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Based on policy reviews, staff interview, review of EMS records, and Life Flight trip records, the Critical Access Hospital (CAH-A) failed to ensure 1 of 20 sampled patients (Patient 1) was provided a Medical Screening Examination (MSE) to determine within the hospital's capabilities the presence of an Emergency Medical Condition (EMC) existed, in accordance with the facility Medical Screening Examination and Stabilization policy and procedure. Patient 1 presented to the Emergency Department (ED) via ambulance with EMS requesting medical care twice and the staff failed to provide the MSE. This failure to follow the hospital's policy and procedure for performing an MSE to determine an EMC has the potential to cause harm or death due to a delay in treatment. According to the facility provided information the ED sees an average of 216 patients per month.

Findings are:

See also 2406

A. Review of Medical Screening Examination and Stabilization policy (Last Reviewed 10/2022) reveals:
- An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and:
- The individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition,
-When an MSE is Required
A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: (i) to any individual, including a pregnant woman having contractions, who requests such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC, or a pregnant woman is in labor. An MSE is required when:
Emergency medical Services (EMS) personnel may request an evaluation or treatment on an individual's behalf.
- Example: If an individual is on a gurney or stretcher or in an ambulance or on a helipad at the hospital and EMS personnel, the individual or a legally responsible person acting on the individual's behalf requests examination or treatment of an EMC from hospital staff, an MSE must be provided.
- An individual is in a ground or air ambulance for purposes of examination and treatment for a medical condition at a hospital's DED, and the ambulance is either:
- Owned and operated by the hospital, even if the ambulance is not on hospital grounds, or
- Neither owned nor operated by the hospital but on hospital property.

B. In a telephone interview with (EMS F) at 3:19 PM it was verified, that the EMS squad (a community volunteer Basic Life Support (BLS) group of lay personnel) showed up on the hospital property (CAH A) on 12/25/22 at 7:52 AM and pulled in front of their ER ambulance bay door and it wouldn't open due to maintenance or something. The EMS crew member (EMS F) went into the hospital emergency department area and talked to the Registered Nurse (RN A) and told her that the squad was here with a patient but could not open the door to the ambulance bay. The (RN A) told the squad member that they "can't accept the patient due to the life flight was on the way to the hospital, because they called them". The crew member told the nurse the life flight was just on stand by. (EMS F) went back to the squad and told them that the hospital wouldn't accept the patient. A few minutes later (EMS F) re-entered the (CAH A) to talk to the registered nurse and asked again, why won't you let us bring the patient in? The nurse told me "they (the helicopter) were about 7 minutes out and by the time we would get (the patient) in here and do the assessment it would take 30 minutes and the helicopter would already landed". (EMS F) returned to the squad.

When asked (EMS F) if the EMS squad was on the hospital property and the hospital staff knew the EMS squad had a patient for them, (EMS F) stated, "Yes, we were parked in front of their ambulance bay door and I went in and told the nurse (RN A) we were here with the patient and couldn't get in and re-entered again to question why they would not accept the patient." "The squad's intent was to deliver this patient to the hospital for care."

C. In an interview on 3/22/2023 at 1:00 PM (RN-A) confirmed that when the squad arrived at (CAH-A) ED bay doors and they were unable to get into the bay, this was due to the subzero weather. (EMS -F) came into the ED and informed (RN-A) that they arrived and they had the patient and could not get in. (RN A) informed them that if their intent was for the patient to go by Life Flight that they would not see the patient. The (EMS-F) member informed the staff that Life Flight was only on standby. (RN A) stated that (EMS-F) member returned again and asked the nurse, "If this was an accident patient and the Life Flight was on standby, would you see that patient?" The nurse told the (EMS-F) member, "Yes, they would have protocols to follow." (RN-A) talked to the supervisor and was told to get a refusal of care form, so (RN-A) went out to squad around 8:20 AM to have Patient 1's parent sign the form. (RN-A) then returned to the building.

D. Patient 1 arrived in the squad at the (CAH-A) on 12/25/2022 at 7:52 AM and was not provided any medical care. The Life Flight helicopter arrived 15 minutes after the EMS squad arrived at the (CAH A), during which time Patient 1 remained in the ambulance under the volunteer squad members care.

E. An interview on 3/21/23 at 11:55 AM with the (CAH A) administrative staff revealed that they did not have a medical record for (Patient 1) as the patient was not in their facility, was not entered in the Emergency Department log and the refusal of care paper was not produced.

