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Based on documentation review and staff interview, the hospital's administrative staff failed to ensure the hospital staff followed its policies and procedures and provided an adequate medical screening examination within its capabilities and capacity to one individual (patient # 17) out of 54 medical records reviewed from June 2013 through May 2017.

Failure to follow its policies and procedures to provide an adequate medical screening examination to any individual presenting to the emergency department (ED) requesting care could delay care for a potential emergency medical condition and place the individual at risk for complications including injury or death.

Findings included:

1. Review of the Medical Staff Bylaws of Crawford County Memorial Health adopted 7/25/16, revealed in part, "The hospital will provide a medical screening exam, a process of examination and treatment necessary to determine whether an emergency medical condition exists. An appropriate screening shall be provided within the Hospital's capabilities, including all ancillary services routinely available, to any individual who comes to the hospital and requests examination or treatment for a medical condition. The medical screening examination must be performed by a physician or other Qualified Medical Personnel as defined in the Medical Staff Bylaws, Rules and Regulations, Hospital EMTALA policy, and hospital operational policies and protocols."

The bylaws continued: If the patient has an emergency medical condition ...the hospital will treat or stabilize the patient. The patient will not be transferred to another facility unless the patient's condition is stabilized or it is in the patient's best interest to be transferred due to the hospital's inability to provide the needed services or level of care and if the requirements for transfer outlined in the Medical Staff Bylaws, Rules and Regulations, and the hospital operational policies and protocols are met.

2. Review of the "Emergency Medical Treatment and Labor Act" (EMTALA) Policy, revised 9/15, revealed the hospital will provide an appropriate Medical Screening Examination (MSE) and stabilizing treatment within its capacity and capability to any individual presenting to the hospital property and when a request for emergency care and treatment is made by the individual or on the individuals behalf.

3. Review of closed medical record showed Patient #17, a 19 year old patient, presented to the ED on 11/26/2014 at 2:55 PM after an intentional overdose of Lorazepam 0.5 mg (an anti-anxiety medication known as Ativan) and an unknown amount of Advil (Ibuprofen) over the prior 16 hours. Further documentation showed at 3:10 PM "Poison control center notified. Labs and symptomatic supportive care recommended."

ED physician H did not obtain any blood or urine lab testing to determine any abnormalities in patient # 17's liver and kidney function after she alleged an intentional overdose of Lorazepam and Advil due to recent stress. Prior to discharge patient # 17 demonstrated symptoms of an overdose of Lorazepam which included drowsiness and difficulty walking.

At 6:20 p.m., patient # 17 left the ED in a wheelchair to go home with family. Patient # 17 returned to the ED within approximately fifteen hours of discharge and blood and urine testing revealed the patient was in acute renal and liver failure and required mechanical ventilation and air ambulance transport to a Level 1 Trauma Center Hospital BB for care of an emergency medical condition.

The medical record did not contain evidence that the critical access hospital provided patient #17 with a medical screening examination sufficient to determine the presence of an emergency medical condition. Patient # 17 died fifteen days after transfer to Hospital BB.

Please refer to C 2406 for additional information.

Based on review of hospital documents, and medical records, the Critical Access Hospital (CAH) failed to ensure one patient (#17) that presented to the Emergency Department (ED) received an appropriate medical screening examination within the CAH's capabilities and capacity out of 54 medical records reviewed from June 2013 through May 2017. The CAH had an average of 415 patients presenting to the emergency department (ED) requesting emergency care monthly.

Failure to provide an appropriate medical screening examination within the CAH's capabilities and capacity delayed treatment for patient # 17's life threatening emergency medical condition. The CAH's failure had the potential to place all patients presenting for care at risk, including unnecessary delays, suffering, avoidable pain, disability or death.

Review of a closed medical record showed Patient #17 presented to the ED by wheelchair accompanied by family on 11/26/2014 at 2:55 PM after ingesting approximately 10 tablets of Lorazepam .5 mg (also known as Ativan, a tranquilizing medication known as a benzodiazepine) and an unknown amount of Advil (over the counter pain relieving medication known as Ibuprofen). Symptoms of an Ativan (benzodiazepine) overdose include drowsiness, difficulty walking, decreased muscle tone, confusion, and suppression of breathing. Symptoms of an Ibuprofen overdose include headache, ringing in the ears, drowsiness, nausea, vomiting and abdominal pain.

Documentation by the ED nurse showed "unsure what time or how many she took today." Further documentation showed that patient #17 had been feeling stressed about college, had recently been prescribed Lorazepam and that she had taken more because "she was so stressed." Documentation also showed patient # 17 was prescribed Sertraline (an anti-depressant known as Zoloft). The was no documentation in the medical record to indicate the prescribed dosage, frequency for administration, or when patient # 17 had taken her last dose of Sertraline.

