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Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 records reviewed (Patient # 4) with an appropriate medical screening examination (MSE) after presenting to their Emergency Department (ED). Failure to provide an appropriate MSE at the CAH's ED resulted in Patient #4 requiring transportation to another CAH for a MSE. The CAH's administrative staff identified an average of 278 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy EMTALA, Medical Screening Exam, last revised 5/2/23, revealed in part: "...The purpose of this policy is to ensure that [CAH] meets its EMTALA obligations associated with providing medical screening examinations ("MSE"). A MSE shall be provided to all individuals who 'come to the emergency department' as that phrase is defined herein, and a request (implied by word or action) is made by the individual or on the individual's behalf for examination or treatment of a medical condition regardless of diagnosis, financial status, race, color, national origin, or disability...The term "comes to the emergency department" is defined, in part, to mean that the individual: (1) Has presented at a hospital's dedicated emergency department...and requests examination or treatment for a medical condition, or has such a request made on their behalf...The MSE must be appropriate to the medical complaints and sufficient to determine whether the individual has an emergency medical condition ('EMC')...."

"A MSE is an ongoing process. Depending on the patient's condition, a MSE may involve:
1. A simple process such as a brief history and physical examination;
2. A complex process such as a history and physical examination, followed by ancillary studies
and procedures
3. Anything in between".

2. Review of the policy, "Refusal of Medical Screening Exam or Left Without Being Seen PLHED-3050", last revised 01/2022, revealed in part: "If an individual presents requesting screening for an emergency medical condition and then withdraws the request or refuses the offer of an emergency medical screening exam offered
by GPLHC staff, a Refusal of Medical Screening Exam form needs to be completed."

3. Review of Patient #4's medical record revealed:

a. Patient #4 presented to the emergency department (ED) in a wheelchair accompanied by law enforcement on 4/20/23 at 1:07 PM. MD C documented that Patient #4 had impaired mobility and history of a brain injury due to a subarachnoid hemorrhage (bleeding in the space that surrounds the brain). Further documentation by MD C indicated that patient #4 "is well known to the hospital, and there have been legal issues associated with [patient #4] last stay here." MD C documented that they had encountered Patient #4 with Jail Administrator B and Correction Officer H in the back hallway/ambulance entrance of the ED. They chatted about the purpose of Patient #4's ED visit and not once during the conversation with Patient #4, Jail Administrator B and Correction Officer H was there any mention of any concern for any acute medical needs. RN A arrived and wanted to contact hospital's legal department to clarify Patient #4's status given the fact that the hospital had recently filed charges against Patient #4. MD C continued to observe Patient #4 and discussed the situation with them and law enforcement. Patient #4 denied any acute medical complaints, their general appearance was similar to when they had been an inpatient at the CAH. Patient #4 was not in distress. MD noted: "Psychiatric: Comments: Normal affect. Cooperative. Doesn't seem to have insight into legal/social situation."

MD C further documented that "several members of the hospital administration and legal team did come to assess the situation. They presented a document which I did not personally have a chance to look at, that apparently said there was a restraining order against the patient." "If [patient #4] had a medical screening exam and no acute stabilization needs were determined, we would consider the patient to be trespassing and call law enforcement anyway." The patient's Discharge Disposition was "Left Without Being Seen [LWBS] - No Intervention."

The medical record did not contain evidence that MD C provided patient # 4 with an appropriate medical screening examination to determine why the patient "lacked insight" into their "legal/social situation", or if patient #4 who required a wheelchair had any physical or neurological problems, or whether the patient had an emergency medical condition.

4. Review of a letter to Patient #4's guardian and Iowa State Penitentiary, dated 4/12/23, signed "[CAH] Health System," revealed in part: Patient #4 is not authorized to enter any hospital clinic or affiliate except for the "limited purpose of receiving emergency medical care through our hospital's Emergency Services department...If your ward disregards this notice [CAH] will not hesitate to turn this matter over to local law enforcement authorities for prosecution on trespassing and other grounds."

