HospitalInspections.org

Based on document review, record review, policy review and interview the Critical Access Hospital (CAH) failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide an appropriate medical screening exam (MSE) for 2 (Patient 8 and Patient 9) of 20 patients and failing to provide stabilizing treatment for 1 (Patient 9) of 20 patients who presented to the emergency department (ED) seeking emergency medical care. Failure to provide an appropriate MSE and stabilizing treatment has the potential to place patients at risk for harm and injury.

Findings Include:


Review of document provided by CAH titled "Medical Staff Rules and Regulations Community Memorial Healthcare, INC" Revised April 2022 shows " ...Designation of Qualified Medical Personnel able to Perform Emergency Medical Screenings. As required by law Community Memorial Healthcare [CMH] and its Medical Staff approve the following: Personnel qualified to do a medical screening are registered nurses in consultation with the physician or their extenders (i.e. physician assistants or advanced registered nurse practitioners) and physicians. It is understood that when PA's [Physician Assistant] and/or ARPN's (sic) [Advance Practice Registered Nurse] are utilized, they have appropriate physician back-up. In the event that a medical screener other than a physician believes that there is a need for a physician extender to be present, that person will be notified. See Emergency Room [ER] policies and procedures manual regarding examination, treatment and transfer of patients ...


Review of a CAH document titled, "Medical Screening Competency" with a date 11/07, in the footer of the document, showed, a space for the name and date at the top and then a table with the columns labeled, "Skills, Performance Assessment (+/-), Performance Corrected (X), and Trainer Initials." Under the "Skills" column, the first box showed, "A. Performs Medical Screening per CMH Policy Addressing all Ten Components." The "Ten Components" included:

A. Performs Medical Screening per CMH Policy Addressing all Ten Components

1. Chief Complaint- Acute Condition, High Risk, Pregnancy or Obvious True Emergency?
2. Medical History- including Current Medications, Date of Last Tetanus and Allergies
3. Vital Signs- on Admission, PRN [as needed] and Prior to Discharge
a. Critical Patients- Every 5-15 minutes as indicated
b. Intermediate - Every 30- 60 minutes
c. All Other Patients- Every 1-2 hours
4. Mental Status- Consciousness, Orientation, Behavior
5. Skin- Evidence of Dehydration, Perfusion, Skin Color
6. Ability to Walk
7. Focused Medical Examination- Complete Assessment of Organ Related to Chief Complaint. If OB Pt 20 weeks or more, Assessment of Fetal Heart Tones with a Documented Fetal Monitor Strip.
8. Pain Assessment- Onset, Location, Duration, Characteristics, Associating/ Relieving Factors , Pain Score and Treatment
9. General Appearance- Obvious Injury or Distress
10. Complete Documentation- and ER E-Forms

B. Communication by ER or Charge RN [registered nurse] to the On-Call Practitioner all Elements of the Medical Screening Within 15 Minutes of Pt Arriving to ER.

C. Documentation

1. Time and Findings of Chief Complaint, Medical History, Vital Signs, Mental Status, Skin, Ability to Walk, Physical Exam, Pain Assessment, Appearance and Notification of On-Call Practitioner
2. Emergency Medical Condition or Non-Emergency Medical Condition
3. Physician Orders- including Date and Time
4. Medications Administered or Dispensed and Patient Response
5. Patient Education and Acknowledgment of Understanding
6. Appropriate Order for Admission, Transfer or Discharge
7. Discharge Instructions and Pt Acknowledgement of Understanding
8. Pt Condition Prior to Transfer or Discharge
9. Consent Forms
10. Any Observations and/ or Comments made by the Patient or their Families
11. Pt Disposition, Mode of Transport and Accompaniment

At the bottom of the document is a place for the Employee and Trainer Signature.


Review of a CAH policy titled "EMTALA Guidelines for Emergency Department Services" review 3/2022 shows Definitions: " ...Emergency Medical Condition: A medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individual's health at risk ...

Medical Screening exam: The process required to reach, with a reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not ...

