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Based on record review, policy review, interviews, and review of the emergency room log, it was determined the provider failed to comply with the provider agreement defined in 489.20 and 489.24. Findings include:

1. The provider failed to document 1 of 20 sampled patients (20) presenting to the emergency department (ED) for emergency care had been entered into the emergency room log.

2. The provider failed to ensure a medical screening had been performed for 1of 20 sampled patients (20) presenting to the ED for emergency care.

3. The provider failed to ensure 1 of 20 sampled patients (20) presenting to the ED for emergency care had been stablized prior to sending the patient to another health care provider.

4. The provider failed to ensure there had been no delay in treatment for 1 of 20 sampled patients (20) presenting to the ED for emergency treatment.

5. The provider failed to ensure eight of nine sampled patients (2, 8, 9, 10, 13, 15, 16 and 18) being transferred to another health care facility had been informed of the risks and benefits of the transfer specific to the patients condition.

6. Refer to C2405, C2406, C2407, C2408 and C2409.

Based on record review and interview, the provider failed to follow the facility policy and to ensure one of one patient (20) presenting to the emergency department (ED) had been entered into the ED log book.
Findings Include:

1. Review of the ED log failed to show an entry had been made for patient 20 on May 18, 2010.
Review of the emergency screening, stabilization, and transfer requirements policy dated August 1996 and last revised September 2007 revealed:
The medical screening examination would:
a. Be done in a non-discriminatory manner.
b. Include the following element:
1. Log entry with disposition.

Interview with the hospital director of nursing (DON) on 7/01/10 at 8:23 a.m. revealed she was not aware of any issues with the ED. She stated patients were only sent to the clinic if they had come to the ED by mistake and wanted to go to the clinic. Sometimes an ambulance showed up with a patient that wanted to go to the clinic. Those patients still received a medical screening before sending them to the clinic. She did recall a patient from the nursing home that had fallen and was taken to the clinic prior to being sent to the ED. The patient did not have any ED orders and was sent back to the clinic.

Interview with a certified nurse practitioner (CNP) from Horizon Clinic on 7/01/10 at 9:32 a.m. revealed she had received a call from the nursing home informing her a resident had fallen and had struck her head. The resident had been crying and had been confused since the fall. The CNP instructed the nursing home staff to take the resident to the emergency department at the hospital. According to the CNP when the nursing home staff arrived at the hospital the DON told them the patient did not need to be seen in the ED, and the patient needed to be taken to the clinic. Further interview with the CNP indicated that had happened in the past with nursing home patients.

Interview with the former DON from the nursing home on 7/01/10 at 10:20 a.m. revealed on 5/18/10, patient 20 had fell in the nursing home and struck her head. The patient had a previous history of a "bleed". The nursing home DON called the CNP on call and was told to take the resident to the hospital ED. The resident was taken to the hospital and was told by the hospital DON the patient did not need to be seen in the ED and should be taken to the clinic.

Review of progress notes from Horizon Clinic dated 5/18/10 revealed patient 20 had presented to emergency department at the hospital and had been sent to the clinic without a medical screening.

Based on record review, policy review, and interview, the provider failed to follow the facility policy and provide a medical screening for 1 of 20 patients (20) who had presented to the emergency department (ED) for treatment. Findings Include:

1. Review of the ED log failed to show an entry had been made for patient 20 on May 18, 2010.

Review of the emergency screening, stabilization, and transfer requirements policy date August 1996 and last revised September 2007 revealed "The facility will provide every patient seeking acute medical care with an appropriate medical screening examination to determine whether the patient has an emergency medical condition or is in active labor. All medical screening examinations beyond triage will be provided by a physician, physician's assistant, or a certified nurse practiitioner, to include hospital owned ambulances." The following will be used as a guideline for hospital staff:
1. The Centers for Medicare and Medicaid Servives (CMS) State Operations Manual defines a medical screening examination as the non-discriminatory process required to reach with reasonable clinical confidence whether a medical emergency does or does not exist.
2. CMS prohibits hospitals from seeking authorization from an individual insurance company until a medical screening examination has been provided and necessary stabilizing treatment has been initiated.
3. When a person comes to the emergency department such presentation triggers a hospital's obligation
to provide a medical screening examination.
4. It is the obligation of this facility and a requirement of CMS to maintain an on-call list if physicians who see patients with potential emergency medical conditions in the emergency department in a manner that bests meets the needs of the hospital patients receiving services.
5. The medical screening examination will:
a. Be done in a non-discriminatory manner.
b. Include the following elements:
1. Log entry with disposition.
2. Triage record.
3. Ongoing recording of vital signs.
4. Oral history.
5. Physician examination.
6. Use of all necessary testing resources to check for an emergency medical condition.
7. Use of on-call physicians as needed.
8. Discharge or transfer vital signs.
9. Adequate documentation of all of the above.

Interview with the hospital director of nursing (DON) on 7/01/10 at 8:23 a.m. revealed she was not aware of any issues with the ED. She stated patients were only sent to the clinic if they had come to the ED by mistake and wanted to go to the clinic. Sometimes an ambulance showed up with a patient that wanted to go to the clinic. Those patients still received a medical screening before sending them to the clinic. She did recall a patient from the nursing home that had fell and was taken to the clinic prior to being sent to the ED. The patient did not have any ED orders and was sent back to clinic.