5. Review of medical record from Hospital A revealed in part:

a. On 04/20/2023 at 1:55 PM, RN D triaged Patient #4 and noted their chief complaint was that they had been in jail for the last 40 days and brought to the ED accompanied by law enforcement after release because the patient had no place to go.

b. At 2:07 PM, DO E noted that patient #4 was a 70 year old homeless dependent adult with a history of high blood pressure, anxiety, brain aneurysm/subarachnoid hemorrhage,was wheel chair bound and provided the patient with an appropriate medical screening examination.

6. During an interview on 6/20/23 at 8:47 AM, Jail Administrator B explained that a judge had released Patient #4 from jail so they had contacted multiple people to determine where to take Patient #4 without success. Patient #4 had a brain injury and was in a wheel chair so it was not safe for them just to be released and rolled out of the jail. Every day jail staff had washed them, showered them, wiped them when they used the bathroom. Jail Administrator B determined that the ED was the safest place to take someone who had a brain injury, couldn't walk, and needed help with all their cares.

Jail Administrator B recalled pulling up to the ED in the squad car, nurses came out, let them in the corridor but wouldn't let them in the ED. Jail Administrator B was caught off guard, they thought the ED was there for an emergency. Jail Administrator B acknowledged they were irritated and told RN A and MD C that they hoped that this was never their family member. Jail Administrator B stated to them that if you don't think that Patient #4 needed help, then after they evaluate them, they can just roll Patient #4 out onto the street. Recalled staff members weren't argumentative, they were just saying that they couldn't take Patient #4 because they scared people in the hospital. Jail Administrator B recalled being agitated, to them this was an emergency and they did not understand why this was a problem. After about 25-30 minutes, hospital staff then shared a letter with them and Correction Officer H which basically said that Patient #4 was trespassing.

Jail Administrator B recalled that Patient #4 was confused that day. Jail Administrator B stated they were not a doctor so they could not evaluate whether or not this was normal for Patient #4. Jail Administrator B confirmed he took Patient #4 to the ED so they would be safe.

Hospital staff said they would do an assessment, check Patient # 4's vitals (blood pressure, heart rate, respiratory rate and temperature), that was it, and then they were going to let him go and they would need to take Patient #4 somewhere else. Jail Administrator B confirmed that hospital staff did not do an assessment or check vitals because Jail Administrator B put Patient #4 in the squad car and drove them to Hospital A.

7. During an interview on 6/22/23 at 5:45 AM, Correction Officer H explained that they took Patient #4 to the ED to be admitted, but the hospital would not admit them because they had some kind of order that said Patient #4 was not allowed in the hospital. Recalled that Jail Administrator B and hospital staff were doing most of the talking, Correction Officer H confirmed that hospital staff had wanted to check Patient #4's vitals and do an assessment to see if something was wrong, and had also stated that they would refuse Patient #4 if there wasn't anything wrong with them. They then left the hospital with Patient #4, Jail Administrator B dropped Correction Officer H off at work as it was the end of their shift.

8. During an interview on 6/20/23 at 1:00 PM, MD C recalled coming upon Patient #4 and Jail Administrator B in the ambulance hallway when they were using the back stairs of the hospital. MD C asked if they were here to be seen, what was going on with Patient #4? Jail Administrator B stated that they were bringing Patient #4 to the ED because they had been discharged from jail but Patient #4 did not have anywhere to go. MD C asked if Patient #4 was feeling sick or had a complaint. Jail Administrator B replied no, but they just couldn't put him on the curb. MD C talked to them for a bit and then RN A arrived and said they had been directed that if Patient #4 came to the ED, and he didn't have an Emergency Medical Condition (EMC), they could not keep them there. MD C asked Patient #4 if they had any chest pain, shortness of breath, fevers and they said they were fine, they wanted to get to a room to watch TV. MD C offered that it goes without saying that if Patient #4 had had any problems they would have taken care of them.
They obtained the legal letter and shared this with Jail Administrator B. MD C recalled Jail Administrator B was frustrated of course, they had been told by their supervisor to bring Patient #4 to the hospital ED. MD C stated that they would wheel Patient #4 back to a room, take their vital signs and do a full examination. Jail Administrator B said no, they were just going to take Patient #4 somewhere else. Jail Administrator B refused the medical screen.