Stabilize: No material deterioration of the condition is likely, within resalable medical probability, to result from or occur during the transfer of the individual from a facility or with respect to an emergency medical condition ...

...All Patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic..."


Review of a CAH policy titled "Medical Screen and Treatment" reviewed 03/2022 showed,

"PURPOSE: To facilitate medical screening to adhere to EMTALA guidelines.

POLICY: It shall be the policy of Community Memorial Healthcare that all persons presenting to the Emergency Department (ED) requesting treatment shall be provided with an appropriate medical screening exam by qualified medical personnel (QMP) to determine if a medical emergency exists.

Members of the active medical staff and ED RNs in conjunction with a medical provider are designated as QMPs. It is understood that all mid-level providers shall have appropriate physician back-up. Medical students are not able to complete a medical screening.

A list of RN QMPs shall be maintained in the Emergency Department Policy and Procedure Manual.

ADMINISTRATION: Procedure for admission and treatment in the ED shall be followed.

All persons presenting to the ED shall be provided a Medical Screening exam regardless of diagnosis, financial status, race, color, national origin, handicap, and etc., beyond initial triaging to determine if an emergency medical condition exists.

The Medical Screening shall be initiated by the ED RN within 15 minutes of arrival in ED and include a complete set of vital signs initially and ongoing monitoring and documentation if condition indicates. Assessment is to be done in relationship to chief complaint and actual clinical presentation of signs and symptoms.

The ED RN shall contact the provider on call for the ED and communicate the findings of the medical screening exam. If a medical emergency condition exists, the provider on call shall come to the ED. If no emergency condition exists, the on-call provider shall come to the ED at the request of the nurse and/or patient.

The ED RN shall notify the provider of an incoming medical emergency or of a critical situation enabling the provider to be on site upon patient arrival.

The "On Call" provider shall respond within 30 minutes in all cases of any "Emergency Medical Conditions" and defined as a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in posing threat to the health or safety of the individual. Examples may include but are not limited to the following:

...2. Patients with acute pain or complications associated with pregnancy ...

...If a medical emergency is determined, the screening examination is an ongoing process and the record must reflect continued monitoring in accordance with the individual's needs and must continue until the individual is stabilized or appropriately transferred. There shall be evidence of evaluation immediately prior to discharge or transfer.

If a patient presents to the ED requesting treatment that could be provided in a physician's office, a medical screening still has to be completed and documented. In consultation with the on-call provider it is determined that it the patient does not have an emergency medical condition they may be referred to the physician's office ...


Review of a CAH policy titled "Assessment and Triage of the Emergency Department Patient" reviewed 06/2023 showed PURPOSE: To ensure a uniform "appropriate" medical screening exam to meet compliance of the three (3) distinct requirements of EMTALA and to follow the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist.

The three (3) requirements are:

1. The hospital must provide every patient seeking medical care at the hospital with an appropriate medical screening exam sufficient to determine if the patient has an emergency medical condition or is in active labor.

2. If the medical screening exam reveals that an emergency medical condition exists the hospital must then provide the patient with treatment necessary to stabilize this condition.

3. The Federal Register explains that a hospital is responsible for providing care "until the condition ceases to be an emergency medical condition or until the patient is properly transferred to another facility". The hospital may transfer un-stabilized patients provided that it has done all it can within its capabilities to first treat and stabilize the patient and that certain other statutory requirements are satisfied.

4. ADMINISTRATION: The Emergency Department RN or other qualified medical personnel qualified to perform an EMS [emergency medical screen] per Med Staff Rules and Regulations shall follow the ten components to a medical screening exam: Diagnostic testing cannot be delayed to avoid calling in the on-call person.