Interview with a certified nurse practitioner (CNP) from Horizon Clinic on 7/01/10 at 9:32 a.m. revealed she had received a call from the nursing home informing her a resident had fell and had struck her head. The resident had been crying and had been confused since the fall. The CNP instructed the nursing home staff to take the resident to the emergency department at the hospital. According to the CNP when the nursing home staff arrived at the hospital the (DON told them the patient did not need to be seen in the ED, and the patient needed to be taken to the clinic. The CNP further indicated that had happened in the past with nursing home patients. She had problems with the hospital DON changing orders on patients she had sent to the hospital for care.


Interview with the former DON from the nursing home on 7/01/10 at 10:20 a.m. revealed on 5/18/10, patient 20 had fell in the nursing home and had struck her head. The patient had a previous history of a "bleed". The nursing home DON called the CNP on call and was told to take the resident to the hospital ED. The resident was taken to the hospital and was told by the hospital DON the patient did not need to be seen in the ED and should be taken to the clinic.

A confidential interview with a nursing home employee on07/01/10 at 8:45 a.m. revealed 5-6 times in the past year hospital staff had told nursing home staff they were busy and could they wait until theclinic was open. The nursing home employee had went to the hospital and had verified they were not busy.

Review of progress notes from Horizon Clinic dated 5/18/10 revealed the nursing home had called to inform the clinic patient 20 had been found on the floor after an apparent fall. Patient 20 was unable to verbalize what had happened and was unable to stand without assistance. The nursing home nurse was instructed to take patient 20 to the hospital ED, and have patient 20 triaged due to confusion, pain, and a possible fracture. Fifteen minutes later the hospital DON came to the clinic and stated they would not see patient 20 in the ED, and she was going to have her wheeled to the clinic. The provider attempted to reason with the DON to have patient 20 triaged/treated through the ED due to potential for fracture/head bleed. The patient was then seen in the clinic due to refusal to be seen at Bennett County Hospital. Patient 20 was found to have dizziness, confusion, disorientation, and memory lapses/loss. Patient 20 was sent to the hospital for bilateral hip and pelvis x-rays that were read as no fractures. Nursing home staff were told to monitor patient 20 closely for falls and patient could be placed in a geriatric walker for assistance and safety while unsteady and to prevent injury.

Based on record review, policy review and interview the provider failed to ensure one of one patient (20) presenting to the emergency department (ED) received the medical screening and was stable prior to being sent to the clinic to be seen by a practitioner. Findings Include:

1. Review of the ED log failed to show an entry had been made for patient 20 on May 18, 2010.

Review of the emergency screening, stabilization, and transfer requirements policy dateAugust 1996 and last revised September 2007 revealed under "Stabilizing Treatment":
All patients presenting to the Bennett County Emergency Department will be offered medical stabilization within the staff and facilities available:
1.) Definition of Stabilization:
a. With respect to an emergency medical condition, that no material deterioration of the condition is likely within reasonable medical probability to result from or occur during the transfer of the individual from this hospital.
b. With respect to OB, that the woman has delivered including the placenta.
2.) The patient is deemed stabilized if the treating physician determines within reasonable clinical confidence that the emergency medical condition has been resolved or if the treating physician determines that the patient is stable to transfer of stable for discharge.
3.) Any individual who comes to the hospital and is determined to have an emergency medical condition, the hospital must provide:
a. Within the staff and the facilities available at the hospital for such further medical examination and such treatment as may be required to stabilize the medical condition.
b. For transfer of the individual to another medical facility.

Interview with the hospital director of nursing (DON) on 7/01/10 at 8:23 a.m. revealed she was not aware of any issues with the ED. She stated patients were only sent to the clinic if they had come to the ED by mistake and wanted to go to the clinic. Sometimes an ambulance showed up with a patient that wanted to go to the clinic. Those patients still received a medical screening before sending them to the clinic. She did recall a patient from the nursing home that had fell and was taken to the clinic prior to being sent to the ED. The patient did not have any ED orders and was sent back to clinic.


Interview with a certified nurse practitioner (CNP) from Horizon Clinic on 7/01/10 at 9:32 a.m. revealed she had received a call from the nursing home informing her a resident had fell and had struck her head. The resident had been crying and had been confused since the fall. The CNP instructed the nursing home staff to take the resident to the emergency department at the hospital. According to the CNP when the nursing home staff arrived at the hospital the (DON told them the patient did not need to be seen in the ED, and the patient needed to be taken to the clinic. The CNP further indicated that had happened in the past with nursing home patients. She had problems with the hospital DON changing orders on patients she had sent to the hospital for care.


Interview with the former DON from the nursing home on 7/01/10 at 10:20 a.m. revealed on 5/18/10, patient 20 had fell in the nursing home and had struck her head. The patient had a previous history of a "bleed". The nursing home DON called the CNP on call and was told to take the resident to the hospital ED. The resident was taken to the hospital and was told by the hospital DON the patient did not need to be seen in the ED and should be taken to the clinic.

