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Based on interview, medical record and policy and procedure review, the critical access hospital (CAH) failed to follow its policies and procedures and did not provide an appropriate and sufficient medical screening examination prior to coercing a patient (Patient 1) to leave the emergency department (ED) and seek care elsewhere. Twenty ED medical records were reviewed.

Staff's failure to follow policies and procedures led to a delay in patient 1's care and treatment, and placed him and other patients who present to the ED seeking care at significant risk for inappropriate and/or insufficient clinical decision-making, and undetected emergency medical conditions leading to further deterioration in their health, up to and including death.

Findings include:

Review of the facility's policy titled, "Patient Transfers and Emergency Medical Treatment and Active Labor Act (EMTALA)," last revised 11/2018 showed, "The Hospital is obligated to perform an MSE to determine if an Emergency Medical Condition exists. It is not appropriate to merely 'log in' a patient and not provide an MSE...An MSE is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred."

Review of Patient 1's medical record showed he presented to the ED at 8:38 PM on 4/19/19 seeking care for a serious chain saw accident. The medical record did not contain evidence that staff performed a triage to determine the severity of the patient's injuries or the appropriate timeliness for examination and treatment. At 9:28 PM, approximately 50 minutes after arrival ED nurse E brought patient 1 and his family member to an examination room. Further review of the medical record showed that Physician Assistant F documented "Presents to ER with C/O [complaint of] chain saw accident...cutting deep into bilateral mid-thighs. Reports that the saw then jumped up and caught him on the face, causing abrasion to his nose...severity scale 7 [scale of 1-10]...approximate 12 cm [centimeters], full thickness laceration, multiple layer down to bone...I advised he was going to likely require surgical debridement and repair." The Discharge Disposition was documented as, "Left AMA [Against Medical Advice]" and Patient 1 signed the form at 9:20 PM. Documentation on the form specified that Physician Assistant F offered stabilizing treatment and transfer to a trauma center, but patient 1 refused. The medical record lacked documentation of patient 1's vital signs, an evaluation/inspection of his wounds, any orders for pain medication, wound debridement or care, or any attempts to contact an available surgeon or arrange for transport by ambulance to a hospital providing a higher level of care.

During a telephone interview on 04/29/19 at 1:00 PM, RN E reported caring for Patient 1 in the ED on 04/19/19. RN E stated that she did not know Patient 1 was waiting to be seen, or the nature of Patient 1's injury until Registration Clerk H came to report Patient 1 and his family were "upset and going to leave." RN E stated she brought patient 1 to an examination room and that she did not witness Physician Assistant F offer or order any interventions for Patient 1's wounds. RN E also stated that at no time did she witness Physician Assistant F call another facility or the ambulance service to consult about a transfer. RN E stated there was not time to check patient 1's vital signs. RN E stated that Physician Assistant F immediately said "you need a trauma center, transport is at least 2 hours out, if I were you I wouldn't waste any time, get in your car and go." RN E verified giving disposable "chux" pads to Patient 1's family with instructions to apply steady pressure to the wounds in case of bleeding on their way to the next facility. RN E confirmed she witnessed the patient's signature on the AMA form and stated "my mistake, I did have him sign."

Please refer to A-2406 for details.

Based on record review, interviews, and facility policy review, the facility failed to provide a medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (Patient 1) of 20 emergency department (ED) patient records reviewed. The facility also failed to provide annual training related to the Emergency Medical Treatment and Labor Act (EMTALA) to ED providers.

Failure to provide a timely and sufficient MSE places patients at risk for undetected emergency medical conditions and delays in receiving stabilizing treatment, which could lead to negative outcomes for all patients who present to the ED seeking care.

Findings include:

Review of the facility's policy titled, "Patient Transfers and Emergency Medical Treatment and Active Labor Act (EMTALA)," last revised 11/2018 showed, "The Hospital is obligated to perform an MSE to determine if an Emergency Medical Condition exists. It is not appropriate to merely 'log in' a patient and not provide an MSE...An MSE is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred."

Review of Patient 1's medical record showed a service date at the facility's ED of 04/19/19 at 8:38 PM. An assessment documented by Physician's Assistant (PA) F was timed at 9:28 PM (50 minutes after Patient 1 arrived) and included the entry, "Presents to ER with C/O [complaint of] chain saw accident...cutting deep into bilateral mid-thighs. Reports that the saw then jumped up and caught him on the face, causing abrasion to his nose...severity scale 7 [scale of 1-10]...approximate 12 cm [centimeters], full thickness laceration, multiple layer down to bone...I advised he was going to likely require surgical debridement and repair." The Discharge Disposition was documented as, "Left AMA [Against Medical Advice]." A "Refusal of Services" form, also known as an AMA form was signed by Patient 1 at 9:20 PM. The medical record lacked documentation of vital signs, orders, or interventions.

Further review of the medical record showed that Physician Assistant F documented "Disposition;" "Left Before Triage" and that Patient 1's "Condition:" "Not Assessed", "Discharge Date/Time:" "04/19/19 21:35" (9:35 PM).

Review of a second medical record showed that Patient 1 presented to the ED at Hospital B on 4/19/19 at 9:57 PM (37 minutes after signing out AMA) for examination and treatment of his lacerations, inpatient admission, and surgical repair.

