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Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to enforce policies 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 for 6 of 20 emergency department patient records (Patients #1, #2, #3, #4, #6, and #7) reviewed.

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of §489.24. Failure of the CAH to enforce their Emergency Medical Treatment and Labor Act policy limited the CAH's ability to track the quality of care and disposition of patients who presented to the emergency department, to ensure appropriate treatment for emergency department patients, and to ensure safe care of patients transferred from the emergency department.

Findings include:

The Critical Access Hospital (CAH) failed to maintain an accurate and complete emergency department central log (Refer to C2405); failed to ensure the emergency department (ED) provider conducted an appropriate medical screening examination within the capability of the hospital's ED (Refer to C2406); and failed to ensure a qualified medical provider signed a certification stating the medical benefits of a transfer outweighed the risks for patients with unstabilized medical conditions (Refer to 2409).

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to maintain an accurate and complete emergency department central log for 4 of 20 sampled emergency department patients (Patients #1, #2, #6, and #7). Failure to maintain an accurate and complete emergency department central log limited the CAH's ability to track the quality of care and disposition of patients who presented to the emergency department.

Findings include:

Review of the policy "ER [Emergency Room] Central Log" occurred on 07/29/20. This policy, dated 05/2019, stated, "Policy: Mountrail County Medical Center will maintain a central log of all patients who come to the Emergency Department for either emergency room care or outpatient services provided at the hospital. . . . Procedure: The log will contain the following data:
Patient name
Date of admission
Time of arrival and admission
Presenting complaint
Final diagnosis
Name of provider and nurse providing care
Disposition to include: Refused treatment
Admitted and treated
Stabilized and transferred
Discharged.
Left without being seen
Time of disposition"
The policy failed to include "was refused treatment" and "was transferred" and failed to define "stabilized" and "left without being seen."

Review of the CAH's ER Central Log occurred on 07/29/20. The 2019-2020 log showed the following:
Patient #1 - presented to the emergency department and had a medical screening exam by a provider on 04/21/20. CAH staff failed to enter this patient in their ER Central Log.
Patient #2 - presented to the emergency department and had a medical screening exam by a provider on 07/26/20. CAH staff inaccurately entered this patient in the ER Central Log with a disposition of "left without being seen."
Patient #6 - presented to the emergency department and had a medical screening exam by a provider on 03/25/20. CAH staff failed to enter the patient's disposition (refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged).
Patient #7 - presented to the emergency department and had a medical screening exam by a provider on 06/05/20. CAH staff failed to enter the patient's disposition (refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged).

During interview in the afternoon of 07/29/20, an emergency department administrative staff member (Provider #1) confirmed CAH staff had not entered dispositions for all ER Central Log entries.

During interview at 9:30 a.m. on 07/31/20, an administrative nursing staff member (#3) stated the nurses are responsible for making entries in the ER Central Log through communication with the ER providers. Staff Member #3 stated she had not monitored the ER Central Log for accuracy and completeness.

During interview at 11:56 a.m. on 08/03/20, Provider #1 stated he was not aware CAH staff had not entered Patient #1 in the ER Central Log.

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the emergency department (ED) provider conducted an appropriate medical screening examination within the capability of the hospital's ED to determine whether 2 of 20 sampled emergency department patients (Patient #1 and #2) had an emergency medical condition or were in active labor. Failure to determine if patients were in active labor or had an emergency medical condition before transfer by privately owned vehicle limited the CAH's ability to ensure the safety of the patients and the unborn children.

Findings include:

Review of the policy "EMTALA [Emergency Medical Treatment and Labor Act]" occurred on 07/29/20. This policy, revised 06/2019, stated,
". . . Hospitals that participate in the Medicare program are subject to the regulations of EMTALA which consist of:
1. Appointed staff must provide an appropriate medical screening exam to determine if an emergency condition exists or if the patient is in active labor.
2. If the patient does have an emergency medical condition or is in active labor, the hospital must stabilize the patient before discharge or transfer. . . .
Emergency Medical Condition Under EMTALA: A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could be reasonable [sic] expected to result in: - Placing the health of the individual (or, with respect to a pregnant women [sic], the health of the woman and her unborn child) in serious jeopardy. . . ."