MD C had seen Patient #4 during prior inpatient and ED visits and felt they were at their baseline mental status, seemed to be in their normal state of health and their normal mentation. MD C did not believe Patient #4 had an EMC based on their observations and conversation with them. MD C explained that you can observe many things during those interactions, for example mentation, posture, skin color, respirations.

When asked if they considered having Patient #4 sign a document that confirmed that they were refusing a medical screen or didn't want to be seen, MD C couldn't remember the details but thought there were some attempts to get a signature on the form but the officer was upset and frustrated and they left.

9. During an interview on 6/20/23 at 11:30 AM, RN A recalled MD C was present when RN A arrived. MD C was visiting with Patient #4 and Jail Administrator B who explained that Patient #4 had just been released from jail and they were just going to leave Patient #4 at the ED as they didn't know what else to do. RN A knew there had been some legal paperwork related to Patient #4, was not sure exactly what to do with them so contacted Compliance Specialist F who explained that they should do a medical screen but if Patient #4 was medically stable they would not keep them at the hospital. RN A relayed that information to Jail Administrator B, and Compliance Specialist F also came down to the ED and reiterated what RN A had just relayed.

RN A asked why Patient #4 was at the ED, were having any type of medical emergency? Again, Jail Administrator B said they just did not know what to do with Patient #4 now that they had been released from jail. RN A again explained that they would do a medical screen but if no EMC Patient #4 could not stay at the hospital. Jail Administrator B asked if we would then just turn Patient #4 out on the street and RN A replied that they would probably reach out to Jail Administrator B to come get Patient #4. Jail Administrator B kept saying that they were refusing care, and RN A kept saying, no, we will do a medical screen. Jail Administrator said no, you are refusing to care for Patient #4 and Jail Administrator B left the ED with Patient #4.

RN A also recalled Patient #4 from pervious inpatient admission and felt this was Patient #4's norm as far as they could tell. Also recalled MD C had asked some screening questions and Patient #4 had communicated appropriately. They had denied pain, did not have any complaints, were not in distress. RN A stressed they didn't do any vitals because Jail Administrator B kept saying they were refusing to care for Patient #4 and then wheeled them out of the ED.

10. During an interview on 6/20/23 at 2:00 PM, Compliance Specialist F believed that the ED staff called the Director of Outpatient Services (who was the Administrator on Call that day), and they had come to Compliance Specialist F for some direction. They then called legal and while waiting for legal, Compliance Specialist F went down to the ED to make sure it was going well and staff were doing a MSE. RN A relayed that Jail Administrator B just wanted to drop Patient #4 off at the hospital and leave, but Jail Administrator B may need to take Patient #4 back with them depending on the results of the MSE. RN A had explained that they said they need to do a MSE but Jail Administrator B had interrupted and said Patient #4 did not have an emergency condition, there was just no place to take them now that they had been released from jail. Compliance Specialist F explained that they would treat Patient #4, transfer them, or release them depending on the results of the MSE. Jail Administrator B kept saying that Patient #4 was no longer in their custody and they had no place to go. Compliance Specialist F stated they went back and forth on this several times, finally Jail Administrator B just said they were going and they took off. Compliance Specialist F emphasized that Patient #4 was offered a MSE.

When asked if they considered having Patient #4 sign a document that confirmed that they were refusing a medical screen or didn't want to be seen, Compliance Specialist F responded that they do have a forms that patients sign if they leave Against Medical Advice (AMA) or LWBS but they left quickly before they could have them fill it out.

