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Based on record reviews and review of the facility Emergency Treatment and Labor Act (EMTALA) policies and procedures the facility failed to provide 1 of 19 sampled patients a Medical Screening Examination (MSE) within the hospital's capabilities that was sufficient to determine the presence of an Emergency Medical Condition (EMC). Patient 2 had an inadequate MSE to evaluate 10/10 left arm pain and was then was sent to Hospital B without following the facility policies and procedures related to transfers. The facility Emergency Department (ED) Medical Doctor (MD) A failed to document the ED exam in the record as required in the facility EMTALA policies. The total sample was 20 patient records with 1 patient who left without being seen by the provider. Findings are:

See also 2406

A. Record review of ED records and EMS (Emergency Medical Services)Prehospital Care Report revealed the patient arrived by local rescue squad on 11/27/20 at 4:53 AM. The squad report notes that the patient on arrival to the home had Oxygen on at 3 liters and told them he "thinks has a blood clot in his left arm." The patient told them he had pain since the evening before and the pain would come and go in his left arm and radiate to the chest. Pain score was severe 10/10 (highest pain score). History from the patient noted he was diagnosed with Covid 10/31/20 and had spent 3 weeks in the hospital in Omaha with pneumonia and was discharged earlier in the week. Event log in the patient ED record notes the patient was taken to an ED room at 4:53 AM. He was listed as "Discharged" at 5:00 AM. Vital signs at 4:59 were Temperature 97.5 Fahrenheit, Pulse 107, Oxygen saturation of 95% (normal) with Oxygen on at 2 liters per minute. Pain score 10 in left arm. Patient was noted as being Alert and Oriented.
Late documentation addendum by RN B timed 11/27/20 at 8:49 PM related to 11/27/20 5;00 AM events states ED MD A "assesses patient and discusses with patient at bedside should go to [Location of Hospital B], patient agrees." RN B documented second RN discusses need for laboratory blood work before transferring which was declined by ED MD A. RN B documented bringing the Electrocardiograph (ECG) machine to the bedside to do study (documents electrical activity of the heart, can indicate presence of a heart attack or irregular rhythm). RN B documented ED MD A also declined to do an ECG. The EMS squad staff agreed to transfer the patient to Hospital B. RN B also documented that the patient was sent to Hospital B without any documentation by nursing, registration or physician provider.
Late documentation by ED MD A dated 11/27/20 at 10:42 AM notes seeing the patient who complained of left arm pain which on exam was reproducible. No swelling or redness present and good radial pulses present ruling out an arterial block. Vitals stable and "clinical suspicion of a DVT [Deep Vein Thrombosis] clot was high. MD A documented the patient did not "mention any chest pain." ED MD documented "Since I did not perform evaluation, I did not call the [Name of Hospital B] ER. Time spent in the ED was about 5 minutes 49 seconds.

B. Record review of facility policy titled "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - EMTALA- Schuyler" last revisited 4/2018 revealed requirements for the following:
Medical Screening Examination: The Hospital will provide a MSE to a patient that requests an examination or treatment for a medical condition whether presenting to the Dedicated ED (DED), an off campus department DED or while on hospital property. The MSE will be performed by a physician or other Qualified Medical Person (per by-laws Physician, Nurse Practitioner or Physician Assistant). The physician or QMP will determine with reasonable clinical confidence whether the individual has an EMC, as defined by EMTALA, utilizing the services within the capabilities of the DED and ancillary services and resources routinely available to the DED for individuals with similar symptoms.
Documentation requirements: The MSE process must be documented in the Medical Record.
Regarding Transfer: When an emergency patient is in need of transfer to another facility or physician, the receiving facility will be contacted and acceptance of transfer of the patient will be documented. Transfers of emergency patients shall be made only after all steps required by the EMTALA regulations have bee followed and the physician and nurse have completed the required documentation.

Based on record reviews, staff interviews, provider interviews and review of facility EMTALA( Emergency Medical Treatment and Labor Act) policies the Critical Access Hospital failed to perform a Medical Screening Examination (MSE) for 1 of 19 sampled patients (Patient 2) presenting to the ED (Emergency Department for treatment. The patient who was brought by rescue squad for evaluation of severe left arm pain failed to have an MSE, including blood work and ECG (Electrocardiograph), which were available, to identify if the patient had an Emergency Medical Condition. The patient was then subsequently sent inappropriately to another hospital {hospital B] without prior acceptance. Hospital B records reveal the patient on arrival was having a STEMI. An Emergency Medical Condition requiring immediate stabilizing treatment. A STEMI according to ecgmedicaltraining.com dated 6/24/15 is a "very serious type of heart attack during which one of the heart's major arteries (one of the arteries that supplies oxygen and nutrient-rich blood to the heart muscle) is blocked. ST-segment elevation is an abnormality detected on the 12 lead ECG. It is a profoundly life-threatening medical emergency." Hospital B did not have the capability to provide the patient with potential life saving heart catheterization procedure and had to transfer the patient to Hospital C resulting in additional delay and risk to Patient 2's life. The facility's failure to ensure adequate MSE's are done within the hospitals capability to determine if an EMC exists has the potential for any patient with an EMC to have a potentially life threatening delay in treatment. The facility provided ED records from 6/2020 to 1//2020 revealed the ED sees on average 115 patients per month. The total sample was 20 (one patient refused to be seen by a provider). Findings are:

