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Based on interview and document review, the hospital failed to provide emergency services necessary to meet the needs of the patients for 3 of 26 patients (P1, P2, P3). P1 suffered a serious outcome when he did not receive a timely medical screening exam at hospital A, and after over 2 hours of waiting after a dog bite to the eye, left to seek treatment at hospital B. P1's injured eye ruptured resulting in an immediate jeopardy for P1. In addition, P2 and P3 sought treatment at the emergency department, waited several hours and also left without being seen by a physician or registered nurse for a medical screening.

The IJ began on 7/1/19, at 9:07 p.m. when P1 did not receive the medical screening exam in a timely manner, and suffered a serious eye injury when his eye ruptured. The IJ was identified on 7/17/19, and the hospital's administrative staff were notified of the IJ finding on 7/17/19, at 2:05 p.m. The IJ was removed on 7/18/19, but the hospital remained out of compliance with the Condition of Emergency Services at 42 CFR 485.618. The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to meet this condition.

Findings include:

A review of P1's emergency department (ED) medical record dated 7/1/19, revealed P1 arrived to the hospital's emergency department on 7/1/19, at 9:07 p.m. due to a dog bite to his left eye. P1 was triaged by nursing staff at an acuity level 3, indicating he required urgent intervention, but did not have a life threatening emergency. The medical record indicated nursing staff had noted blood in the patient's anterior eye, blood in the iris, and impaired vision to the eye. However, the record revealed P1 was never assessed by a physician at the hospital. At 11:33 p.m. the patient left against medical advice.

A review of P1's ED record dated 7/2/19, from hospital B (the receiving hospital, where P1 ultimately received care after he'd left the ED from hospital A), revealed P1 presented with a dog bite to his eye, eye pain, and obvious open globe rupture, (globe rupture occurs when the integrity of the outer membranes of the eye is disrupted by blunt or penetrating trauma (globe rupture is an ophthalmologic emergency and requires definitive management by an ophthalmologist). Hospital B's ED physician notes included: "The lens is obviously dislocated and dislodged from the eye, there is a large laceration to the lower eyelid, large blood clot or tissue from muscle. Pupil is misshapen on the left." Further, the notes indicated P1 underwent emergency surgery on 7/2/19. Hospital B's ED physician further noted, "Discussed poor prognosis at length with patient and wife."

During an interview with registered nurse (RN)-J on 7/16/19, at 9:20 a.m. she stated that she worked 3:00 p.m.-11:30 p.m. on 7/1/19 at hospital A. RN-J stated she cared for P1 when he came to hospital A's ED. RN-J stated she did not get P1's full triage completed until 9:44 p.m. RN-J noted blood in P1's eye, and visual loss in the eye. Although physician (MD)-L went into P1's room for a moment, RN-J stated he did not assess the patient's condition, prior to leaving the room. RN-J stated she attempted to get MD-L to see P1, but he declined. RN-J stated she attempted to appeal to MD-L at least three times to see P1, even bringing him the trauma training indicating that this type of injury is considered a trauma and needs to be prioritized, but MD-L refused to see P1 stating P1 could wait. RN-J stated MD-L had an ongoing difficult time prioritizing patients' medical needs. RN-J stated the nursing staff had reported this to administration both verbally and in writing.

During an interview on 7/16/19, at 9:40 a.m. RN-K stated she worked on 7/1/19 at hospital A. RN-K stated on 7/1/19, nurses tried to appeal to MD-L to see P1. RN- K stated MD-L refused to see P1, stood up and yelled at the nursing staff, pointed at all the rooms and stated the other patients needs were more urgent, and he had to get them finished before he could see anyone else. RN-K stated MD-L had told her to stop triaging patients for over two hours in the past. RN-K stated when that happened, patients came to the ED, but waited over two hours for any kind of medical assessment. RN-K also stated MD-L had told her to stop bringing patients back to open rooms in the ED as he would not see them. RN-K stated none of the other ED physicians had trouble prioritizing patient needs. RN-K stated she had brought her concerns to administrative staff in the past both verbally and in writing.

During an interview with RN-I on 7/16/19, at 9:00 a.m. she stated she worked the night shift from 7/1-7/2/19 at hospital A. RN-I stated she came on at about 11:00 p.m. and assessed P1. RN-I stated she had also tried to appeal to MD-L to see the patient soon, but MD-L had declined stating he had more critically ill patients to see first. RN-I stated she'd apologized to P1 for the wait to see a physician, and P1 and his family member decided to leave against medical advice (AMA) to try to get medical help elsewhere.

During an interview with MD-L on 7/16/19, at 10:05 a.m. MD-L stated he recalled P1. MD-L confirmed he had never evaluated P1's condition, or conducted a medical screening examination on him. MD-L stated that there had been other patients who were more in need, so he had not evaluated P1. MD-L stated he determined P1 was stable, because he had an isolated trauma to his eye, although he confirmed he had not assessed P1. MD-L further stated that if P1 would have waited at hospital A, the ED there did have equipment to measure eye pressure.