1. Assessment of the chief complaint and actual clinical sign(s) and symptoms (i.e., acute condition, high risk, true emergency, chronic condition). For example, competency shall be displayed in performing appropriate use of cardiac monitor, EKG, glucometer, pulse ox, rhythm strip interpretation.
a. A medical history, current meds and allergies.
b. Vital signs (obtain on admission, PRN during care as indicated and immediately upon discharge.
c. Mental Status (alert and oriented times 3, behavior).
d. Skin (evidence of dehydration, profusion, skin color).
e. Ability to walk (by self, with assistance).
f. A focused physical exam (an exam appropriate to the organ system, any problem identified with pulmonary cardiovascular neurological and/or related to the chief complaint and symptom).
g. Pain Assessment (the onset, the location, the duration, the characteristics associating relieving factors and treatment, degree of pain according to the pain scale.
h. General appearance (obvious injury or distress, pale, cyanosis).
i. Pregnancy/near, term? Contractions, etc. (Any OB patient presenting to the Emergency Department for any reason 20 weeks gestational or more shall have fetal heart tones checked and a fetal monitor strip performed and documented.)

2. The RN shall communicate to "the on-call provider" and report all elements of the medical screening exam including:
a. Observation of the ten components to the medical screening exam.
b. Diagnostic test results that support a conclusion that an emergency medical condition does or does not exist.

The Critical Access Hospital (CAH) failed to ensure an appropriate medical screening examination (MSE) for 2 of the 20 patients (Patient 8 and Patient 9). (Refer to tag C-2406)

The Critical Access Hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 9). (Refer to tag C-2407)

Based on record review, interview, document review and policy review the Critical Access Hospital (CAH) failed to ensure an appropriate medical screening examination (MSE) for 2 of the 20 patients (Patient 8 and Patient 9) who presented to the emergency department (ED) with seeking emergency medical care. The hospital's failure to ensure an appropriate MSE has the potential for all patients to be discharged with an unidentified emergency medical condition (EMC) which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition, including harm and death.

Findings Include:

Patient 8

Review of Patient 8's "Face Sheet" dated 09/10/23, showed a handwritten notation that said, "Nursing Assessment Only" The admitting diagnosis showed, pregnancy cramping, with an onset date and time of 09/09/23 at 10:00 (does not specify AM or PM). The admission time showed 10:34 PM and a discharge time of 11:15 PM.

Review of Patient 8 medical record showed a document titled "Emergency Nursing Record" the document showed Patient 8 was 23 years old and presented to the ED on 09/10/23 at 10:34 PM with the chief complaint of abdominal cramping. The document included sections to document vital signs, allergies, infectious diseases screening, sepsis screening, glascow coma scale, pain assessment, skin assessment, general appearance, home medications, past medical history, valuables/personal items, past surgery/procedures, family health history, neurological, visual acuity, respiratory, cardiovascular, abdominal, last menstrual period, OB (obstetrics), abuse screen, social history, urine character, emesis (vomiting) Trauma/wounds, interventions and reassessment. All sections had spaces and/or boxes to mark findings.

The "Pain Assessment" section of the document showed pain present marked "yes", Pain Scale 3, Quality: Dull, Ache, Cramp, with alleviating factors marked repositioning.

The " Last Menstrual Period" (LMP) section showed space to document the approximate 1st day of LMP and pregnancy history, that included the number of pregnancy (G - Gravida), the number of live births (P-Para), abortions (Ab), and estimated date of conception (when pregnancy began). There was no documentation in any of these space. The fetal heart tones (FHT) were 138.

The OB (Obstetrical) section showed the WNL (with in normal limits) box checked, Weeks Gestation This Visit: 17, abdominal cramping box checked. No other boxes in the OB section were checked and no other spaces completed, including the LMP, EDC, T (term), Pt (preterm), P, A (abortion), contractions, frequency, or FHTs.

The medical record failed to show documentation of a completed OB [obstetrical] history.

Review of "Nurses Notes" section of the document showed, Staff D, Registered Nurse (RN), documented, "2234 [10:34 PM] - pt [patient] presents with abdominal cramping that started a couple of days, pt states that she spoke with her ob [obstetrics] doctor dr.[Staff A, MD] earlier in the day and alerted him of s/s [signs and symptoms]. Fetal heart tones obtained, urine collected and sent to lab. 2050 [10:50 PM] dr [Staff A, MD] notified of pt and s/s, vitals, and FHT reproted (sic), and he advised to schedule pt for ultrasound and send urine to lab for testing, and advise pt that if s/s [signs and symptoms] become worse to come back into ER, otherwise he would follow up with pt in morning regarding ua [urinalysis] results and ultrasound. 2315 [11:15 PM] - pt provided with dc [dismissal] instructions, pt scheduled for ultrasound at 2pm [2:00 PM], radiology notified. pt denied questions and concerns at this time, pt dc'd [dismissed] stable and ambulatory to home."

