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Based on review of policy/procedure, documentation, and staff interviews, the Critical Access Hospital (CAH) failed to provide a medical screening examination to determine if an individual (Patient # 24) had an emergency medical condition during the patient's presentation to the hospital seeking emergency care on 1/31/15. The CAH staff identified an average of 480 emergency room patient visits per month.

Failure to provide an appropriate medical screening exam could potentially result in patients with an unidentified emergency medical condition not receiving appropriate and timely care.

Findings include:

1. Review of CAH policy/procedure titled "EMTALA - Requirements and Responsibilities", dated 12/14, revealed in part: ". . . The hospital must provide an appropriate medical screening examination, within its capability to do so, by qualified medical personnel to determine whether or not an emergency medical condition exists. . . ."

Review of CAH policy/procedure titled "Medical Screening Examination and Transfer", dated 4/13, revealed in part: ". . . POLICY: Any individual who comes to the emergency department and requests an examination or treatment of a medical condition, an appropriate medical screening examination shall be provided, within the hospital's capabilities, by qualified medical personnel to determine whether or not an emergency medical condition exists. . . ."

2. Review of the Emergency Department (ED) log on 2/9/15 revealed a late entry was made on 2/2/15 for Patient #24 presentation to the emergency department on 1/31/15 with complaints of nausea and vomiting.

3. Review of the CAH's Patient Grievance/Complaint Forms revealed CAH staff A, DON (Director of Nursing), received a complaint from Patient # 24 who stated she had come to the ED on 1/31/15 at 6:00 PM with orders from Physician A, a physician from an acute care hospital (Hospital B) located 33 miles from the CAH to be admitted and the CAH staff would not see her. Physician A was not a member of the medical staff at the CAH.

4. The following interviews were conducted on 2/9/15.

a. During an interview on 2/9/15 at 2:00 PM, Staff A, DON, and Staff B, ED Nurse Manager, reported Staff A received a call from Patient #24 on 2/2/15. Staff A said Patient #24 stated she had come to the hospital on 1/31/15 with orders from Physician A, a Physician from Hospital B, to be admitted. Patient #24 stated the weather was bad so she came to this hospital to be admitted. Staff A stated Patient #24 reported the nurse said "we can't help you here" that night and told the patient to go to Hospital B where she had orders to be admitted. Staff A stated she checked the computer and could not find a chart for Patient #24 on 1/31/15. Staff A and B stated they spoke with Staff C, ED Nurse, who verified Patient #24 had been to the hospital on 1/31/15.

b. During an interview on 2/9/15 at 2:25 PM, Staff D, Admissions Staff, stated on 1/31/15 at around 6:00 PM Patient #24 came in the ED door and she asked the patient if she needed to be seen. Patient #24 said she did, so Staff D got the patient's name and date of birth and entered the information into the computer. Staff D took the patient's stickers to the ED nurse and let the nurse know the patient was in the waiting room for the ED. Staff D stated some time later one of the ED nurses instructed her to take the patient out of the system because the patient was not going to be seen. Staff D stated she removed the name of Patient #24 from the computer.

c. During an interview on 2/9/15 at 3:00 PM, Staff C, ED Nurse, stated on 1/31/15 she was in the ED helping as the ED was busy when Staff D called to say there was another patient and the patient was in the secondary waiting room. A few minutes later, Staff C stated she took Patient #24 to ED exam room #6 and asked the patient why she was there. Staff C stated Patient #24 said she needed to be admitted to the hospital. Staff C stated Patient #24 had talked to her physician's nurse from another hospital and that nurse told the patient to come to Hospital B to be admitted. Staff C stated Patient #24 said she didn't want to drive to Hospital B so the patient came to the CAH instead.

Staff C stated Patient #24 reported she had nausea and vomiting for 24 hours and had undergone gastric bypass in December of 2014 and she was to be admitted and if there were any questions the ED nurse was to call Physician A at Hospital B. Staff C reported calling Hospital B and was told by a nurse at Hospital B that Physician A had left orders at Hospital B for Patient #24 to be a direct admit to Hospital B. Staff C reported telling Patient #24 that she was to be a direct admit to Hospital B and Patient #24's driver said they could drive to Hospital B.

Staff C acknowledged she did not do a patient assessment on Patient #24, did not take any vital signs, and did not inform the ED physician Patient #24 had made a request to be admitted for nausea and vomiting. Staff C verified she instructed Staff D to take patient #24 out of the computer as the patient was not going to be seen in the ED. Staff C stated after she received a phone call on 2/2/15 from the ED Nurse Manager Staff C entered Patient #24 in the ED log and filled out a chart on Patient #24 visit to the ED on 1/31/15.

5. During an interview on 2/9/15 at 5:55 PM, Patient #24 stated she had received a call from Physician A's nurse said she was to tell the CAH to call her physician as she needed IV fluids and antinausea medication. Patient #24 stated she went to the CAH due to a snow storm and could not get to Hospital B. The CAH ED staff didn't offer her and opportunity to see a doctor. The ED staff placed me in an ED room and called Hospital B and then told her she had orders to be admitted at Hospital B.

6. Review of Patient #24 ED record on 2/9/15 revealed Staff C, ED Nurse, recorded the medical record on 2/2/15 at 1:56 PM. Documentation revealed Patient #24 presented to the ER on 1/31/15 and stated she needed to be admitted at the CAH as she had been vomiting for 24 hours and had gastric bypass surgery in December of 2014. Patient #24 stated if the CAH staff had any questions, they were to call Physician A at Hospital B. Patient #24 stated she had talked to Physician A's nurse today and was told to go to Hospital B for admission. Patient #24 stated she had come to the CAH instead because of the weather.

Patient #24 was taken to ER Exam room 6 and was informed the ED nurse would call nurse at Hospital B. Staff C documented she spoke with Patient #24 and her driver regarding the conversation with a nurse at Hospital B about admission to Hospital B. Staff C documented since this was a bariatric issue, Hospital B would be able to help the patient better. Staff C documented Patient #24 was visibly not happy with the news but did nod her head in understanding. Staff C documented the Patient's driver stated they can go over there. Patient #24 then left the ED at 7:11 PM.

Patient #24 ED record of 1/31/15 lacked documentation of vital signs, assessment, or medical screening examination.