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Based on record review, review of policies/procedures, and staff interview, the Critical Access Hospital (CAH) failed to enforce policies and procedures to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 on 1 of 1 day of the on-site revisit survey (September 19, 2011).

Centers for Medicare and Medicaid Services (CMS) requires hospitals to adopt and enforce a policy to ensure compliance with the requirements of ?489.24. Failure of the CAH to enforce their policies and procedures relating to the Emergency Medical Treatment and Labor Act (EMTALA) placed patients at risk for harm.

Findings include:

The CAH failed to enforce their policy/procedure regarding maintaining a central log on each individual who comes into the emergency department seeking assistance (refer to C2405).

The CAH failed to enforce their policy/procedure regarding maintaining a medical record for individuals who present to the emergency room (refer to C2407).

The CAH failed to enforce their policy/procedure regarding the need to document the date and time the CAH contacted the receiving facility to request acceptance of transfer and provision of treatment (refer to C2409).

The CAH failed to enforce their policy/procedure regarding the need to send the receiving hospital all of the patient's medical records (or copies thereof) related to the emergency condition available at the time of transfer, including available history, records related to the patient's emergency medical condition, observations of signs or symptoms, etc. (refer to C2409).

Based on policy/procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to maintain a central log listing each individual seeking assistance for 1 of 2 patients (Patient #1) reviewed who signed a refusal for medical screening examination form; and failed to document in the central log the required information of the individual seeking assistance for 1 of 2 patients (Patient #2) reviewed who signed a refusal for medical screening examination form. Failure to maintain a central log listing each individual seeking assistance and documenting the required information limited the CAH's ability to track the care provided to emergency department patients.

Findings include:

Review of the CAH's policy and procedure titled, "Scope of Carrington Health Center Emergency Department," occurred on September 19, 2011. This policy/procedure, undated, stated, ". . . A register is maintained and contains the following information for every individual seeking care: patient name, age, and sex; date, time, and means of arrival; chief complaint; disposition of patient; date and time of discharge. . . ."

Review of the CAH's policy and procedure titled, "EMTALA [Emergency Medical Treatment and Labor Act]: Treatment & Transfer of Individuals in Need of Emergency Medical Services," occurred on September 19, 2011. This policy/procedure, dated January 2011, stated, ". . . III. PROCEDURES . . . J. Record-Keeping . . . 3. A central log must list each individual seeking or in need of emergency services who comes to the Hospital, the dedicated emergency department, anywhere else on the Hospital campus. The log must include an indication whether the individual did not consent to treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged . . . 4. A central log must also include the name of the individual who comes to the Hospital and makes it clear (if it is unclear) that the medical condition is not an emergency nature, and a medical screening examination is performed to determine that the individual does not have an emergency medical condition. . . ."

- Reviewed on September 19, 2011, a form titled "Refusal of Emergency Medical Screening" for Patient #1 indicated the patient sought medical assistance from the CAH on 09/07/11. Reviewed on 09/19/11, the CAH's emergency department logbook did not include an entry for Patient #1 on 09/07/11.

- Reviewed on September 19, 2011, a form titled "Refusal of Emergency Medical Screening" for Patient #2 indicated the patient sought medical assistance from the CAH on 09/02/11. Reviewed on 09/19/11, the CAH's emergency department logbook did not include the first name, age, and chief complaint of Patient #2.

During interview on 09/19/11 at 3:00 p.m., an administrative nursing staff member (#2) confirmed the CAH did not enter Patient #1 in the emergency department logbook and did not include in the emergency department logbook the required information for Patient #2.




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Based on policy/procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to maintain a medical record for 2 of 2 patients (Patients #1 and #2) who signed refusal for medical screening examination forms. Failure to ensure maintenance of medical records limited the CAH's ability to provide information regarding patients' presentations to the emergency department.

Findings include:

Review of the CAH's policy and procedure titled, "Scope of Carrington Health Center Emergency Department," occurred on September 19, 2011. This policy/procedure, undated, stated, ". . . A medical record is maintained on every patient seeking emergency care and is incorporated into the patient's permanent medical record. . . ."

Review of the CAH's policy and procedure titled, "Admission to the Emergency Department," occurred on September 19, 2011. This policy/procedure, dated January 2011, stated,
"B. NURSING ASSESSMENT - A nursing assessment will be completed on all Emergency Department patients to include:
* Time of assessment
* Method of arrival
* Chief complaint
* Complete set of vital signs . . .
* History of present illness
* Subjective & objective signs and symptoms related to complaint . . .
E. ADMISSION DOCUMENTATION: All patients admitted to the Emergency Room shall have an emergency room chart initiated. . . ."