During a telephone interview on 04/29/19 at 9:15 AM, Patient 1 stated that upon arrival to the ED on 04/19/19, his family member completed the registration process. Patient 1 stated that he waited "about half an hour" then briefly went outside to retrieve a cell phone from a vehicle, came back to the waiting room and was brought back to an ED examination room by Registered Nurse (RN) E. Patient 1 stated that no assessment was conducted, and that during the wait, no person except the registration clerk looked at his wounds. Patient 1 stated that Physician Assistant F entered the exam room before there was time to change into a gown, and that Physician Assistant F looked at his wounds through the cut in his jeans and stated "I'm not a trauma doctor, you'll have to go to (Hospital B) or (a Hospital C)." Patient 1 stated that Physician Assistant F said that both ambulances were out and he would have to wait on an ambulance to get to another facility for treatment. Patient 1 recalled saying, "It is time to go" and at Physician Assistant F's request, signed an AMA (Against Medical Advice) form in the presence of Registered Nurse (RN) E and left to seek treatment elsewhere. Patient 1 denied receiving any care, or offer for care, for the leg lacerations prior to leaving the ED.

During an interview on 04/29/19 at 11:00 AM, a family member stated she stayed with Patient 1 throughout the ED visit on 04/19/19. The family member stated that Patient 1's jeans were cut and soaked with blood and that Physician Assistant F did not examine Patient 1, or offer any treatment, or any pain medication. The family member stated that when Physician Assistant F entered the exam room he stated "I'm not a trauma doctor, you need a trauma doctor at [hospital B] or [hospital C], both ambulances are out, will be awhile until they are available, or you can go on your own." The family member stated that as they left, ED nurse E provided them several "chux" pads (drapes with absorbent gauze on one side) to use in case Patient 1's wounds began bleeding as they drove to the next facility. The family member also stated that they were called back to "sign a paper" and that nobody had time to explain the "AMA" form (the benefits of staying for examination or the risks of leaving).

During a telephone interview on 04/29/19 at 1:00 PM, RN E reported caring for Patient 1 in the ED on 04/19/19. RN E stated that she did not know Patient 1 was waiting to be seen, or the nature of Patient 1's injury until Registration Clerk H came to report Patient 1 and his family were "upset and going to leave." RN E stated she brought patient 1 to an examination room and that she did not witness Physician Assistant F offer or order any interventions for Patient 1's wounds. RN E also stated that at no time did she witness Physician Assistant F call another facility or the ambulance service to consult about a transfer. RN E stated there was not time to check patient 1's vital signs. RN E stated that Physician Assistant F immediately said "you need a trauma center, transport is at least 2 hours out, if I were you I wouldn't waste any time, get in your car and go." RN E verified giving disposable "chux" pads to Patient 1's family with instructions to apply steady pressure to the wounds in case of bleeding on their way to the next facility. RN E confirmed she witnessed the patient's signature on the AMA form and stated "my mistake, I did have him sign."

During a telephone interview on 04/29/19 at 4:00 PM, Physician Assistant F stated he was the provider in the ED on 04/29/19 when Patient 1 was brought to an ED examination room. Physician Assistant F stated that after looking at the leg lacerations of Patient 1, he determined that a trauma surgeon would be required, but that an ambulance would not be available for two to three hours. Physician Assistant F stated, "There was no surgical coverage that night" and that he offered to "clean up" the lacerations, but Patient 1 declined. Physician Assistant F stated he offered to arrange transport by ambulance to another facility, but Patient 1 declined. Physician Assistant F stated that Patient 1 decided to leave the ED and be transported to another facility by private vehicle. Physician Assistant F stated that he explained the risks of leaving AMA and that Patient 1 agreed to sign the AMA form prior to leaving.

During a telephone interview on 04/30/19 at 3:00 PM, Registration Clerk H recalled registering Patient 1 with the help of his family member on 04/19/19. Registration Clerk H reported following regular registration procedures for ED patients, getting Patient 1's name, date of birth, and reason for the visit ("leg laceration") into the computer and bringing a file to the ED nurse's station. Registration Clerk H could not recall how long Patient 1 waited in the waiting room but did recall his family asking, "How much longer, we're going to leave." Registration Clerk H stated that she went to the ED nurse's station and told RN E about the family's complaint, and then saw RN E take Patient 1 to an exam room. Registration Clerk H stated that patients are usually brought to an exam room right away, but the ED was "very busy" on 04/19/19.

During a telephone interview on 04/29/19 at 3:15 PM, the ED Medical Director stated upon review of Patient 1's medical record, "At the least, the patient should have had the wound cleansed and a dressing applied." ED Medical Director C also stated, "We have a general surgeon. We all know we can call him even when he's not on-call," and stated no attempt to call the surgeon was documented in the medical record. The ED Medical Director also stated that all ED providers know the ambulance schedules can be modified when needed and stated that Physician Assistant F could have called the ambulance to inquire about their availability. The ED Medical Director C stated that no such call to the ambulance service was documented in Patient 1's medical record.

During an interview on 04/29/19 at 8:10 AM, the Director of Quality and Risk Management stated that an internal review of Patient 1's care in the ED on 04/19/19 was still being conducted at the time of this survey. The Director provided a transcript of the timeline of the care of Patient 1 from video surveillance of the ED on 04/19/19. The timeline showed Patient 1 entered the ED waiting room at 2037 (8:37 PM). The timeline showed Patient 1 being escorted to an exam room at 2113 (9:13 PM). The timeline showed that Patient 1 and Physician Assistant F were in the examination room for two minutes. The Director agreed that no triage of Patient 1 took place during the time Patient 1 waited to see Physician Assistant F.

During a second interview on 04/30/19 at 3:15 PM, the Director of Quality and Risk Management stated that the facility has no policy but does have an expectation for ED providers to complete EMTALA training annually. The Director stated that the facility Staff Education Department schedules these trainings.

Review of the personnel files for all Physician Assistants working in the ED (F, I, J, K, L, and M) showed that the most recent training for EMTALA requirements was completed in October 2017.