Review of the policy "Medical Screening Exam (MSE)" occurred on 07/29/20. This policy, dated 12/2019, stated,
"Purpose: To assure appropriateness of medical screening and care for patients presenting to Mountrail County Medical Center's Emergency Department (ED).
Policy: Any patient presenting at Mountrail County Medical Center seeking emergency care will receive an appropriate medical screening exam. . . . This screening examination will utilize all appropriate capabilities of the hospital, as deemed appropriate by the on-call ED provider and/or an ED RN [Registered Nurse] in consultation with the on-call ED provider, to reach a definitive diagnosis. . . .
Procedure: A medical screening exam will consist of a history and physical appropriate to the patient's complaint, with ancillary testing as necessary. . . ."

Review of the medical staff's bylaws occurred on 07/30/20. These bylaws, effective 03/13/13, stated, ". . . Article V. Divisions of the Medical Staff . . . Section 5. Allied Health Professionals a. Allied Health Professionals are individuals qualified by academic and clinical training to practice in a medical support role in providing medical services, including emergency services. Allied Health Professionals are permitted to provide patient care services independently. . . ."

Review of the medical staff's rules and regulations occurred on 07/30/20. These rules and regulations, effective 01/15/15, stated, ". . . 15. All patients presenting to the ER [Emergency Room] will be seen and given a medical screening examination regardless of their ability to pay. . . ."

Review of Provider #1's credentialing file occurred on 07/29/20. Provider #1's privileges, approved 09/30/19, included: ". . . Gynecologic Problems . . . Childbirth pending . . . Pregnancy . . ."

- Review of Patient #1's emergency department medical record occurred on 07/29/20. This record, dated 04/21/20, stated,
"G1P0 [gravida (pregnancies) 1, para (live births) 0] at 6 months by report presents with sudden onset abdominal pain this morning.
No vaginal bleeding, discharge, fluid.
No miscarriage history.
She moved here approx [approximately] 1 month ago from Mexico, they have no PCP [primary care provider] or established OB [obstetrician] locally.
No respiratory symptoms by report.
She presents with her mother and sister. The patient and the patients [sic] mother do not speak English. The patients [sic] sister provided all Spanish-English translation.
Exam:
Vitals: BP [blood pressure] 124/76 SpO2 [blood oxygen saturation] 98 HR [heart rate] 84 RR [respiratory rate] Temp [temperature] 98.0
General: in pain
Abdomen: the patient is guarding her entire abdomen, there is diffuse tenderness but exam difficult due to patient presentation, guarding
Assessment:
Abdominal Pain
Pregnancy at at [sic] least 20 weeks, but possibly 24 weeks by report
No prenatal care
Plan:
Broad differential, worst case would be preterm labor, abruption, previa, but needs assessment at an OB [obstetric] capable facility, which is not available here. No ultrasound here. No fetal toco [instrument that measures contraction frequency and approximate duration] available here. No bleeding and her vitals are stable so massive hemorrhage or preclampsia [sic] unlikely. Discussed with [name of acute hospital physician] at [name of acute hospital], patient will be direct [admit] to OB there. She is stable appearing otherwise so I think POV [Privately Owned Vehicle] transport is safe at this time, also probably best option as the only English speaker would be isolated if EMS [Emergency Medical Services] involved. I did not do any additional assessment or intervention in the ED given that the most appropriate facility is in Minot [55 miles away] and further assessment here would not alter treatment course."