The medical record showed Patient 8 discharged on 09/10/23 at 11:15 PM with a disposition of home or self-care with dismissal instructions for outpatient ultrasound and follow up with primary care physician.

The "Levels" section of the document had a box check marked, "ER [emergency room] I", that showed, "Low Level - Nursing assess only, vitals, verbal orders (ie. Suture removal, abrasions, uncomplicated bug bites)"

The "Emergency Nursing Record" showed the nurse was Staff D, RN with a date and time of 09/10/23 at 11:00 PM.

The medical record failed to show Patient 8, who was 17 weeks pregnant and presented with abdominal cramping received appropriate Medical Screening exam to rule out emergency medical condition.

Review of Staff D, RN's personnel file failed to show evidence of a completed "Medical Screening Competency."

During an interview on 09/13/23 at 9:15 AM Staff D, RN stated, "I have been traveling for 11 months. MSE it is required on everyone who walk ins, I am RN MSE qualified I did not receive any training as a traveler. I have not filled out a competency at [this hospital] most RNs are qualified to do an MSE. I never been trained on triage since I am a traveler. Two days ago, I had a patient that was 17 weeks pregnant. I spoke the doctor on the phone he had already seen her earlier in the day and he did not come to see patient in ER. All we did was schedule the ultrasound and collect a urine ..."

Review of Staff L, RN's personnel file dated 12/13/19 showed a completed "Medical Screening Competency."

During an interview on 09/13/23 at 7:40 AM Staff L, RN stated, "I have worked here for 3 years I have not been trained on how to triage and am not MSE trained. We pick levels if they are a low-level patient such as bug bites or dermal abrasion it would be providers discretion to come in and see patient.

During interview on 09/13/23 8:50 AM, Staff H RN, Director of Nursing, stated, "If they [RNs] have ER experience, they can do MSE. I'm not sure that they have formal training, or I have anything in their files to say that they can do MSE. Staff L RN and Staff D, RN has had no EMTALA training last 12 months. We do not have any formal training on triage, because all the patients are seen immediately and there is no wait. We don't have any patients that are not seen by a provider ..."

During interview on 09/12/23 at 6:27 PM with Staff A, MD, stated "I don't know what MSE or medical screening exam is, and we come in on all patients when on call ..."

During an interview on 09/12/23 at 6:38 PM Staff B, APRN, stated "We have to be at hospital in 15 minutes for trauma and other patients 20-30 minutes. I did not know that RNs could do MSE, I always come in and see all patients that come to ER ..."

During an interview on 09/13/23 AT 9:58 AM Staff G, Chief Executive Officer, (CEO) stated, " ...The rule is that everyone is seen by a provider in ER. The nurse doing the MSE does not rule out provider coming in to see patient ..."


Patient 9

Review of Patient 9 medical record showed she was 84 years old and presented to the ED on 07/13/23 at 12:34 AM.

Review of the "History of Present Illness" showed patient 9 "...presents to the ER (emergency room) with complaints of left rib pain. Pt [patient] presents to the ER by POV [private vehicle] and ambulatory. Pt states she was getting up to use the restroom when she tripped and landed on her left rib cage. Pt rates the pain in left rib cage 8/10 [0 meaning no pain, 10 meaning the worst pain]. pt has a small cut to left arm. Pt denies having hit her head. Pt is alert and orient. Denies any neck or back pain. She denies any abdominal pain. She did ambulate into the ED. Denies any injury to her extremities. Does have a small 2 cm abrasion to the left upper arm. No active bleeding noted."

The ER (emergency room) Course showed, "Initial workup and treatment: Chest with left ribs-appears to have left 9/10 rib fractures, radiology read pending."