11. During an interview on 6/21/23 at 10:00 AM, DON recalled coming out a meeting when they were informed that Patient #4 was in the ED. DON went down to the ED and saw that Compliance Specialist F, RN A and MD C were all talking with Jail Administrator B and Patient #4. They offered to have Patient #4 come into the ED for a medical screening, but Jail Administrator B stated Patient #4 did not have a medical emergency. Patient #4 was no longer in their custody but they had not place to go. Jail Administrator B was told that they would need to do a medical screen but they also had a no trespass order. Jail Administrator B did not seem to understand what they were trying to convey, and ended up taking Patient #4 back to the car and left the ED.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 records reviewed (Patient # 4) with an appropriate medical screening examination (MSE) after presenting to their Emergency Department (ED). Failure to provide an appropriate MSE at the CAH's ED resulted in Patient #4 requiring transportation to another CAH for a MSE. The CAH's administrative staff identified an average of 278 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #4's medical record revealed:

a. Patient #4 presented to the emergency department (ED) in a wheelchair accompanied by law enforcement on 4/20/23 at 1:07 PM. MD C documented that Patient #4 had impaired mobility and history of a brain injury due to a subarachnoid hemorrhage (bleeding in the space that surrounds the brain). Further documentation by MD C indicated that patient #4 "is well known to the hospital, and there have been legal issues associated with [patient #4] last stay here." MD C documented that they had encountered Patient #4 with Jail Administrator B and Correction Officer H in the back hallway/ambulance entrance of the ED. They chatted about the purpose of Patient #4's ED visit and not once during the conversation with Patient #4, Jail Administrator B and Correction Officer H was there any mention of any concern for any acute medical needs. RN A arrived and wanted to contact hospital's legal department to clarify Patient #4's status given the fact that the hospital had recently filed charges against Patient #4. MD C continued to observe Patient #4 and discussed the situation with them and law enforcement. Patient #4 denied any acute medical complaints, their general appearance was similar to when they had been an inpatient at the CAH. Patient #4 was not in distress. MD noted: "Psychiatric: Comments: Normal affect. Cooperative. Doesn't seem to have insight into legal/social situation."

MD C further documented that "several members of the hospital administration and legal team did come to assess the situation. They presented a document which I did not personally have a chance to look at, that apparently said there was a restraining order against the patient." "If [patient #4] had a medical screening exam and no acute stabilization needs were determined, we would consider the patient to be trespassing and call law enforcement anyway." The patient's Discharge Disposition was "Left Without Being Seen [LWBS] - No Intervention."

The medical record did not contain evidence that MD C provided patient # 4 with an appropriate medical screening examination to determine why the patient "lacked insight" into their "legal/social situation", or if patient #4 who required a wheelchair had any physical or neurological problems, or whether an emergency medical condition existed.

2. Review of letter to Patient #4's guardian and Iowa State Penitentiary, dated 4/12/23, signed "[CAH] Health System," revealed in part: Patient #4 is not authorized to enter any hospital clinic or affiliate except for the "limited purpose of receiving emergency medical care through our hospital's Emergency Services department...If your ward disregards this notice [CAH] will not hesitate to turn this matter over to local law enforcement authorities for prosecution on trespassing and other grounds."

3. Review of medical record from Hospital A revealed in part:

a. On 04/20/2023 at 1:55 PM, RN D triaged Patient #4 and noted their chief complaint was that they had been in jail for the last 40 days and brought to the ED accompanied by law enforcement after release because they had no place to go.

b. At 2:07 PM, DO E noted that patient #4 was a 70 year old homeless dependent adult with a history of high blood pressure, anxiety, brain aneurysm/subarachnoid hemorrhage, was wheel chair bound, and provided the patient with an appropriate medical screening examination.