During interview at 4:45 p.m. on 07/29/20, Provider #1 stated he saw Patient #1 in the vestibule of the the emergency department entrance and did a full medical screening exam. He stated Patient #1 had right upper quadrant pain and no vaginal discharge. He said he called the emergency room physician at [name of acute hospital] to let them know they would need a translator for this patient. Provider #1 stated the patient was to go to the emergency room and straight to OB. He said he offered Patient #1 an ambulance ride to [name of acute hospital], but she declined saying her sister would take her. Provider #1 stated he discharged, not transferred the patient.

During interview at 9:30 a.m. on 07/31/20, the director of nursing (Staff member #3) stated the hospital had the following OB equipment and supplies available: OB delivery kit, Doppler (a hand-held ultrasound transducer used to detect the fetal heartbeat), bedside ultrasound (to detect fetal heart tones), nitrazine paper (to detect amniotic fluid), speculums (for vaginal exams), and various medications. Staff member #3 stated the hospital did not have fetal toco capability.

During interview at 10:15 a.m. on 07/31/20, Provider #1 stated he did not feel there was an indication to do a bedside ultrasound to check fetal heart tones due to the location of Patient #1's pain in the upper right quadrant, no reported contractions, no bleeding, no fluid leak, no increased heart rate, and good vitals.

- Review of Patient #2's emergency department medical record occurred on 07/29/20. This record, dated 07/26/20, stated, "G1P0 at twelve weeks confirmed by US [ultrasound] at [name of health care center] last week, woke up this morning and had frank bloody vaginal discharge. No pain. No cramping. Denies passing of any tissue. No history of miscarriage or STI [sexually transmitted infection]. No history of Tubal Pregnancy. Per Patient report the fetus was in the uterus on US this week. She has not seen an OB yet. She denies chest pain, trouble breathing, seizure activitiy, headache, or any other complaints or concerns at this time. She was driven here by her partner.
Exam:
Vitals: BP 104/80 SO2 98 HR 70 RR 20 Temp 98.0
General: in no acute distress
Abdomen: soft, non tender, non distended
Assessment:
Vaginal bleeding
Pregnancy at 12 week by ultrasound
No prenatal care to date
Threatened abortion
Plan:
Discussed limitation of OB assessment available here, markedly that we do not have ultrasound/bHCG [beta human chorionic gonadotropin - a hormone produced during pregnancy] capability which is what she needs.
Offered ED assessment here, and then transfer. Patient declined.
Offered ED assessment and ambulance transfer. Patient declined stating 'I can have my boyfriend drive me.'
Discussed risk of personal, non medical, transportation, patient understands these risks.
Stable vitals, known uterine pregnancy, normal exam, and no other concerning symptoms on presentation/assessment here today. There is no evidence of a life threatening pregnancy related emergency at this time.
Based on examination tonight there is no further emergent medical condition that would necessitate additional ED workup or treatment at this time.
The patient is in agreement with this plan."

During interview at 4:45 p.m. on 07/29/20, Provider #1 stated he saw Patient #2 and did an MSE. He stated he offered an ambulance transfer and the patient declined saying her partner will drive her to see an OB.

During interview at 10:15 a.m. on 07/31/20, Provider #1 stated Patient #2 was not actively bleeding when she was in the ED. He stated he gave the patient verbal instructions to go to [name of acute hospital] ER (emergency room).

1. Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a qualified medical provider signed a certification stating the medical benefits of a transfer outweighed the risks for 4 of 13 transferred patients (Patients #1, #2, #3, and #4) sampled with unstabilized medical conditions. Failure to appropriately transfer patients with unstabilized emergency medical conditions limited the CAH's ability to ensure the benefits of the transfers outweighed the risks.

Findings include:

Review of the policy "EMTALA [Emergency Medical Treatment and Labor Act]" occurred on 07/29/20. This policy, revised 06/2019, stated,
". . . Hospitals that participate in the Medicare program are subject to the regulations of EMTALA which consist of: . . .
2. If the patient does have an emergency medical condition or is in active labor, the hospital must stabilize the patient before discharge or transfer. . . .
Emergency Medical Condition Under EMTALA: A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could be reasonable [sic] expected to result in: - Placing the health of the individual (or, with respect to a pregnant women [sic], the health of the woman and her unborn child) in serious jeopardy. . . ."

