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Based on review of medical records, policy and procedures, Medical Staff Bylaws, ambulance trip report and staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 (#20) of 20 sampled patients. Refer to findings at Tag A- 2406.

Based on review of, facility Policy and Procedure, Emergency Department logs, Ambulance Reports, and Facility Admission to ER Emergency Room) tracer form, and staff interviews it was determined the facility failed to ensure that a central log is maintained on each individual who comes to the emergency department seeking assistant and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted, and treated, stabilized, and transferred or discharged for 1 (#20) of 20 sampled patients.

Findings were:

Ambulance Trip Report

Review of the ambulance trip report dated January 20, 2019, the patient's chief complaint was Hypoglycemia (low blood sugar) and secondary complaint was pitting edema to all extremities. Review of the initial assessment at 11:20 p.m., revealed that patient #20's mental status was alert to verbal stimuli, able to answer some questions, is confused, and some words/speech are slurred, and the patient is able to follow simple commands. Patient #20's skin was pale, cool, and clammy, patient clothing is wet, bedding wet, and has a staining consistent with serous fluid. The patient also has pitting edema to all 4 (four) extremities. The patient's lungs were assessed as Left lower: Decreased; left Upper: Clear; Right lower: Decreased, Right Upper: Clear; Left Lower: Rales; Left Lower: Rhonchi; Left Lower: Wheezing: Left Upper: Rales; Left Upper: Rhonchi. The patient's abdomen was assessed as distended and tenderness in all 4 quadrants and positive for nausea and vomiting. The patient was incontinent of urine. The narrative of the report revealed in part, " EMS (emergency medical services ) called ref (reference) sick person, upon arrival was met by (family member) ...she explained that patient #20 has been sick and not gotten out of bed for two (2) days, she has not eaten and now she has started throwing up. Family member led us to the back bedroom of the residence, we found a 69 year old female patient (#20) lying in bed, pt.(patient) appeared to be sleeping, pt. is alert to verbal stimuli and appears to be confused, her speech is garbled and skin is wet to the touch and cold. Pt baseline vitals obtained and found to be Pulse 80; RR (respiratory Rate) 14 and Reg (regular) but shallow. EMS noted that Pt. has pitting edema (swelling) to all 4 extremities. Pt. BGL (blood glucose level) is found to be 18 (normal blood glucose levels 60-100). EMS attempted IV (intravenous-is a therapy that delivers liquid substances directly into the vein) access x (times) 2 and was unsuccessful. Pt given one tube of oral glucose, Pt. was able to follow simple commands and swallow. The glucose level. BGL 24. Pt. was given glucagon (hormone that raises the level of glucose (sugar) in the blood) IM (intra-muscular). Pt. moved by draw sheet carry to stretcher. Pt. secured and moved to ambulance ...Pt. transport initiated. EMS contacted CIH (Cherokee Indian Hospital) ER via viper radio and Pt. report given, EMS was advised by CNA/Clerk that EDMD #1 (ED physician at CIH) suggests due to recent medical history of Chemo (Chemotherapy) treatments that pt. would not be admitted. EMS advised that pt. was not stable enough for further transport and that our ETA (Estimated time of Arrival) to CIH ER would be less than 6 mins (minutes). Same CIH staff advised per ED MD #1 EMS is (to) remain for further transport of pt. EMS advised that we understood and that we would be available for further transport of Pt. EMS arrived CIH at 00:06 (12:06 am - 1/21/2019) and entered CIH ER and was met by two RN's (Registered Nurses) who directed us to ER room #3. Pt. remained on ER stretcher after brief . Pt. update several attempts were made by both RN to establish an IV all unsuccessful. BGL at this time was < 20 as shown on their monitor. No further vitals were obtained by CIH ER staff. 2nd (second) tube of oral glucose administered. Several wounds to pt. skin was dressed with appropriate type bandages by both EMS and CIH ER staff. Pt. IV established by ED RN #3; 20 gauge in left upper arm and NS (normal saline) at a KVO (keep vein open) rate. Pt. BGL rechecked and found to be 137. Pt. was packaged for further transport and family was permitted to briefly visit with pt. EMS continued transport on to Hospital B ER at 01:07 (1:07 AM). Pt. rested more comfortably. ..Pt. had periods of decreased 02 (oxygen) SAT (saturation) (oxygen saturation- measures how much oxygen the blood is carrying) readings due to shallow respirations when sleeping, pt. remained on 4 liters of 02 via ...NC (nasal cannula) and 02 sat would rise to a more normal level when she was more awake. Pt. remained stable during transport. Hospital B's ER was contacted by viper radio and report given."

