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Based on review of the hospital's dedicated emergency department log, policies and procedures, and interviews with hospital staff, the hospital failed to maintain a dedicated emergency room log.

This failed practice had the likelihood to result in delayed or inaccurate communication between health care providers as the medical record provides a sequential record of patient care by promoting patient safety through timely documentation of physical assessments and interventions to decrease adverse health outcomes and ensure quality patient care.

Findings:

The dedicated emergency room log did not include documentation for patient #5 on 05/08/23.

Based on record review and interview, the hospital failed to ensure a MSE was completed per policy for 1 (patient #5) of 23 patients. This failed practice has the likelihood for an emergency medical condition to go unidentified and untreated thereby, increasing the risk of an undesirable health outcome.

Findings:

Review of Antlers Fire/EMS run report showed EMS staff called a report on patient #5 to MRH staff RN at approximately 02:10pm stating they were unable to secure air transport and was bringing patient to MRH. Upon ambulance arrival to MRH at 02:36pm, Staff RN came out and stated hospital could not accept patient based on CT scanner was out of service, and they had no way to evaluate patient status. MRH staff secured Airvac transport at 02:13pm for patient #5. Ambulance docked at MRH ED Bay 02:36pm. Staff D entered ambulance at 02:40pm documented an incomplete MSE for visit 05/08/23 on 05/07/23 visit as an "Addendum".

Patient #5 was never registered at hospital and Staff D failed to provide patient #5 a complete MSE for visit date of 05/08/23. MSE by Staff D obtained an incomplete set of vital signs. A full set of vital signs is required per hospital policy defined below. No respiratory rate, temperature, blood pressure, pulse, or oxygen saturation level were documented. No additional contact or assumption of care was made by MRH staff. The ambulance was in the ED Bay until 03:20pm (Approximately 44 minutes) before rendezvous occurred with Airvac transport.

Review of CT Scanner maintenance documentation showed that CT Scanner was down at the time of 05/08/23 visit. CT Scanner was not returned into use until 05/09/23.

Policy: McAlester Regional Health Center Policy effective 01/05/21 until 06/08/23 states: "EMTALA Guidelines" Medical Screening Exams should include at a minimum the following: (1) Emergency Department Log entry including disposition of patient: (2) Patient's triage record: (3) vital signs: (4) History (5) Physical exam of affected systems and potentially affected systems; (6) Exam of known chronic conditions; (7) Necessary testing to rule out emergency medical conditions: (8) Notification and use of on-call personnel to complete previously mentioned guidelines; (9) Notification and us of on-call physicians to diagnose and/or stabilize the patient as necessary: (10) Vital signs upon discharge or transfer; (11) Complete documentation of the medical screening exam.



Interviews:

On 08/04/23, the surveyor asked Staff D for an EMTALA is there a range of service area that is covered. Staff D states anyone in the vicinity of the hospital/campus is covered. Surveyor asked can you think of, or have you experienced a reason a person would not have been registered or a completed MSE done. Staff D stated I cannot think of any reason someone would not be seen.

On 08/03/23, the surveyor asked Staff E when a MRH Staff RN accepts report from EMS and then presents in the ambulance bay, what is the procedure to go from there. Staff E stated patient is taken from ambulance into hospital, then a MSE is completed. Patient is treated per symptoms. Surveyor asked can you describe a time that a patient has shown up in the ambulance bay and not been seen in the ED. Staff E stated I cannot think of anytime we have not seen anyone.

On 08/03/23, the surveyor asked Staff A regarding an EMTALA, can you think of any reason a person would not be received or given a MSE. Staff A stated I cannot think of any reason or any time that we have not followed our policy of providing an MSE so we can treat the patient.

On 08/03/23, the surveyor asked Staff B to describe a reason a person would not be registered or receive a medical screening exam when they came in by ambulance. Staff B responded I cannot think of any reason a person is not registered or treated when they come in by ambulance. I do not recall that ever happening.

Based on review of records and policy MRH failed to affect an appropriate transfer for 1 (patient #5) out of 23 reviewed. This failed practice had the potential to result in delayed care and possible deterioration of health due to the lack of information provided to the receiving facility.

Findings:

Patient #5 presented to MRH ED department by EMS on 05/08/23 at 2:36pm with possible aortic dissection. Air transport had been attempted to be arranged by EMS but was unsuccessful. Airvac transport was arranged by MRH medical staff. MRH did not provide a certification of risk/benefits, patient request for transfer in writing, patient record of MSE, vital signs, medical records to include (CT scan, Laboratory tests, or past medical treatment provided), or acceptance from receiving hospital. Patient did not sign consent for transfer or refusal of care.

Review of MRH Policy showed "EMTALA Guidelines" in effect from 01/05/21 through 06/08/23 #07& #10 were not followed:
#07: If a patient is to be transferred for medical necessity the following guidelines must be followed: (a) A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be documented, and the patient's medical record must support these, or (b) The patient request transfer in writing. (c) The receiving hospital must give acceptance in advance. The acceptance must be documented in the medical record; The patient gives written consent for transfer; The patient must be transferred by an appropriate medical transfer vehicle unless physician deems patient stable to transport by private vehicle. An unstable or critical patient may not be transferred in a private passenger vehicle unless the patient refuses to be transported by ambulance. (d) The patient's refusal must be in writing.

#10: Copies of the medical record, x-rays and laboratory tests will accompany the patient when transferred. In the event copying the records could jeopardize the patient, the records may be sent on a STAT basis to the receiving facility.