Based on policy reviews, staff interview, review of EMS records, and Life Flight trip records, the Critical Access Hospital (CAH-A) failed to ensure 1 of 20 sampled patients (Patient 1) was provided a Medical Screening Examination (MSE) to determine within the hospital's capabilities the presence of an Emergency Medical Condition (EMC) existed, in accordance with the facility Medical Screening Examination and Stabilization policy and procedure. Patient 1 presented to the Emergency Department (ED) via ambulance with EMS requesting medical care twice and the staff failed to provide the MSE. This failure to follow the hospital's policy and procedure for performing an MSE to determine an EMC has the potential to cause harm or death due to a delay in treatment. According to the facility provided information the ED sees an average of 216 patients per month.

Findings are:

A. Review of the prehospital care report dated 12/25/22 at 7:17 AM, revealed the EMS squad (a community volunteer Basic Life Support (BLS) squad of lay personnel) was paged out to a 26 year old having a seizure, foaming from the mouth and breathing hard. The EMT's arrived to the patient's home at 7:33 AM and assessed the patient (Patient 1) and notified dispatch to have Life Flight put on stand-by due to a past medical history of an accident resulting in a traumatic brain injury 3-4 years prior and no history of seizures since the accident. The squad left the scene enroute to the Critical Access Hospital (CAH- A). The squad called the (CAH-A) to notify staff of ETA (estimated time of arrival) of 5 minutes and provide report. Per the prehospital care report, it was the EMS team's plan to bring the patient to (CAH-A) and have the medical staff care for the patient, the life flight was just on standby. (Patient 1's) skin was cool and clammy to touch; had a small emesis; was mentally confused and attempting to undo the safety buckles and sit up. Upon arrival to the (CAH A) at 7:52 AM, the over head squad door would not open (due to the subzero temperatures). The driver proceeded to the side walk-in door for access, it to was locked or would not open. The EMS member (EMS F) then went to emergency walk in door and talked to the Registered Nurse (RN A) in the emergency department area. The nurse told (EMS F) that the (CAH A) could not accept our patient because they had life flight enroute and if they let our patient into the (CAH A) they would become liable for that patient. (RN A) advised it was MD C's call. They would have to do a full assessment of the patient, call the patients neurologist and then they at (CAH A) would determine if life flight was necessary. The (RN A) was advised that we did not instruct life flight to be enroute only to be on standby. The nurse was asked, "So what if we cancel life flight?" (RN A) said it doesn't matter, "Your bird is only 7 minutes away." In disbelief the squad member went back to advise squad personal of the conversation. At that point in the squads opinion that it would not be wise to cancel life flight as we had no other medical assistance that would help the patient since the (CAH A) refused. Dispatch was phoned as we were second guessing ourselves if we did put them (life flight) on standby or to proceed. Dispatch verified we put them on standby but since they were coming from Crete they were going to proceed. We advised dispatch that the hospital would not accept our patient and life flight would be needed. (The Dispatcher's) reaction was total surprise that this happened and was upset about it. The squad personal went back to the (CAH A) Emergency Door and another nurse answered the door. I wanted to understand fully why they would not accept a patient and was told, "Well you have life flight coming" to which I repeated, "We Put Them On Standby!" It was pointless to argue any further and went back to the squad. EMS continued to care for patient in the ambulance while awaiting life flight for 15 minutes.

B. Review of life flight trip run summary reveals that helicopter landed at (CAH A's) helicopter pad on 12/25/2022 at 8:07 AM.

C. An telephone interview with (EMS F) at 3:19 PM verified, that the EMS squad (a community volunteer Basic Life Support (BLS) group of lay personnel) arrived on the hospital property (CAH A) on 12/25/22 at 7:52 AM and pulled in front of their ER ambulance bay door and it wouldn't open due to maintenance or something. The EMS crew member (EMS F) went into the hospital emergency department area and talked to the Registered Nurse (RN A) and told her that the squad was here with a patient but could not open the door to the ambulance bay. The (RN A) told the squad member that they "can't accept the patient due to the life flight was on the way to the hospital, because they called them". The crew member told the nurse the life flight was just on stand by. (EMS F) went back to the squad and told them that the hospital wouldn't accept the patient. A few minutes later (EMS F) re-entered the (CAH A) to talk to the registered nurse and asked again, why won't you let us bring the patient in? The nurse told me "they (the helicopter) was about 7 minutes out and by the time we would get (the patient) in here and do the assessment it would take 30 minutes and the helicopter would already landed". (EMS F) returned to the squad.

