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Based on document review and staff interviews, the critical access hospital's (CAH) administrative Staff's failed to ensure staff followed the CAH's policies and procedures and provided an examination sufficient to determine whether or not an emergency medical condition existed for one (patient # 1) out of 24 patient charts reviewed. The hospital's failure to provide patient # 1 with a medical screening examination within its capabilities and capacity delayed stabilizing treatment and placed patient # 1 at risk for sudden death. The investigation findings showed patient # 1 returned to the emergency department (ED) twelve hours after discharge with an intracranial bleed, a life threatening emergency.

1. Review of policy "Emergency Medical Treatment and Active Labor Act (EMTALA): Emergency Transfer of Stabilized Patients", origination 03/2002, last revised 10/2017 revealed in part, "Purpose(s)/ Objective(s): To demonstrate the requirements that must be met to comply with the 1989 Omnibus Budget Reconciliation Act ...When a person comes to the emergency department and a request is made for examination or treatment for a medical condition, the hospital must provide an appropriate medical screening within the capability of the hospital's emergency department."

The CAH is designated by the State as a level IV trauma center and it's capabilities included an ED physician, the ability to report and monitor abnormal vital signs, emergency radiology services of computed tomography scans (CT-Scan) and magnetic resonance imaging (MRI). Specialized radiology tests to assist in the diagnosis of Strokes through the ED.

2. Review of a closed medical record showed that patient # 1 presented to the ED on 1/18/2018 at 7:56 AM complaining of headache that was not like her typical migraine headache. The ED physician documented in the medical record that Patient #1 reported she had experienced migraines before but "never had a headache as bad as this one." Further documentation identified the patient reported her headache began suddenly at 1:00 AM and that she had vomited 12 times since. The medical record failed to contain evidence that staff evaluated the cause of Patient #1's sudden onset of vomiting and severe headache. Further review of the medical record showed that Patient #1's medications included Plavix, a blood thinner. The medical record failed to contain evidence that determined whether Patient #1 had been prescribed Plavix due to a prior stroke or heart attack caused by a blood clot or whether Patient #1 was at risk for abnormal bleeding in the brain (possible cause for a severe headache) as a side effect of taking a blood thinner (Plavix). ED Director documented the pain as severe and unrelenting in the bi-frontal area of the head. Patient # 1 received pain medication which provided some relief "but not as much as she hoped" and was discharged within 90 minutes of arrival.

Refer to tag C2406 for further details.

I. Based on documentation review and staff interviews, the critical access hospital (CAH) administrative staff failed to ensure emergency department (ED) staff provided an appropriate medical screening examination (MSE) to 1 (patient # 1) of 24 patient records reviewed between 12/1/2018 and 6/4/2018. The CAH identified caring for an average of 773 patients in the emergency department (ED) each month.

Failure to provide an appropriate MSE prior to discharing patient # 1 delayed care and treatment of an emergency medical condition. Approximately twelve hours after discharge, patient # 1 returned to the ED by ambulance unresponsive as a result of an extensive brain bleed.

1. Review of policy "Emergency Medical Treatment and Active Labor Act (EMTALA): Emergency Transfer of Stabilized Patients", origination 03/2002, last revised 10/2017 revealed in part, "Purpose(s)/ Objective(s): To demonstrate the requirements that must be met to comply with the 1989 Omnibus Budget Reconciliation Act ...When a person comes to the emergency department and a request is made for examination or treatment for a medical condition, the hospital must provide an appropriate medical screening within the capability of the hospital's emergency department."

2. Review of Patient #1's medical record for the morning of 1/18/2018 at 7:56 AM revealed: the ED Physician documented Patient #1 reported she had experienced migraines before but never had a headache as bad as "this one." Further documentation identified the patient reported her headache began suddenly at 1:00 AM and that she had vomited 12 times since. The medical record failed to contain evidence that staff evaluated the cause of Patient #1's sudden onset of vomiting and severe headache. Further review of the medical record showed that Patient #1's medications included Plavix, a blood thinner. The medical record failed to contain evidence that determined whether Patient #1 had been prescribed Plavix due to a prior stroke or heart attack caused by a blood clot or whether Patient #1 was at risk for abnormal bleeding in the brain (possible cause for a severe headache) as a side effect of taking a blood thinner (Plavix). ED Director documented the pain as severe and unrelenting in the bi-frontal area of the head.

According to the Nursing Notes section of the medical record, Patient #1's blood pressure was 185/62 (normal blood pressure is 100/60 to 140/90) upon arrival to the ED at 8:00 AM on 1/18/2018. After Demerol 100 milligram (mg) and Phenergan 50 mg administered Intravenously (IV), Patient #1 reported the relief was not what they had hoped it would be. A second blood pressure was documented at 185/67 at 9:19 AM on 1/18/2018. The ED nurse documented patient # 1 left the ED in a wheelchair.

Patient #1's medical record revealed the ED Physician's spent 13 minutes with Patient #1 on 1/18/2018 prior to discharge at 9:30 AM.

3. Review of a second medical record showed Patient # 1 returned to the ED by ambulance on 1/18/2018 at 8:45 PM, approximately twelve hours after discharge earlier in the day. Documentation showed patient #1 began to have symptoms of an altered mental status. The patient's spouse contacted the ED and reported patient # 1 was confused and dropping things. The hospital staff advised the spouse to contact 911. Upon arrival to the ED documentation showed patient # 1 was not able to speak. A CT scan of the brain (special type of x-ray) showed that patient # 1 had extensive bleeding in her brain involving 5 different locations, 2 of which were in the front of the head (Subarachnoid Hemorrhage). Patient # 1 reported her headache was at the front of her head during her fist visit to the ED. Further documentation showed the staff arranged patient # 1's transfer to another hospital for surgery to evacuate the blood in her brain.

4. Interview with ED RN A on 6/6/2018 at 10:15 AM revealed: ED RN A worked 13 years as a nurse in the emergency department. ED RN A stated that the physician is told about vital signs only if the nurse feels it is a trigger. ED RN A said she did not report the patient's elevated blood pressures to the physician prior to discharge.

5. During an interview on 6/5/2018 at 4:10 PM, the ED Director stated when asked what he remembered about Patient #1's visit to the ED, "I remember I probably screwed up." The ED Director confirmed that a CT scan was not completed until patient # 1 returned to the ED.

6. During an interview on 6/5/2018 at 6:03 PM, ED RN B reported Patient #1 presented to the hospital the evening of 1/18/2018. ED RN B said it was obvious Patient #1 was having a stroke as Patient #1 was lethargic and could not speak wehn stimulated. ED RN B stated that when anyone comes in with a migraine headache, staff assess the severity and if the patient reports that they are having the worst headache ever, the ED nurse would follow the hospital's stroke protocol, get the CT scanner warmed up, insert an intravenous catheter and immediately notify the physician.