Emergency Department Log

The facility's ED log for January 2019 was reviewed. The ED log failed to reveal that Patient #20 was entered into the log when she presented to the hospital's ED via ambulance on January 21, 2019.

Admission to ER Tracer Form

The facility's ER tracer form for patient #20 was reviewed. The ER tracer form verified that patient presented to the ED via ambulance entrance on 1/21/2019. The form revealed that Patient #20 was assigned trauma Room 2, and that at 12:02 am Patient Registration was notified.

Staff Interviews

An interview was conducted on 3/26/2019 at 11:30 am with the ED Manager. She stated that when a patient comes in via ambulance, the tracer form is used, and we know that we have registered that patient in the system.

An interview was conducted on 3/27/2019 at 2:01 P.M., with PA-C #1. She stated that she was in the ED on 1/2/12019 when patient #20 presented to the ED, and that they were very busy that day. She also stated that the patient was brought into the ED via ambulance for stabilization and IV access. She stated that when patients come into the ED they are usually registered in the ED log.

A telephone interview was conducted on 3/27/2019 at 3:00 p.m. with Registration Clerk #1. She verified that on 1/21/2019 that she was the registration clerk on duty when Patient #20 presented to the ED. She stated that EMS called us on the viper radio, and wanted our help to obtain IV access for patient #20. The EMS staff was requesting our help, and after we helped them with IV access, the patient would be transported to Hospital B. She continued to state that when a patient comes to ED she registers patient information into the computer. She stated that since we were told by EMS they just needed IV access and that they were not going to stay, that is why I did not register Patient #20 in the ED log on 1/21/2019.


Policy and Procedure
The facility's policy titled "EMTALA - Emergency Medical Treatment and Active Labor Act" Effective 08/14/2017, Version: 1, was reviewed. The section of the policy 12. D specified in part, "Central Log. The hospital will maintain a central log on each individual who comes to the Hospital seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged." The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that patient #20 was entered on the ED log when she presented to the hospital's ED via ambulance on January 21, 2019.

Based on review of medical records, policy and procedures, Medical Staff Bylaws, ambulance trip report and staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 (#20) of 20 sampled patients.

Findings were:


Policy and Procedure:

The facility's Policy and Procedure titled "EMTALA- Emergency Medical Treatment and Active Labor Act, Effective Date: 08/14/2017, Version: 1 was reviewed. The policy stated in part, " The hospital shall comply with emergency care obligations imposed by EMTALA. These obligations include the following: 1. Medical Screening Examination. If a person comes to the Hospital and a request is made for their emergency care or, if the person is unable to communicate, a reasonable person would believe that a person in need of emergency care, then a qualified medical personnel will, within the hospital's capability and capacity, conduct an appropriate medical screening examination reasonably calculated to identify an emergency medical condition. An appropriate medical screening examination should address the presenting symptoms and comply with current policies and procedures for assessment of those presenting symptoms, including but not limited to a history of the presenting problem; a documented physical examination of the involved area or system; and the use of ...ancillary services routinely available to their Hospital if needed to determine whether an emergency medical condition exists. The chart should document continued monitoring until the patient is stabilized or transferred.

Medical Staff Bylaws
The facility ' s Medical Bylaws, Effective Date: 7/28/2019, Version 5 stated in part, " . . . (10) Emergency Room Physician ... (b). the emergency room physician responsible is responsible for the disposition of all patients receiving care in the emergency department. This includes the examination and treatment of all patients with emergency conditions. "

Ambulance Trip Report (Patient #20)

A review of the ambulance report dated 1/20/2019 at 11:20 P.M., revealed in part, " ...Pt. moved by draw sheet carry to stretcher. Pt. secured and moved to ambulance ...Pt. transport initiated. EMS contacted CIH (Cherokee Indian Hospital) ER via viper radio and Pt. report given, EMS was advised by CNA/Clerk that EDMD #1 (ED physician at CIH) suggests due to recent medical history of Chemo (Chemotherapy) treatments that pt. would not be admitted. EMS advised that pt. was not stable enough for further transport and that our ETA (Estimated time of Arrival) to CIH ER would be less than 6 mins (minutes). Same CIH staff advised per ED MD #1 EMS is remain for further transport of pt. EMS advised that we understood and that we would be available for further transport of Pt. EMS arrived CIH at 00:06 (12:06 am- 1/21/2019) and entered CIH ER and was met by two RN ' s (Registered Nurses) who directed us to ER room #3. Pt. remained on ER stretcher after brief Pt. update several attempts were made by both RN to establish an IV all unsuccessful. BGL at this time was < 20 as shown on their monitor. No further vitals were obtained by CIH ER staff. 2nd (second) tube of oral glucose administered. Several wounds to pt. skin was dressed with appropriate type bandages by both EMS and CIH ER staff. Pt. IV established by ED RN #3; 20 gauge in left upper arm and NS (normal saline) at a KVO (keep vein open) rate. Pt. BGL rechecked and found to be 137.