Review of the policy "Transfer Patient To Another Hospital From ER [Emergency Room]" occurred on 07/29/20. This policy, revised 02/2019, stated,
"Purpose: To provide for a safe and orderly transfer to another hospital for further care not provided at this facility.
Equipment: 1. Copies of pertinent information: . . . completed transfer form . . .
Procedure: 1. Have transferring Provider complete the transfer form . . ."

Review of the document "Request For Transfer" occurred on 07/29/20. This undated document stated, ". . . Physician/Provider Certification: The above transfer is considered necessary because: (summarize risks and benefits) [two blank lines] History of current ED [Emergency Department] episode, a focused physical exam and relevant chronic conditions have been communicated with the receiving physician. I conclude that the benefits of transfer outweigh the risks. [one blank line] Transferring Physician/Provider Signature . . ."

Review of the medical staff's bylaws occurred on 07/30/20. These bylaws, effective 03/13/13, stated, ". . . Article V. Divisions of the Medical Staff . . . Section 5. Allied Health Professionals a. Allied Health Professionals are individuals qualified by academic and clinical training to practice in a medical support role in providing medical services, including emergency services. Allied Health Professionals are permitted to provide patient care services independently. . . ."

Review of the medical staff's rules and regulations occurred on 07/30/20. These rules and regulations, effective 01/15/15, stated, ". . .
16. The on-call ER healthcare provider will follow established medical staff and facility's policy and procedure regarding transfers and mode of transfers. All proper forms will be sent with the patient."

Review of Provider #1's credentialing file occurred on 07/29/20. Provider #1's privileges, approved 09/30/19, included:
". . . Gastrointestinal System . . . New abdominal pain . . .
Gynecologic Problems . . . Childbirth pending . . . Pregnancy . . .
Signs and symptoms . . . Unstable patient . . .
Musculoskeletal System . . . Mild trauma to extremities . . .
Emergency Room Problems . . . Amputated limb . . ."

Review of Provider #2's credentialing file occurred on 07/29/20. Provider #2's privileges, approved 07/02/18, included: ". . .
Neurologic System Cerebrovascular accident, acute . . ."

- Review of Patient #1's emergency department medical record occurred on 07/29/20. This record, dated 04/21/20, stated,
"G1P0 [gravida (pregnancies) 1, para (live births) 0] at 6 months by report presents with sudden onset abdominal pain this morning.
No vaginal bleeding, discharge, fluid. . . .
Exam:
Vitals: BP [blood pressure] 124/76 SpO2 [blood oxygen saturation] 98 HR [heart rate] 84 RR [respiratory rate] Temp [temperature] 98.0
General: in pain
Abdomen: the patient is guarding her entire abdomen, there is diffuse tenderness but exam difficult due to patient presentation, guarding
Assessment:
Abdominal Pain
Pregnancy at at [sic] least 20 weeks, but possibly 24 weeks by report . . .
Plan:
Broad differential, worst case would be preterm labor, abruption, previa, but needs assessment at an OB [obstetric] capable facility, which is not available here. . . . No bleeding and her vitals are stable so massive hemorrhage or preclampsia [sic] unlikely. Discussed with [name of acute hospital physician] at [name of acute hospital], patient will be direct [admit] to OB there. She is stable appearing otherwise so I think POV [Privately Owned Vehicle] transport is safe at this time . . ."
The record lacked evidence the provider determined the patient was not in active labor and was stable for transfer. The record lacked evidence the provider signed a certification stating the benefits of transfer outweighed the risks.

During interview at 4:45 p.m. on 07/29/20, Provider #1 stated Patient #1 had right upper quadrant pain and no vaginal discharge. Provider #1 stated the patient was to go to the emergency room and straight to OB. He said he offered Patient #1 an ambulance ride to [name of acute hospital], but she declined saying her sister would take her. Provider #1 stated he discharged, not transferred the patient.

