HospitalInspections.org

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 2 of 21 patients (Patient #9 and Patient #11) selected for review, who presented to the hospital for emergency care from 12/22/22 through 1/1/23, received all appropriate stabilizing treatment. Failure to provide all appropriate stabilizing treatment at the Emergency Department (ED) resulted in Patient #9 eloping from the ED, which may have resulted in Patient #9 harming themselves or others and potentially averted the death of Patient #11. The CAH's administrative staff identified an average of 456 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings include:


1.. Review of policy, "Abduction and Elopement of Patients/Residents"", reviewed 09/27/2022, revealed in part, "...Purpose...to identify methods in which to keep patients...at risk for ....elopement safe...policy...to maintain the safety of patients..to prevent an unintentional departure from the facility...interventions will be individualized based on the patient risk score...placement in a room close to the nursing station, Use of an alarm system to alert staff...frequent rounding on patient...Documentation of patient's elopement risk will be included in patient's care/treatment plan".

2. Review of policy, "Behavioral Health-Substance Abuse", reviewed 03/22/2022, revealed in part, "...to ensure appropriate evaluation and treatment to patient's presenting to the emergency department for a substance abuse evaluation or that are under the influence of a substance... Provide a safe environment... patient will remain under close observation or 1:1 observation as ordered by the ED Provider...if 1:1 observation is ordered there will be every 15 minute safety checks documented on the patient by the staff member...".

3. Review of policy, "Standard of Practice, Care and Documentation Guidelines-Emergency Department", revised 3/22/2022, revealed in part, "...Elopement: patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety because of legal status...nursing staff will participate collaboratively with ED providers to develop a plan of care for the patient... Nursing staff will anticipate patient clinical, emotional...needs...responsible for ensuring that the plan of care is implemented...


4. Review of Patient #9's medical record revealed:

a. On 12/22/2022 at 11:27 AM Patient #9 presented to the ED accompanied by Patient #9's parents for evaluation of substance use. Patient #9 had just left a substance abuse treatment program a short time ago and parents concerned Patient #9 was using again. RN B documented at 11:42 AM that it was reported that Patient #9 hasn't been acting normally and the parents stated they want to go to the courthouse to have patient #9 committed.

b. PA C medically evaluated Patient #9 at 11:55 AM. PA C talked with Patient #9's parents. PA C ordered screening lab work that included a urine drug screen. The urine drug screen resulted at 12:26 PM and was positive for cannabinoids, amphetamines, and methamphetamine.

c. On 12/22/2022 at 2:29 PM Magistrate A signed a court order for immediate custody and for Patient #9 to be detained in the custody of [name of CAH] or other suitable facility..." Magistrate A's order was based on letters from Patient #9's mother and father who shared information about Patient #9 that made them believe Patient #9 continued to suffer from substance abuse and remained at risk for harm due to continued substance use as well as concerned for own safety.

d. On 12/22/2022 at 7:50 PM RN E documented that Patient #9 reported they were going to leave the facility. RN E then documented at 7:55 PM that RN E called dispatch and requested the sheriff come watch Patient #9. Paramedic D also documented on 12/22/23 at 7:57 PM that Patient #9 stated they wanted to leave and go to parents house, police can just bring me back if they need to. Provider notified and spoke with Patient #9 that they were committed and cannot leave.

f. On 12/23/2022 at 6:17 AM RN B documented night shift reported Patient #9 had a spell where they wanted to leave and had to be redirected.

g. On 12/23/2022 at 11:34 AM RN F documented Patient #9's room was empty, search initiated, sheriff's department was called. Patient #9 could not be located in the CAH.

h. Patient # 9's medical record lacked provider orders for frequency of monitoring or 1:1 care, a plan of care and interventions that addressed elopement risks, and lacked documentation that indicated that the patient was under constant surveillance to prevent elopement from the CAH.

5. During an interview on 2/15/2023 at 11:00 AM, PA C reported Patient #9 had been brought in by their parents for help getting Patient #9 into an inpatient substance abuse program and they wanted to get Patient #9 committed. I ordered the typical psychiatric medical clearance screening exam and Patient #9 was medically cleared for a transfer to a psychiatric unit. Usually when there is a court order, someone from the sheriff's department stays with the patient. They are not able to stay 24/7, here all the time, as they may need to leave for an emergency call. I didn't order any special precautions. There are not any special intervals for observation., it depends on the situation. Nurses are constantly there. Room 7 is located where the nurses can easily see from the nurses' station and there is a window in the patient's room door. We certainly try to avoid elopement, if we have the patients we request assistance from law enforcement. I recall the patient required frequent redirection and was having anxiety issues. We let him walk around a bit. We have verbal conversations with nursing staff about precautions that are needed. We don't write orders for precautions and I didn't write any in this situation.