During an interview with P1's family member (FM)-C on 7/15/19, at 12:00 p.m. FM-C stated she and P1 had arrived at hospital A at about 9:15 p. m. on 7/1/19. FM-C said a receptionist took their insurance information, but no nurse came out until about 10:00 p.m. or 10:15 p.m. At that time, the nurse took vital signs and looked at P1's eye. FM-C stated P1 told the nurse he could only see red from that eye and the nurse left to get a physician who came in to introduce himself, but did not check P1's eye. Then the physician left, and never came back. FM-C said about 11:15 p.m. a new nurse came in and said she wanted to check the visual acuity in the eye. FM-C also said the physician had declined to give P1 any pain medication, and had said it would probably be about another hour before he would be seen by a physician. Because his pain was getting worse, FM-C stated she and P 1 had decided to try to drive to the next closest hospital, about 20-30 minutes away when unfortunately, on the way to the next hospital, the P1's eye ruptured. FM-C stated P1 has a poor prognosis for that eye now. FM-C stated the best they can hope for is that he can keep his eye, and he may eventually be able to differentiate between light and dark. FM-C said she questioned if the physician at hospital A had checked his eye, including the pressure, whether it would have made a difference in P1's outcome.

During an interview with MD-G (a hospital A ED physician) on 7/15/19 at 1:30 p.m., MD-G stated she was not present when P1 came to the ED, she would not have allowed a patient with a dog bite to his/her eye to wait more than about 10 minutes before having an examination by a physician.

P2's ED medical record review revealed P2 presented to hospital A's emergency room on 6/25/19, at 10:27 p.m. with a complaint of a finger injury. P2 was registered by registration staff, but was never triaged by nursing staff, nor provided with a medical screening examination. The patient left without being seen by a provider at 12:36 a.m., more than 2 hours after having arrived.

P3's ED medical record review revealed P3 presented at hospital A's emergency room for treatment on 7/6/19, at 9:56 p.m. for tooth pain. The record indicated P3 was never triaged by nursing staff, nor provided a medical screening examination. P3 left without being seen by a medical provider at 12:40 a.m., more than 2 hours after presenting to the ED for treatment.

During an interview with quality manager (QM)-A on 7/16/19, at 12:30 p.m. QM-A confirmed MD-L has had quality concerns reported about him. QM-A further stated MD-L was on a performance improvement plan.

During a review of physician recredentialing on 7/16/19, at 4:00 p.m. MD-N (vice president of medical affairs) stated he would discuss the process to review credentialing, and the oversight of medical quality, but he declined to discuss specifics about MD-L's performance improvement plan, except to say that he was on a Nonroutine Focused Practice Evaluation (NRFPE.) Although MD-N verified MD-L was currently on a plan for improvement, MD-N would not provide any further information stating it was "peer review protected information."

During an interview on 7/16/19, at 4:40 p.m. MD-Q (Hospital A's East Region ED Section Chair) stated MD-L was working on concerns related to his work in the ED, including long wait times in the ED, and elevated numbers of patients who left without being seen in the ED.

When requested on 7/17/19, QM-A indicated MD-L worked 21% of ED shifts, but was responsible for 80% of the patients who had left without being seen in the ED.

The facility's policy EMTALA dated 3/21/17, directed Essentia Health will provide an appropriate Medical Screening Examination (MSE) to all individuals presenting to any of it's Emergency Departments requesting examination or treatment of an EMC, to any individual presenting on hospital property requesting examination or treatment of an EMC, or to any individual presenting on hospital property whose appearance or behavior would cause (or not cause) a prudent lay person observer to believe that examination or treatment for a medical condition is needed and that the individual would request the examination or treatment for him/herself if s/he were able to do so. If an EMC exists, the hospital will stabilize the EMC within the hospital's capability and capacity or affect an appropriate transfer if specialized capabilities are needed.

The facility policy Emergency Department Triage dated 6/1/07, directed patients presenting for care of an emergent medical condition are assessed and triaged on arrival by a registered nurse and are evaluated by a physician/provider who will perform a medical screening examination. The five-level triage assessment scale provides critical information for determining patient priorities based on the presenting problem, related health history or circumstances requiring emergency care...Patients are classified during the triage using the Emergency Severity Index (ESI, 2013):
Level 1: life threatening condition
Level 2: High risk
Level 3: Urgent
Level 4: Less Urgent
Level 5: Non-urgent.

The IJ was removed on 7/18/19, at 11:15 a.m. after on-site confirmation of implementation of an acceptable removal plan including:

Hospital A had removed MD-L from providing medical services in its facility, including any patient care services in the emergency department; pending final resolution of this matter.

An internal investigation into matters concerning the patient named in the complaint (the patient) include:
Immediate review of Essentia Health Stop the Line policy with all nursing staff and providers in the Emergency Department will begin on Thursday, July 18, 2019 and continue until all providers and nursing staff have completed. Operations will record a read/review and sign that indicates responsible staff have received this information on or before 8/1/19.
A review of emergency medicine policies and procedures, including:
a. Emergency Department Triage
b. Emergency Department Standards of Care
c. Emergency Medical Treatment and Active Labor Act
Director of Nursing and Medical Director to ensure education and competencies will be completed for providers and nursing staff of the Emergency Department.
A review of patient and staff complaints and risk events at Hospital A Emergency Department for MD-L for the past 24 months. Any variance to be reported out to the Medical Staff Office of Essentia Health and recommendations for improvement to be brought to the medical executive committee of Hospital A for enforcement.
Essentia Health Human Resources to provide an in-service to staff on "A Culture of Safety, Team Dynamics and Effective Communication."
A review of emergency department activity related to this patient visit to Hospital A Emergency Department by Essentia Health Peer Review.
Ongoing monitoring to include a monthly report on physician clinical and/or professional conduct events to be reviewed at Hospital A Medical Executive Committee. Data to be collected by the DON and reviewed by the MEC. Medical Staff Bylaw process for variances or deviations will be followed.