pain, shortness of breath, and complained of pain worse than previous episodes. An ECG (electrocardiograph- a cardiac test which records the conduction, magnitude and duration of the electrical activity of the heart) performed on patient #1 in the ED at 2:00 AM noted across the top " **CONSIDER ACUTE ST ELEVATION MI** " (a type of heart attack requiring medication to dissolve a blood clot and time-critical treatment in a cardiac catheterization lab) and Staff D documented a description of the ST elevation. At 2:10 AM, Staff D contacted the cardiologist on call at Hospital F and reported the findings and was directed to obtain cardiac enzymes (i.e., Troponin is a blood test that helps determine if your heart muscle is injured). Staff D documented " Enzymes returned with Troponin 5.67 (normal 0 - .1) but Dr. [on call cardiologist at Hospital F] states that ' s down from her admission level @ [Hospital F] and refused to accept tx (transfer). " At 2:50 AM Staff D documented contact with Physician C (the on-call physician at the CAH) to discuss the findings. Physician C did not come to the ED to examine patient # 1 and at 3:00 AM provided Staff D with orders for inpatient admission. At 4:20 AM the nurse documented that patient # 1 complained of increasing chest pain and administered morphine 4 mg (a narcotic used to relieve chest pain). In a follow up note at 4:50 AM the nurse documented that patient # 1 received 10 mg of morphine in the ED and 25 mg of phenergan (a medication used to treat nausea). Review of the medication administration record revealed that patient # 1 received Aspirin and Plavix (two medications used to prevent blood clot formation inside arteries) at 8:18 AM, approximately 6 ? hours after presenting to the ED. At 9:56 AM patient # 1 deteriorated and at 10:00 AM the code blue team (medical personnel specially trained to respond to medical emergencies) initiated advanced life support efforts to stabilize patient # 1. At 10:18 AM documentation in the medical record revealed arrangements for transfer to Hospital F had been made and that patient # 1 ' s condition was critical. At 10:34 AM the ambulance crew presented to patient # 1 ' s bedside for emergent transport to Hospital F.

Review of Hospital F ' s medical record revealed patient # 1 arrived on 6/18/10 at 11:16 AM by ALS (advanced life support) ambulance and was taken directly to the cardiac catheterization lab.

Staff D interviewed on 7/19/10 at 10:30 AM confirmed patient #1 "looked sick like having an MI" (myocardial infarction or heart attack) and entered the ED with classic MI symptoms including pain, sweating, and clutching the chest. Staff D stated the patient required transfer to a hospital with a cardiac catheterization laboratory. Staff D stated they "should have called another cardiologist" since the cardiologist at Hospital F refused to accept the transfer of patient #1. Staff D acknowledged patient #1 required specialized cardiac care that the CAH could not provide.

During an interview on 8/3/10 at 4:40 PM, Physician C confirmed he did not come to the ED to examine patient # 1. Physician C stated that Staff D called him twice in the night on 6/18/10 and that Staff D expressed to him the patient required a higher level of care. Physician C stated he concurred.

According to the statutorily mandated Quality Improvement Organization physician peer review conducted on August 31, 2010, patient # 1 had an emergency medical condition and the cardiac resources necessary to stabilize the patient ' s STEMI (ST elevated MI) were not available at the CAH.

The CAH admitted patient # 1 on 6/18/10 at 3:00 AM with an emergency medical condition. The CAH ' s physician on call did not come to the emergency department to examine patient # 1 as required by its policies and procedures and did not arrange transfer to a hospital with the capabilities to stabilize patient #1's emergency medical condition.