When (EMS F) was asked if the EMS squad was on the hospital property and the hospital staff knew the EMS squad had a patient for them, (EMS F) stated, "Yes,we were parked in front of their ambulance bay door and I went in and told the nurse (RN A) we were here with the patient and couldn't get in, and re-entered again to ask whey they wouldn't accept our patient." "It was the squad's intent to deliver this patient to the hospital for care."

D. Review of the prehospital care report dated 12/25/22, it showed that the EMS crew member [(EMS G)- a crew member that was with the patient in the back of the ambulance from the time that they left Patient 1's residence until the life flight crew took the patient to the helicopter at 8:07 AM)] documented that upon arriving at the (CAH A) we didn't go into the garage like we normally do. After a couple of minutes (EMS F) came to the back of the squad and told us that the nurse (RN A) would not let us in since we sequestered life net. (EMS F) stated they are refusing to let us in. We were all extremely confused why they would not take our patient to the next level of care, which was them. The patient's parent arrived at the (CAH A) and got into the squad with the patient and crew, the parent stated that (Patient 1) was never treated at (CAH A), and confirmed that the patient did not have a history of seizures. That (Patient 1) had one seizure after the accident (4 years ago) and none since.

E. Review of the prehospital care report dated 12/25/22, showed that the EMS crew member [(EMS H)- another crew member with the patient in the back of the squad.] (EMS H) documented that 'upon arrival at (CAH A) we were informed that since life flight was on their way we were unable to admit the patient to the
(CAH A). It is unclear who confirmed with life flight to land. They had decided to come and do stand by in the air since they were flying from Crete, NE.

F. In an interview on 3/21/23 at 1:00 PM, RN-A verified that she was working on 12/25/2022 between 7:00AM-7:30 AM when the ambulance squad (EMS Emergency Medical System) called in to give report of a 26 year old patient with seizures that was alert but unresponsive and the squad was unable to get vitals. RN-A asked EMS if the seizure was witnessed and EMS confirmed it was witnessed. The EMS crew informed us that the Life Flight was on standby. RN-A stated that dispatch notified (CAH-A) of life flight being 7 minutes out from landing at the facility helicopter pad. RN-A and RN-B then went to turn on lights at the helicopter pad. RN-A stated, "MD-C was at nurses' station and told the nurses that "if life flight is landing to transport the patient we do not need to intervene if using our helipad as safe landing zone." RN-A states that there was an EMS person (EMS -F) at the back door and entered the vestibule of the ED and said that they had patient on the ambulance and the ambulance bay doors didn't open. RN-A then asked (EMS-F) "what the intent was"? "Did they (EMS) want the patient seen or flown out"? The (EMS -F) informed RN-A the EMT caring for the patient called the helicopter for standby. RN-A informed (EMS-F) that if the patient came into the ED, they could not guarantee the patient would be life flighted but could be seen and the MD would decide if the patient needed life flighted. The (EMS-F) then returned to the ambulance.

RN-A stated that (EMS-F) returned to the ED back door and said "can I ask you a question? If we scoop and run at an accident can the ambulance bring the patient here would they be seen in the ED while awaiting the helicopter? (EMS F) was told yes, we would see the patient in the ED and have protocols to follow.

RN-A talked to her supervisor and was told to get a refusal of care form, so RN-A went out to squad around 8:20 AM to have Patient 1's parent sign the form. RN-A then returned to the building.

G. An interview on 3/21/23 at 1155 AM with the (CAH A) administrative staff revealed that they did not have a medical record for (Patient 1) as the patient was not in their facility, was not entered into the ED Log and the hospital did not produce the signed refusal of care form that (RN A) had the parent sign on 12/25/22.

H. Review of Patient 1's Acute Care Hospital L (Hosp-L) medical record for the 12/25/2022 ED visit revealed, Patient 1 arrived at 8:55 AM. MSE was provided and testing ordered consisted of a Cat Scan(CT) of the head and lab testing. The CT of head was without acute process. Abnormal lab results included: glucose of 151 (normal 65-99), urine specimen had protein of 15 (normal 0), and ketones of 5 (normal 0). Patient 1 was monitored for greater than 3 hours without recurrence of seizures. Returned to normal baseline. Received Toradol 30 mg IV (a nonsteroidal anti-inflammatory medication used to treat pain) for a headache. Patient 1 was also given a loading dose of Keppra 2000 mg IV (an anticonvulsant medication used to treat seizures) Patient 1 to start taking Keppra 500 mg by mouth two times a day. A prescription for 60 tablets was sent to the pharmacy. Patient 1 was discharged to home on 12/25/2022 at 12:33 PM with instructions to call to schedule appointments with neurology as soon as possible, patients primary care provider as soon as possible and to return the ED if symptoms worsen.