The ED nurse documented patient # 17 "goes between" rambling conversation and coherent. At 3:05 p.m. ED physician H was paged. At 3:10 pm "Poison Control Center notified" (poison centers provide expert medical advice for preventing and treating poison exposures). "Labs and symptomatic supportive care recommended." From 3:10 p.m. to 4:35 p.m., patient # 17's blood pressure ranged from a high of 132/103 to an extreme low of 71/35 as documented by the ED nurse (healthy blood pressure range is 120/80, abnormally low blood pressure range is less than 90/60). At 3:34 p.m. and 3:57 p.m., the ED nurse noted patient # 18 was "tearful" and "crying" with family and friends at the bedside.

At 3:13 p.m. ED physician H examined patient # 17 and documented the patient intentionally ingested Aprazolam (sic) .50 mg (Alprazolam, also known as Xanax is an anti-anxiety / tranquilizing benzodiazepine). Further documentation showed that patient # 17 had a history of anxiety and was prescribed "Apazolam (sic) yesterday." ED physician H also documented that patient # 17 saw her former boyfriend last night and that was upsetting to her. "She took Apazolam (sic) because she was upset." "No suicide intent." The ED physician H documented patient # 17 was "well-appearing," "very sleepy," and "coherent." ED physician H's "Impression" was "Overdose of Alprazolam." ED physician H electronically signed patient # 17's medical record 50 days later on January 14, 2015 at 8:07 a.m.

ED physician H discharged patient # 17 from the ED at 6:18 p.m. with an abnormally low blood pressure of 80/47.

The medical record did not contain evidence that patient # 17 received an appropriate medical screening examination. ED physician H did not order treatment for patient # 17's abnormally low blood pressure, did not order blood tests or urine testing as recommended by the poison control center to determine the type or amount of medication ingested or whether toxic levels were present. And, there was no evidence patient # 17 received a mental health evaluation related to her tearfulness while in the ED or her "intentional" overdose of her recently prescribed Lorazepam, or that ED staff currently providing patient care at the CAH took action to prevent patient # 17's discharge prior to providing an appropriate medical screening examination.

2. Review of a second closed medical record showed Patient #17 returned to the ED on 11/27/14 at 9:37 a.m. by ambulance, approximately fifteen hours following discharge on 11/26/2014.

Review of the pre-hospital ambulance trip report showed that the ambulance crew arrived at patient # 17's home on 11/27/14 at 9:09 a.m. and that the patient was found unresponsive. Further documentation showed the ambulance crew administered Romazicon (medication that reverses the sedative effects of a group of drugs known as benzodiazepines, such as Xanax or Ativan) at 9:28 a.m. with minimal response. At 9:30 a.m. the ambulance crew administered Narcan (medication that reverses the sedative effects of an opiate overdose), and at 9:32 a.m. administered a second dose of Romazicon and noted patient # 17 awoke very agitated. At 9:34 a.m. the ambulance arrived at Crawford County Memorial Hospital's ED.

At 9:45 a.m., the ED physician I examined patient # 17. At 10:57 a.m. blood testing results showed that patient # 17 had acute kidney failure, elevated liver enzymes (impaired functioning of the liver) and a toxic level, 190 ug/mL of Acetaminophen in her blood. Acetaminophen is the main ingredient in Tylenol, a normal level in the blood is 10 to 30 micrograms per milliliter, ug/mL. An overdose of Acetaminophen causes serious damage to the liver and is an emergency medical condition.

At 11:52 a.m. documentation showed that patient # 17 continued to deteriorate and at 12:00 p.m., required intubation (flexible plastic tube inserted into the tracheal to maintain an open airway) and mechanical ventilation. At 12:35 p.m. ED physician I ordered administration of N-acetylcysteine (if this medication is administered within eight hours after an acetaminophen overdose, liver damage may be prevented prevent damage to the liver). Further documentation showed that staff arranged transfer to a level 1 trauma center, Hospital BB by air ambulance for a higher level of care.

3. Review of a third closed medical record showed that patient # 17 arrived at Hospital BB at 1:09 p.m., approximately 22 hours after initially presenting to Crawford County Memorial Hospital for care following an intentional overdose. Further documentation in Hospital BB's medical record showed that physicians admitted patient # 17 due to an intentional overdose. Patient # 17 expired fifteen days later.

4. During an interview on 5/11/17 at 9:39 AM, Chief Executive Officer (CEO) declined to provide additional information related to Patient #17's medical record. The CEO stated that ED physician I was contracted through company AA and was unable to be interviewed per company AA's agreement.