During interview at 10:15 a.m. on 07/31/20, Provider #1 stated he did not feel there was an indication to do a bedside ultrasound to check fetal heart tones due to the location of Patient #1's pain in the upper right quadrant, no reported contractions, no bleeding, no fluid leak, no increased heart rate, and good vitals. Provider #1 said he did not complete a "Request for Transfer" form.

- Review of Patient #2's emergency department medical record occurred on 07/29/20. This record, dated 07/26/20, stated, "G1P0 at twelve weeks confirmed by US [ultrasound] at [name of health care center] last week, woke up this morning and had frank bloody vaginal discharge. No pain. No cramping. Denies passing of any tissue. . . . No history of Tubal Pregnancy. Per Patient report the fetus was in the uterus on US this week. . . . She denies chest pain, trouble breathing, seizure activitiy, headache, or any other complaints or concerns at this time. She was driven here by her partner.
Exam:
Vitals: BP 104/80 SO2 [oxygen saturation] 98 HR 70 RR 20 Temp 98.0
General: in no acute distress
Abdomen: soft, non tender, non distended
Assessment:
Vaginal bleeding
Pregnancy at 12 week by ultrasound . . .
Threatened abortion
Plan:
Discussed limitation of OB assessment available here, markedly that we do not have ultrasound/bHCG [beta human chorionic gonadotropin - a hormone produced during pregnancy] capability which is what she needs.
Offered ED assessment here, and then transfer. Patient declined.
Offered ED assessment and ambulance transfer. Patient declined stating 'I can have my boyfriend drive me.'
Discussed risk of personal, non medical, transportation, patient understands these risks.
Stable vitals, known uterine pregnancy, normal exam, and no other concerning symptoms on presentation/assessment here today. There is no evidence of a life threatening pregnancy related emergeny at this time.
Based on examination tonight there is no further emergent medical condition that would necessitate additional ED workup or treatment at this time.
The patient is in agreement with this plan."
The record lacked evidence the provider determined the patient was not in active labor and was stable for transfer. The record lacked evidence the provider signed a certification stating the benefits of transfer outweighed the risks.

During interview at 4:45 p.m. on 07/29/20, Provider #1 stated he offered an ambulance transfer and Patient #2 declined saying her partner will drive her to see an OB.

During interview at 10:15 a.m. on 07/31/20, Provider #1 stated Patient #2 was not actively bleeding when she was in the ED. He stated he gave the patient verbal instructions to go to [name of acute hospital] ER. Provider #1 said he did not complete a "Request for Transfer" form.

- Review of Patient #3's emergency department medical record occurred on 07/30/20. This record, dated 04/26/20, stated, ". . . History of Present Illness The patient presents with left, finger laceration(s). . . . Physical Examination . . . Musculoskeletal: the left thumb is in a bandana and wrapped on arrived [sic]. On eval [evaluation] there is a near amputation of the left thumb. There is a complex, full thickness laceration running across the great 2/3 of the digit running lengthwise as well as circumferentially. There is some venous appearing bleeding when pressure is released. A sterile dressing was applied. . . . Medical Decision Making . . . Given open fracture, need for future OR [operating room], given 2000mg [milligrams] Ancef [an antibiotic]. Discussed case with [name of physician], on call hand surgeon, will see patient in ED in Minot. Patient in agreement with this plan. ED provider, [name of physician], updated. . . . Impression and Plan . . . Condition: Unchanged. Disposition: Discharged: Time 4/26/2020 11:43, To head to Minot to see [name of hand surgeon]. . . . Follow up with: Go directly to [name of acute hospital] Emergency Dept. . . .
The record lacked evidence the provider determined Patient #3 was stable for transfer. The record lacked evidence Provider #1 signed a certification stating the benefits of transfer outweighed the risks.