See also 2400

A. Record review of ED records and EMS (Emergency Medical Services)Prehospital Care Report revealed the patient arrived by local rescue squad on 11/27/20 at 4:53 AM. The squad report notes that the patient on arrival to the home had Oxygen on at 3 liters and told them he "thinks has a blood clot in his left arm." The patient told them he had pain since the evening before and the pain would come and go in his left arm and radiate to the chest. Pain score was severe 10/10 (highest pain score). History from the patient noted he was diagnosed with Covid 10/31/20 and had spent 3 weeks in the hospital in Omaha with pneumonia and was discharged earlier in the week. Vital signs by EMS were Blood Pressure 128/79, heart rate 107, Respirations 16. Oxygen saturation was 94% on 3 liters of Oxygen. Normal saturation is 92 - 100%. Event log in the patient ED record notes the patient was taken to an ED room at 4:53 AM. He was listed as "Discharged" at 5:00 AM. Vital signs at 4:59 AM were Temperature 97.5 Fahrenheit, Pulse 107, Oxygen saturation of 95% (normal) with Oxygen on at 2 liters per minute. Pain score 10 in left arm. Blood Pressure was not taken. Patient was noted as being Alert and Oriented.
Late documentation addendum by RN B timed 11/27/20 at 8:49 PM related to 11/27/20 5;00 AM events states ED MD A "assesses patient and discusses with patient at bedside should go to [Location of Acute Care Hospital B], patient agrees." RN B documented second RN discusses need for laboratory blood work before transferring which was declined by ED MD A. RN B documented bringing the Electrocardiograph (ECG) machine to the bedside to do study (documents electrical activity of the heart, can indicate presence of a heart attack or irregular rhythm). RN B documented ED MD A also declined to do an ECG. The EMS squad staff agreed to transfer the patient to Hospital B. RN B also documented that the patient was sent to Hospital B without any documentation by nursing, registration or physician provider.
Late documentation by ED MD A dated 11/27/20 at 10:42 AM notes seeing the patient who complained of left arm pain which on exam was reproducible. No swelling or redness present and good radial pulses present ruling out an arterial block. Vitals stable and "clinical suspicion of a DVT [Deep Vein Thrombosis] clot was high. MD A documented Radiology did not have DVT (vascular ultrasound available) . [Review of Radiology on call confirmed vascular ultrasound tech was not available on call that day]MD A documented the patient did not "mention any chest pain." ED MD documented "Since I did not perform evaluation, I did not call the [Name of Hospital B] ER. Time spent in the ED was about 5 minutes 49 seconds.

B. Receiving hospital (Hospital B), 17 miles, away, records reveal the patient arrived at 5:29 AM on 11/27/20 by Schuyler EMS squad. On arrival the patient told staff Left arm pain began the evening before and pain in the left arm "was 100/10 from elbow to shoulder. Vitals were Blood Pressure 137/87 Temperature 97.8 Fahrenheit, pulse 105 and respirations 25. Oxygen saturation was low at 82% on Room Air. The patient also reported having chest pain throughout the night as well. The MSE performed by ED MD C included an immediate ECG which showed a STEMI.. Laboratory blood work also supported the diagnosis. The patient was stabilized within Hospital B's capabilities (No heart Catheterization services available to treat blocked heart arteries) using Oxygen, Aspirin, Heparin (blood thinner), Morphine for pain. The patient was then appropriately transferred to Hospital C by air.