Medial Record Review

The medical record for Patient #20 dated 01/21/2019 at 04:52 (4:52 a.m.) was reviewed. Documentation by ED MD Physician #1, revealed in part, " EMS called to patient ' s home due to altered mental status, vomiting, patient recently transferred to (Hospital B), with hepatorenal syndrome (End stage renal disease), Volume depletion, Hepatpcellar carcinoma. Per report (EMS report) she has not been or drinking for 2 days, refusing to come in for treatment. Increased swelling in arms and legs. EMS was in process of transporting to (Hospital B), However, patient ' s blood sugar was in the 20 ' s, was given oral glucose get and IM injection. Unable to obtain IV access, brought to the ED for help with IV access, to help with hypoglycemia. HR (heart rate) was 74, BP (blood Pressure) 102/79. Significant pitting edema to upper and lower extremities. Patient was given more glucose gel, sugars improved to 137. IV access established. Patient then transported to (Hospital B) by EMS. " There was no documentation of physical examination, nor a triage or that vital signs were done by CIH ED staff while Patient #20 was in the ED on 1/21/2019. Additionally, there was no documentation in the medical record to indicate that the ancillary laboratory services routinely available to the ED was ordered or provided for the patient to determine whether or not an emergency medical condition existed.

Staff Interviews

A telephone interview was conducted on 3/26/2019 at 11:30 am with the EMS crew member who cared for patient #20. He stated that the patient's Chief Complaint was hypoglycemia, and needed IV access. He further stated that the EMS crew called CIH via radio and informed the hospital that they were en-route the hospital with patient #20, because the patient was not stable enough to for further transport to hospital B; as Hospital B was 1.5 hours away. The EMS personnel stated that patient #20's initial blood glucose level was 18. He stated that they went to the hospital and was directed to a room, and report was given to the ED staff, that the patient was confused and very unresponsive. He also stated that the patient was moved to a hospital bed, and treated with oral glucose and glucagon. He stated that RN #3 started an IV, and they dressed the patient's multiple wounds. The patient's blood sugar was checked by hospital staff and the blood glucose reading was 137. He stated that Patient #20 was stabilized at CIH " packaged up" and transported to Hospital B.

During an interview with the Quality Improvement Director on 3/26/22019. She stated that from the review of the medical record, and what she looked at, "An appropriate medical screening examination wasn't done. "

An interview was conducted with ED physician #1, on 3/27/2019 at 1:36 P.M. ED physician #1 was on duty on 1/21/2019 when patient #20 presented to the ED. He stated that he remembered the case and Patient #20 very well. He stated that EMS brought the patient to CIH ED. He stated that he remembered the Patient #20 had edema, liver cancer, low blood sugar, and trouble obtaining an IV. He stated that the staff at CIH helped obtain an IV access for the patient, and that the patient was awake, and had improved upon arrival to the ED. He also stated that the EMS crew planned to take her to Hospital B, but had to detour to CIH because of low blood sugar and could not obtain IV access on the patient so that is why they brought her to CIH.

An interview was conducted with PA-C #1 on 3/27/2019 at 11:00 a.m. She verified that she was in the hospital' s ED on 1/21/2019, she stated that it was busy that day. She stated that when patients enter the ED they are triaged and obtaining vital signs are a part of the process.


An interview was conducted with RN #3, ED RN team lead on 3/27/2019 at 2:25 p.m. RN #3 verified that he was on duty when Patient #20 presented to the ED on 1/21/2019 via ambulance. He stated that the patient was brought to the CIH ED because the patient needed an IV placed for access for transport, and to administer medications. He stated that EMS personnel stopped at CIH, and was not going to bring the patient to Hospital B until an IV access was obtained. He stated that he was able to start an IV for patient #20, and that medications were given orally and intravenously. He also stated that he did not remember what medications were given to patient #20 on 1/21/2019. He also stated that the patient was not in the ED for no more than 30 minutes. RN #3 stated that "no blood was drawn of that nature". He also stated that on 1/21/2019 Patient #20 should have been triaged and vital signs taken while she was in the ED.