Telephone interview with a licensed practical nurse (LPN) from the nursing home on 7/06/10 at 8:25 a.m. revealed he had been told to take patient 20 to the hospital ED after finding her on the floor. Patient 20 had fell and had hit her head. The LPN was told at the hospital the patient did not need to be seen in the ED, and he should take her to the clinic.

Review of progress notes from Horizon Clinic dated 5/18/10 revealed the nursing home had called to inform the clinic patient 20 had been found on the floor after an apparent fall. Patient 20 was unable to verbalize what had happened and was unable to stand without assistance. The nursing home nurse was instructed to take patient 20 to the hospital ED, and have patient 20 triaged due to confusion, pain, and a possible fracture. Fifteen minutes later the hospital DON came to the clinic and stated they would not see patient 20 in the ED, and she was going to have her wheeled to the clinic. The provider attempted to reason with the DON to have patient 20 triaged/treated through the ED due to potential for fracture/head bleed. The patient was then seen in the clinic due to refusal to be seen at Bennett County Hospital. Patient 20 was found to have dizziness, confusion, disorientation, and memory lapses/loss. Patient 20 was sent to the hospital for bilateral hip and pelvis x-rays that were read as no fractures. Nursing home staff were told to monitor patient 20 closely for falls and patient could be placed in a geriatric walker for assistance and safety while unsteady and to prevent injury.

Review of the emergency department (ED) log failed to show an entry had been made for patient 20 on May 18, 2010.

Interview with a certified nurse practitioner (CNP) from Horizon Clinic on 7/01/10 at 9:32 a.m. revealed she had received a call from the nursing home informing her a resident had fell and had struck her head. The resident had been crying and had been confused since the fall. The CNP instructed the nursing home staff to take the resident to the emergency department at the hospital. According to the CNP when the nursing home staff arrived at the hospital the (DON told them the patient did not need to be seen in the ED, and the patient needed to be taken to the clinic. The CNP further indicated that had happened in the past with nursing home patients. She had problems with the hospital DON changing orders on patients she had sent to the hospital for care.


Interview with the former DON from the nursing home on 7/01/10 at 10:20 a.m. revealed on 5/18/10, patient 20 had fell in the nursing home and had struck her head. The patient had a previous history of a "bleed". The nursing home DON called the CNP on call and was told to take the resident to the hospital ED. The resident was taken to the hospital and was told by the hospital DON the patient did not need to be seen in the ED and should be taken to the clinic.

Telephone interview with a licensed practical nurse (LPN) from the nursing home on 7/06/10 at 8:25 a.m. revealed he had been told to take patient 20 to the hospital ED after finding her on the floor. Patient 20 had fell and had hit her head. The LPN was told at the hospital the patient did not need to be seen in the ED, and he should take her to the clinic.

Review of progress notes from Horizon Clinic dated 5/18/10 revealed the nursing home had called to inform the clinic patient 20 had been found on the floor after an apparent fall. Patient 20 was unable to verbalize what had happened and was unable to stand without assistance. The nursing home nurse was instructed to take patient 20 to the hospital ED, and have patient 20 triaged due to confusion, pain, and a possible fracture. Fifteen minutes later the hospital DON came to the clinic and stated they would not see patient 20 in the ED, and she was going to have her wheeled to the clinic. The provider attempted to reason with the DON to have patient 20 triaged/treated through the ED due to potential for fracture/head bleed. The patient was then seen in the clinic due to refusal to be seen at Bennett County Hospital. Patient 20 was found to have dizziness, confusion, disorientation, and memory lapses/loss. Patient 20 was sent to the hospital for bilateral hip and pelvis x-rays that were read as no fractures. Nursing home staff were told to monitor patient 20 closely for falls and patient could be placed in a geriatric walker for assistance and safety while unsteady and to prevent injury.

A confidential interview with a nursing home employee on 7/01/10 at 8:45 a.m. revealed five oor six times in the past year hospital staff had told nursing home staff they were busy, and they should wait until clinic was open. The nursing home employee went to the hospital and verified the hospital staff was not busy.

Based on record review and policy review, the provider failed to ensure risks and benefits for eight of nine patients (2, 8, 9, 10, 13, 15, 16, and 18) transferred to other facilities were specific to the patient's condition and no transfer form had been completed for one of nine patients (7) transferred to another facility. Findings include:

1. Review of the patient transfer form revealed statements of risks and benefits were part of the form. The form also contained a line labeled Other and room to write risks and benefits specific to the patient. Review of patients 2, 8, 9, 10, 13, 15, 16,and 18, records revealed there were no risks or benefits specific to the patient conditions listed on the transfer form. Review of the medical record for patient 7 revealed no transfer form in the record. There was a home instruction sheet that had been marked discharged home and under the other specific instructions a statement stating transfer to Rapid City Regional Hospital Emergency Room. A discharge time of 5:50 a.m. had been noted. It had also been noted accompanied by Bennett County Emergency Medical Services.