The physical exam showed " ...Chest/Lungs: Good air movement noted. Clear to auscultation bilaterally (listening to lungs). No rales (rattling), rhonchi (course lung sounds) or wheezes (breathing with whistling sound) are appreciated, pain to left lateral rib area. Hematoma (bruise) noted to the left lateral rib area ...." Vital signs showed, blood pressure (BP) 107/62 (normal 90/60 - 120/80), Pulse (P) 82 (normal 60 - 100), Respirations (R) 20 (normal 12-18), Temperature (T) 97.7 (normal 97.6 - 99.6) and oxygen saturation (O2) 95% (normal 95-100%) on room air (RA).

The "Assessment" showed, Left 9/10 rib fractures and Left arm abrasion.

Discharge vital signs at 1:28 AM, showed, BP 91/42, P 67, R-18, T-97.2 and O2 95% on RA. There were no additional pain assessments in the medical record.

Patient 9 was discharged on 07/13/23 at 1:30 AM, 56 minutes after her arrival with a disposition of home or self-care.

Review of the "Radiology Report" showed the transcription date of 07/13/23 at 1:21 PM. The findings showed, "Three views of the chest and left rib cage were performed. ...Fractures are in the left rib cage at the sixth, seventh, eighth, and ninth ribs. No other fractures are identified ..." The radiology report was signed by a Radiologist on 07/16/23 at 10:02 AM.

Review of the Hospital Database worksheet showed the CAH employees 6 Diagnostic Radiology Technicians and provides CT (computerized tomography) scan services with facility staff.

The medical record failed to show Patient 9 received an appropriate medical screening exam for left rib fracture with pain rated 8/10 caused by a fall. The medical record lacked evidence Patient 9 was provided pain medication. There was no evidence in the medical record to show Patient 9 received a CT scan to determine if an EMC existed.

During an interview on 09/12/23 at 1:22 PM Patient 9, stated, "I was at someone house when I lost my balance and fell in to tv stand I knew I broke something. I went to (above named hospital), and they told me I broke 1 rib. They didn't do much for me, just told me I had one broken rib and that I was fine to drive. Then that Friday I went to my doctor office in (hometown) and he sent me to ER and told me that I had broken 4 ribs, from there they sent me to a Trauma Hospital. I was told I broke 6 ribs, from 5 through 10 ribs some of them were broke in two places. I had my spleen fixed because it was leaking and there was some blood in my lungs that they had to pump out. Then I went to rehab for 20 days..."

During an interview on 09/12/23 at 6:38 PM Staff B, Advanced Practice Registered Nurse (APRN), stated, " ... Patient 9 was a very odd situation they came in middle of the night and were driving through and were in a hurry, I took X-ray." She stated that she would call on x-ray discrepancies and that it's easier to get a hold of people who live in town.

During an interview on 09/13/23 9:36 AM Staff I, Risk Manager and Quality RN stated that for X-ray discrepancies, radiology does quality studies. Once the final read comes in the ER providers are supposed to have a system to follow up with patient.

Review of Patient 9's Hospital B's medical record showed Patient 9 presented to the ED on 07/14/25 at 9:10 PM and was admitted to the intensive care unit (ICU) with diagnosis of spleen laceration, hemoperitoneum (internal bleeding in which blood gathers in your abdominal cavity), six rib fractures and left lung base contusion (bruise).

Based on record review, document review and interview the Critical Access Hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 9) who presented to the emergency department (ED) seeking emergency medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death.

Findings Include:

Patient 9

Review of Patient 9 medical record showed she was 84 years old and presented to the ED on 07/13/23 at 12:34 AM.

Review of the "History of Present Illness" showed patient 9 "...presents to the ER (emergency room) with complaints of left rib pain. Pt [patient] presents to the ER by POV [private vehicle] and ambulatory. Pt states she was getting up to use the restroom when she tripped and landed on her left rib cage. Pt rates the pain in left rib cage 8/10 [0 meaning no pain, 10 meaning the worst pain]. pt has a small cut to left arm. Pt denies having hit her head. Pt is alert and orient. Denies any neck or back pain. She denies any abdominal pain. She did ambulate into the ED. Denies any injury to her extremities. Does have a small 2 cm abrasion to the left upper arm. No active bleeding noted."