During interview at 11:56 a.m. on 08/03/20, Provider #1 stated he felt he had corrected the emergency medical condition for Patient #3, and the patient was stable. He said he did not complete a "Request for Transfer" form. Provider #1 said the only way to expeditiously arrange after care for patients who need to see the hand surgeon was through the ER since same day clinic appointments were not usually available.

- Review of Patient #4's emergency department medical record occurred on 07/30/20. This record, dated 05/31/20, stated, ". . . History of Present Illness The patient presents with abdominal pain. . . . The degree at present is moderate. The location of pain at present is right, lower and mid epigastric. . . . Physical Examination . . . Gastrointestinal: Tenderness: Severe, generalized, epigastric, right lower quadrant, Guarding: Severe, Rebound: Present . . . Medical Decision Making . . . Concerning abdominal exam with guarding, rebound. At this time given history, pancreatitis vs [versus] acute appendicitis. . . . Reexamination/Reevaluation . . . Notes: Pain slightly improved . . . discussed with [name of physician] (ED) and [name of surgeon] (Surgery) accepted patient at [name of acute hospital] Minot. . . . Refusing ambulance transfer at this time, would like to go POV. Given she has an early acute appendicitis, vitals are stable, pain is improved, and she got both cefazolin [an antibiotic] and flagyl [an antibiotic] I think this is reasonable, of course taking into consideration the usual risks of traveling in a car. The patient understands these risks. Plan for the patient to finish her antibiotic, we will leave the IV [intravenous] in place, she will travel by POV to [name of acute hospital] Minot. . . . Condition: Improved. Disposition: Discharged . . . Patient was given the following educational materials: Travel directly to [name of acute hospital] Minot for further care and evaluation. . . ."
The record lacked evidence the provider determined Patient #4 was stable for transfer. The record lacked evidence Provider #1 signed a certification stating the benefits of transfer outweighed the risks.

During interview at 11:56 a.m. on 08/03/20, Provider #1 stated Patient #4's vitals were stable. He felt Patient #4 was a stable transfer and should have documented that in the record. Provider #1 said he did not complete a "Request for Transfer" form.


2. Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a qualified medical provider contacted the receiving hospital to accept transfer of 1 of 13 transferred patients (Patient #2) sampled with unstabilized medical conditions. Failure to contact the receiving hospital regarding transfer of a patient limited the CAH's ability to ensure the receiving hospital had the capacity and capability to provide appropriate medical attention.

Findings include:

Review of the policy "Transfer Patient To Another Hospital From ER [Emergency Room]" occurred on 07/29/20. This policy, revised 02/2019, stated,
"Purpose: To provide for a safe and orderly transfer to another hospital for further care not provided at this facility. . . .
Procedure: . . . 2. Provider will contact an accepting MD [medical doctor] who will assume care of the transferring patient. . ."

- Review of Patient #2's emergency department medical record occurred on 07/29/20. This record, dated 07/26/20, stated, "G1P0 [gravida (pregnancies) 1, para (live births) 0] at twelve weeks confirmed by US [ultrasound] at [name of health care center] last week, woke up this morning and had frank bloody vaginal discharge. No pain. No cramping. Denies passing of any tissue. . . . No history of Tubal Pregnancy. . . . She was driven here by her partner. . . .
Plan:
Discussed limitation of OB assessment available here, markedly that we do not have ultrasound/bHCG [beta human chorionic gonadotropin - a hormone produced during pregnancy] capability which is what she needs.
Offered ED [Emergency Department] assessment here, and then transfer. Patient declined.
Offered ED assessment and ambulance transfer. Patient declined stating 'I can have my boyfriend drive me.'
Discussed risk of personal, non medical, transportation, patient understands these risks. . . ."
The record lacked evidence the provider contacted the receiving hospital to accept the transfer.

During interview at 10:15 a.m. on 07/31/20, Provider #1 stated he gave the patient verbal instructions to go to [name of acute hospital] ER.