4. During an interview on 6/20/23 at 8:47 AM, Jail Administrator B explained that a judge had released Patient #4 from jail so they had contacted multiple people to determine where to take Patient #4 without success. Patient #4 had a brain injury and was in a wheel chair so it was not safe for them just to be released and rolled out of the jail. Every day jail staff had washed them, showered them, wiped them when they used the bathroom. Jail Administrator B determined that the ED was the safest place to take someone who had a brain injury, couldn't walk, and needed help with all their cares.

Jail Administrator B recalled pulling up to the ED in the squad car, nurses came out, let them in the corridor but wouldn't let them in the ED. Jail Administrator B was caught off guard, they thought the ED was there for an emergency. Jail Administrator B acknowledged they were irritated and told RN A and MD C that they hoped that this was never their family member. Jail Administrator B stated to them that if you don't think that Patient #4 needed help, then after they evaluate them, they can just roll Patient #4 out onto the street. Recalled staff members weren't argumentative, they were just saying that they couldn't take Patient #4 because they scared people in the hospital. Jail Administrator B recalled being agitated, to them this was an emergency and they did not understand why this was a problem. After about 25-30 minutes, hospital staff then shared a letter with them and Correction Officer H which basically said that Patient #4 was trespassing.

Jail Administrator B recalled that Patient #4 was confused that day. Jail Administrator B stated they were not a doctor so they could not evaluate whether or not this was normal for Patient #4. Jail Administrator B confirmed he took Patient #4 to the ED so they would be safe.

Hospital staff said they would do an assessment, check Patient # 4's vitals (blood pressure, heart rate, respiratory rate and temperature), that was it, and then they were going to let him go and they would need to take Patient #4 somewhere else. Jail Administrator B confirmed that hospital staff did not do an assessment or check vitals because Jail Administrator B put Patient #4 in the squad car and drove them to Hospital A.

5. During an interview on 6/22/23 at 5:45 AM, Correction Officer H explained that they took Patient #4 to the ED to be admitted, but the hospital would not admit them because they had some kind of order that said Patient #4 was not allowed in the hospital. Recalled that Jail Administrator B and hospital staff were doing most of the talking, Correction Officer H confirmed that hospital staff had wanted to check Patient #4's vitals and do an assessment to see if something was wrong, and had also stated that they would refuse Patient #4 if there wasn't anything wrong with them. They then left the hospital with Patient #4, Jail Administrator B dropped Correction Officer H off at work as it was the end of their shift.

6. During an interview on 6/20/23 at 1:00 PM, MD C recalled coming upon Patient #4 and Jail Administrator B in the ambulance hallway when they were using the back stairs of the hospital. MD C asked if they were here to be seen, what was going on with Patient #4? Jail Administrator B stated that they were bringing Patient #4 to the ED because they had been discharged from jail but Patient #4 did not have anywhere to go. MD C asked if Patient #4 was feeling sick or had a complaint. Jail Administrator B replied no, but they just couldn't put him on the curb. MD C talked to them for a bit and then RN A arrived and said they had been directed that if Patient #4 came to the ED, and he didn't have an Emergency Medical Condition (EMC), they could not keep them there. MD C asked Patient #4 if they had any chest pain, shortness of breath, fevers and they said they were fine, they wanted to get to a room to watch TV. MD C offered that it goes without saying that if Patient #4 had had any problems they would have taken care of them.
They obtained the legal letter and shared this with Jail Administrator B. MD C recalled Jail Administrator B was frustrated of course, they had been told by their supervisor to bring Patient #4 to the hospital ED. MD C stated that they would wheel Patient #4 back to a room, take their vital signs and do a full examination. Jail Administrator B said no, they were just going to take Patient #4 somewhere else. Jail Administrator B refused the medical screen.

MD C had seen Patient #4 during prior inpatient and ED visits and felt they were at their baseline mental status, seemed to be in their normal state of health and their normal mentation. MD C did not believe Patient #4 had an EMC based on their observations and conversation with them. MD C explained that you can observe many things during those interactions, for example mentation, posture, skin color, respirations.