- Reviewed on September 19, 2011, a form titled "Refusal of Emergency Medical Screening" signed by Patient #1 indicated the patient sought medical assistance from the CAH on 09/07/11. Other than the refusal form, the CAH failed to maintain a medical record including other information/data, such as the time the patient presented to the emergency room; method of arrival; chief complaint; the reasons for refusal of a medical screening; and a description of the examination or treatment the patient refused.

- Reviewed on September 19, 2011, a form titled "Refusal of Emergency Medical Screening" signed by Patient #2 indicated the patient sought medical assistance from the CAH on 09/02/11. Other than the refusal form, the CAH failed to maintain a medical record including other information/data, such as the time the patient presented to the emergency room; method of arrival; chief complaint; the reasons for refusal of a medical screening; and a description of the examination or treatment that was refused.

During interview on 09/19/11 at 3:00 p.m., an administrative nursing staff member (#2) confirmed the CAH did not maintain medical records, other than the refusal forms, for Patients #1 and #2.


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1. Based on policy/procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to document the date and time the CAH made the transfer request to the receiving facility for 1 of 6 sampled records (Patient #3) reviewed of patients transferred to another facility from the CAH's emergency department. Failure to document the date and time of the transfer request to the receiving facility limits the CAH's ability to ensure the receiving facility accepts the transfer before the CAH transfers the patient.

Findings include:

Review of the CAH's policy and procedure titled, "Transfer" occurred on September 19, 2011. This policy/procedure, dated 01/21/11, stated, ". . . 3. Telephone contact must be made by the attending or Emergency Room physician/midlevel to the institution's receiving physician where the patient is transferred. The receiving physician's name, date and time of acceptance and receiving facilities name should be placed on the Transfer Record. . . ."

Review of the CAH's policy and procedure titled, "EMTALA [Emergency Medical Treatment and Labor Act]: Treatment & Transfer of Individuals in Need of Emergency Medical Services," occurred on September 19, 2011. This policy/procedure, dated January 2011, stated, ". . . III. PROCEDURES . . . E. An Individual Who Has An Emergency Medical Condition . . . 3. When the Hospital transfers an individual with an unstabilized emergency medical condition to another facility the transfer shall be carried out in accordance with the following procedures. . . . b. A representative of the receiving facility must confirm that: . . . ii. The receiving facility agrees to accept transfer of the individual and to provide appropriate medical treatment. . . ."

- Reviewed on September 19, 2011, Patient #3's medical record lacked evidence of the date and time the CAH contacted the receiving facility to request acceptance of transfer and provision of treatment. The CAH treated Patient #3 in the emergency room on 08/19/11 for trauma due to a motor vehicle accident.

During interview on 09/19/11 at 2:05 p.m., an administrative nursing staff member (#2) confirmed the medical record for Patient #3 lacked evidence of the date and time the CAH contacted the receiving facility to request acceptance of transfer and provision of treatment.

2. Based on policy/procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff sent the medical records related to the emergency condition to the receiving facility for 1 of 6 sampled records (Patient #4) reviewed of patients transferred to another facility from the CAH's emergency department. Failure to ensure staff sent pertinent medical records to the receiving facility placed the patient at risk of not receiving appropriate treatment at the receiving facility.

Findings include:

Review of the CAH's policy and procedure titled, "EMTALA: Treatment & Transfer of Individuals in Need of Emergency Medical Services," occurred on September 19, 2011. This policy/procedure, dated January 2011, stated, ". . . III. PROCEDURES . . . E. . . . 3. . . . c. The Hospital shall send the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2) records related to the individual's emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; and (8) a copy of the completed applicable sections of the Transfer Summary . . . The Hospital shall forward relevant records, pending lab work and test results to the receiving facility that was not available at the time of transfer. . . ."

Review of the CAH's policy and procedure titled, "Transfer" occurred on September 19, 2011. This policy/procedure, dated 01/21/11, stated, ". . . 5. A complete Transfer Record is sent with the patient. Copies to include:
a. Transfer form (signed by MD [medical doctor])
b. Emergency Room Nurse's Notes (transfers from E.R. [emergency room])
c. Face Sheet (if available)
d. Lab reports
e. X-rays
f. EKG's [electrocardiogram]
g. H & P [history and physical] (if available)
h. Discharge Summary (if available)
i. Trauma transfer form (pertains only to trauma patients)
j. EMS [emergency medical services] run ticket (must be enclosed with all trauma transfers)
k. If time does not allow for all the above paperwork to be completed before the patient is transferred it is allowable to fax the information to the receiving facility when completed. This should be done in a timely manner with the facility to receive the paperwork via fax before the patient's arrival. . . ."

- Reviewed on September 19, 2011, Patient #4's medical record lacked evidence the CAH sent the medical record related to the emergency condition to the receiving facility upon transfer on 07/29/11.

During interview on 09/19/11 at 2:05 p.m., an administrative nursing staff member (#2) confirmed the medical record for Patient #4 lacked evidence the CAH sent copies of pertinent medical records to the receiving facility.


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