ER (emergency room) Course showed, "Initial workup and treatment: Chest with left ribs-appears to have left 9/10 rib fractures, radiology read pending."

The physical exam showed " ...Chest/Lungs: Good air movement noted. Clear to auscultation bilaterally (listening to lungs). No rales (rattling), rhonchi (course lung sounds) or wheezes (breathing with whistling sound) are appreciated, pain to left lateral rib area. Hematoma (bruise) noted to the left lateral rib area ...." Vital signs showed, blood pressure (BP) 107/62 (normal 90/60 - 120/80), Pulse (P) 82 (normal 60 - 100), Respirations (R) 20 (normal 12-18), Temperature (T) 97.7 (normal 97.6 - 99.6) and oxygen saturation (O2) 95% (normal 95-100%) on room air (RA).

The 'Assessment" showed, Left 9/10 rib fractures and Left arm abrasion.

The "Plan" showed, "Take 10 to 15 slow deep breaths at least 4 times each day. This will lower your chances of getting a lung infection. Hold a pillow to your chest when you take deep breaths, sneeze, cough, or laugh. It may hurt less to sleep in a reclined position. You can also sleep with your head and shoulders propped up on pillows. Tylenol as needed for discomfort. Ice may help you ease pain and swelling. Place an ice pack wrapped in a towel over the painful part. Never put ice right on the skin. Do not leave the ice on more than 10 to 15 minutes at a time. Use for the first 24 to 48 hours after an injury. If you smoke, try to quit. Broken bones take longer to heal if you smoke. Continue Current Medications Follow up: as needed"

Discharge vital signs at 1:28 AM, showed, BP 91/42, P 67, R-18, T-97.2 and O2 95% on RA. There were no additional pain assessments in the medical record.

Patient 9 was discharged on 07/13/23 at 1:30 AM, 56 minutes after her arrival with a disposition of home or self-care.

Review of the "Radiology Report" showed the transcription date of 07/13/23 at 1:21 PM. The findings showed, "Three views of the chest and left rib cage were performed. ...Fractures are in the left rib cage at the sixth, seventh, eighth, and ninth ribs. No other fractures are identified ..." The radiology report was signed by a Radiologist on 07/16/23 at 10:02 AM.

The medical record failed to show Patient 9 received appropriate stabilizing treatment for left rib fracture with pain rated 8/10. There was no evidence in the medical record to show Patient 9 was offer or given pain medication while in the emergency department.

During an interview on 09/12/23 at 1:22 PM Patient 9, stated, "I was at someone house when I lost my balance and fell in to tv stand I knew I broke something. I went to (above named hospital), and they told me I broke 1 rib. They didn't do much for me, just told me I had one broken rib and that I was fine to drive. Then that Friday I went to my doctor office in (hometown) and he sent me to ER and told me that I had broken 4 ribs, from there they sent me to a Trauma Hospital. I was told I broke 6 ribs, from 5 through 10 ribs some of them were broke in two places. I had my spleen fixed because it was leaking and there was some blood in my lungs that they had to pump out. Then I went to rehab for 20 days..."

During an interview on 09/12/23 at 6:38 PM Staff B, Advanced Practice Registered Nurse (APRN), stated, " ... Patient 9 was a very odd situation they came in middle of the night and were driving through and were in a hurry, I took X-ray." She stated that she would call on x-ray discrepancies and that it's easier to get a hold of people who live in town.

During an interview on 09/13/23 9:36 AM Staff I, Risk Manager and Quality RN stated that for X-ray discrepancies, radiology does quality studies. Once the final read comes in the ER providers are supposed to have a system to follow up with patient.

Review of Patient 9's Hospital B's medical record showed Patient 9 presented to the ED on 07/14/25 at 9:10 PM and was admitted to the intensive care unit (ICU) with diagnosis of spleen laceration, hemoperitoneum (internal bleeding in which blood gathers in your abdominal cavity), six rib fractures and left lung base contusion (bruise).