C. Interview with Registered Nurse (RN) B on 12/7/20 at 9:25 AM revealed the EMS squad called and said they were bringing in a patient with 10/10 left arm pain, RN B got Patient 2 settled in the ED room. The patient was able to use his arms to help transfer self. RN B recalled his color was normal and he was not diaphoretic (moist skin). All were aware he had a history of COVID. Put him on 2 liters Oxygen here and saturation increased to 96%. Blood Pressure was normal as were respirations. ED MD A then came in patient said his pain was 10/10 sharp in the antecubital area of his arm. Patient 2 stated he had the pain all night but 10/10 this morning. He said the pain went up his arm. RN B had no recall of the patient mentioning or anyone asking if he had chest pain. ED MD A arrived before the patient was hooked up to the heart monitor. He was aware there was no vascular ultrasound services on call that day. ED MD A told the EMS crew the hospital did not have the resources (vascular ultrasound) to treat patients like this. ED MD A talked to the patient, palpates and pushes on Left arm which the patient said did hurt. ED MD A told the patient that since the pain was reproducible it was probably a DVT. RN B recalled having the ECG machine ready since with Left arm pain the cause could be cardiac. ED MD A told RN B not to use it. ED MD spoke to the patient about going to Hospital B to be treated as we did not have the ultrasound resources here and more cost effective to be treated there. RN B recalled then asking again to do the ECG and td"ED MD A refused and said "will transfer right away." The other ED RN asked about doing blood work D-Dimmer test (helps diagnose DVT) and the MD refused that as well. The EMS squad took the patient to Hospital B. RN B said the nurses were not sure if this was an AMA (against medical advice) or what. The patient "did not refuse a MSE or exam." When the patient left there had not been any other vital signs done, no monitoring or checking of the heart and had no Intravenous access (used for patients that may need life saving medications). RN B reported the incident to the ED RN supervisor around 6:30 AM on 11/27/20 and stated "I felt like he had an EMC and needed further testing." Hospital B called around 6:25 AM and asked if we had any laboratory, testing or History and Physical and told them there wasn't any done. Hospital B told us the patient had a STEMI.

D. Phone interview with MD A on 12/8/20 at 8:00 AM revealed the physician works weekends a couple of times per month since August 2020. The provider did not recall reading the hospitals EMTALA policies when beginning work as a contracted ED provider.
ED MD A said that on arrival with Left arm pain it was determined the Radiology Department did not have an on call vascular ultrasound technician. Vascular ultrasound uses a Doppler and ultrasound to evaluate blood flow. MD A stated that "I pressed Left arm, winced in pain. MD A stated that if the work up here was negative the patient would still have to go to a higher level of care. MD A confirmed "I did not do a full MSE." The provider stated he "did not ask" the patient if he had chest pain but asked what brought him to the ED. Patient 2 replied "arm pain." MD A stated he "relied on EMS vital signs, patient was not in distress, felt patient was rerouted. The provider further stated that if he had evaluated the patient (MSE exam) he would have done an EMTALA transfer (includes stabilizing treatment, advance provider and facility acceptance, certification of risk to patient, patient consent and records sent). The provider stated he did not feel the patient had an EMC at his facility.

E. Interview with the ED Medical Director , Doctor of Osteopathic Medicine (DO) E 12/7/20 at 10:30 AM revealed Patient 2 has been his private practice patient for the past 3 months. He saw Patient 2's name on the EMR (Electronic Medical Record) system and looked at the documentation. He had concerns regarding the MSE evaluation of the patient. DO E called ED MD A to ask what had happened. MD A confirmed the lack of MSE and failure to notify Hospital B and get acceptance prior to transfer. He said that the patient was "redirected" to Hospital B to save time. DO E stated they do not divert (redirect patients) who come to the hospital. In review Patient 2's stay the Medical Director stated he "felt the patient had an Emergency Medical Condition when here."

F. Phone interview with receiving Hospital B's ED MD C on 12/9/20 at 9:00 AM confirmed he was the ED MD who treated Patient 2 on arrival in their ED 11/27/20 by Schuyler EMS squad. MD C confirmed they had no advance notice of the patient coming to their ED. MD C stated that the patient "Had the appearance of an EMC on sight on arrival. He was ruddy pale with pain he said was 100/10 in his arm" and "chest killing me all night." MD C recalled that the patient told them he had recently been discharged from the hospital with COVID and thought he had a clot in his left arm. Immediate assessment included an ECG which showed a STEMI. The hospital stabilized the patient within their capabilities but lacking a heart catheterization laboratory the patient had to be transferred again. Due to COVID, bed availability in larger medical hospitals and weather issues the patient was not able to be transferred for nearly 2 hours resulting in unavoidable delay and further risk to the patient. While being loaded into the helicopter his blood pressure and heart rate dropped. ED MD C stated that the Cardiologist at Acute Hospital C said he had a clot in the right coronary artery and had stents put in. The patient survived.

G. Record review of facility policy titled "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - EMTALA- Schuyler" last revisited 4/2018 revealed requirements for the following:
Medical Screening Examination: The Hospital will provide a MSE to a patient that requests an examination or treatment for a medical condition whether presenting to the Dedicated ED (DED), an off campus department DED or while on hospital property. The MSE will be performed by a physician or other Qualified Medical Person (per by-laws Physician, Nurse Practitioner or Physician Assistant). The physician or QMP will determine with reasonable clinical confidence whether the individual has an EMC, as defined by EMTALA, utilizing the services within the capabilities of the DED and ancillary services and resources routinely available to the DED for individuals with similar symptoms.
Documentation requirements: The MSE process must be documented in the Medical Record.
Regarding Transfer: When an emergency patient is in need of transfer to another facility or physician, the receiving facility will be contacted and acceptance of transfer of the patient will be documented. Transfers of emergency patients shall be made only after all steps required by the EMTALA regulations have bee followed and the physician and nurse have completed the required documentation.