When asked if they considered having Patient #4 sign a document that confirmed that they were refusing a medical screen or didn't want to be seen, MD C couldn't remember the details but thought there were some attempts to get a signature on the form but the officer was upset and frustrated and they left.

7. During an interview on 6/20/23 at 11:30 AM, RN A recalled MD C was present when RN A arrived. MD C was visiting with Patient #4 and Jail Administrator B who explained that Patient #4 had just been released from jail and they were just going to leave Patient #4 at the ED as they didn't know what else to do. RN A knew there had been some legal paperwork related to Patient #4, was not sure exactly what to do with them so contacted Compliance Specialist F who explained that they should do a medical screen but if Patient #4 was medically stable they would not keep them at the hospital. RN A relayed that information to Jail Administrator B, and Compliance Specialist F also came down to the ED and reiterated what RN A had just relayed.

RN A asked why Patient #4 was at the ED, were having any type of medical emergency? Again, Jail Administrator B said they just did not know what to do with Patient #4 now that they had been released from jail. RN A again explained that they would do a medical screen but if no EMC Patient #4 could not stay at the hospital. Jail Administrator B asked if we would then just turn Patient #4 out on the street and RN A replied that they would probably reach out to Jail Administrator B to come get Patient #4. Jail Administrator B kept saying that they were refusing care, and RN A kept saying, no, we will do a medical screen. Jail Administrator said no, you are refusing to care for Patient #4 and Jail Administrator B left the ED with Patient #4.

RN A also recalled Patient #4 from pervious inpatient admission and felt this was Patient #4's norm as far as they could tell. Also recalled MD C had asked some screening questions and Patient #4 had communicated appropriately. They had denied pain, did not have any complaints, were not in distress. RN A stressed they didn't do any vitals because Jail Administrator B kept saying they were refusing to care for Patient #4 and then wheeled them out of the ED.

8. During an interview on 6/20/23 at 2:00 PM, Compliance Specialist F believed that the ED staff called the Director of Outpatient Services (who was the Administrator on Call that day), and they had come to Compliance Specialist F for some direction. They then called legal and while waiting for legal, Compliance Specialist F went down to the ED to make sure it was going well and staff were doing a MSE. RN A relayed that Jail Administrator B just wanted to drop Patient #4 off at the hospital and leave, but Jail Administrator B may need to take Patient #4 back with them depending on the results of the MSE. RN A had explained that they said they need to do a MSE but Jail Administrator B had interrupted and said Patient #4 did not have an emergency condition, there was just no place to take them now that they had been released from jail. Compliance Specialist F explained that they would treat Patient #4, transfer them, or release them depending on the results of the MSE. Jail Administrator B kept saying that Patient #4 was no longer in their custody and they had no place to go. Compliance Specialist F stated they went back and forth on this several times, finally Jail Administrator B just said they were going and they took off. Compliance Specialist F emphasized that Patient #4 was offered a MSE.

When asked if they considered having Patient #4 sign a document that confirmed that they were refusing a medical screen or didn't want to be seen, Compliance Specialist F responded that they do have a forms that patients sign if they leave Against Medical Advice (AMA) or LWBS but they left quickly before they could have them fill it out.

9. During an interview on 6/21/23 at 10:00 AM, DON recalled coming out a meeting when they were informed that Patient #4 was in the ED. DON went down to the ED and saw that Compliance Specialist F, RN A and MD C were all talking with Jail Administrator B and Patient #4. They offered to have Patient #4 come into the ED for a medical screening, but Jail Administrator B stated Patient #4 did not have a medical emergency. Patient #4 was no longer in their custody but they had not place to go. Jail Administrator B was told that they would need to do a medical screen but they also had a no trespass order. Jail Administrator B did not seem to understand what they were trying to convey, and ended up taking Patient #4 back to the car and left the ED.