6. During an interview on 2/15/2022 at 2:00 PM, RN B reported they took care of Patient # 9 on both 12/22/2022 and on 12/23/2022. Patient #9 presented to the ED with their mom and dad with a substance abuse issue. The parents wanted Patient #9 committed. Substance abuse cases are hard to place. The parents got Patient #9 committed and we moved Patient #9 into room 7 where we could watch Patient #9 closely. Patient #9 asked what happens if they would leave. I told Patient #9 we would send the police after you. Patient #9 said well I don't want to do that. We try to do an every 15 minute "eyeball" check. RN B acknowledged they could find no documentation that the every 15 minute checks had taken place. RN B reported the morning that Patient #9 eloped, a patient presented to the ED with chest pain. RN F triaged this patient and RN B went in to do the EKG. RN B reported when RN B came out of the room minutes later, Patient # 9 was gone. RN B acknowledged there was no one watching Patient #9 when both RN B and RN F were in the newly arrived patient's room. RN B looked for Patient # 9 for about 5 minutes then called dispatch and filled out a safety form.

7. During an interview on 2/15/2023 at 3:30 PM, RN F reported Patient #9 was sleeping at 6 AM 12/23/2023, the start of RN F's shift. Patient #9 woke up around 9 AM had breakfast then went to the restroom. RN F described Patient #9 as polite and cooperative, not agitated or combative. Around 11:30 a patient presented to the ED with chest pain . RN F transported the new patient into a room and RN B assisted and performed an EKG. RN F reported they came out within 3 to 5 minutes tops and Patient #9 had eloped. RN F acknowledged Patient #9 was an elopement risk but didn't think the risk was high at the time. Patient # 9 had asked what would happen if they left and had been told they would be brought back by the police. Patient #9 accepted that and Patient #9 didn't ask or talk about leaving that morning. RN F reported ED staff routinely screen for suicide and violence on triage assessment but don't routinely do elopement risk screening. Elopement risk screening would have triggered interventions such as putting Patient #9 in paper scrubs, provide chair or door alarms, etc.

8. During an interview on 2/15/2023 at 1:20 AM, PA G reported they took over care for Patient #9 on 12/23/2023 at 7:00 AM. PA G recalled Patient #9 had come in the previous day and was court committed so we kept him here. We try our best to watch patients in these cases. In bigger facilities, they order precautions. Here we are small, we all know what they (patients) are doing. It is such a close unit with good communication. The problem is when they try to leave how do we stop them? I remember Patient #9 asked me what happens when I leave. I believe they did ask for a sitter but none was available. Patient #9 was alert, oriented and cooperative. He wasn't under the influence.

9. During an interview on 2/13/2022 at 1:00 PM ED Manager verified Patient #9 had been in the CAH court committed for substance abuse. ED Manager reported this type of committal was very rare. ED Manager acknowledged staff didn't recognize what that exactly meant and Patient #9 did not have elopement precautions implemented with frequency of observations ordered, patient was not placed in paper scrubs and gown belongings were not secured.



Patient #11:

1. Review of Patient #11's medical record revealed the following:

Pt # 11 presented to the ED on 1/1/23 at 6:21 PM complaining of difficulty breathing. At 6:34 PM certified Physician Assistant (PA-C) I documented in the medical record that patient # 11 stated she had had a sore throat for a couple of days. "Seen in urgent care today and tested positive for strep pharyngitis (commonly known as strep throat). She was prescribed antibiotics which she has not picked up yet. Around 2 PM today she started to feel like she was wheezing. She is coughing up phlegm [thick mucous in the airway]." Further documentation showed the patient was "ill-appearing", was in respiratory distress with stridor (abnormal high pitched sound with breathing, a sign that the upper airway is partially obstructed) labored breathing, and was "nervous/anxious." Initial vital signs showed a blood pressure of 122/88, heart rate 123 [normal at rest 60-100 beats per minute] and an Oxygen saturation level of 89% [normal 95 - 100%]. At 6:30 PM, Patient # 11 received a breathing treatment [nebulized (machine that turns the medication into a fine mist) epinephrine] which failed to resolve the patient's respiratory symptoms. At 6:48 PM patient # 11 received intravenous levofloxacin 750 mg [antibiotic] and vancomycin 1500 mg [antibiotic] at 7:15 PM. At 6:54 PM patient # 11 received intravenous ondansetron 8mg [anti-emetic, prevents nausea, vomiting]. At 7:19 PM respiratory therapy placed the patient on a BiPAP machine [noninvasive positive-pressure ventilation] to assist with breathing.

The medical record contained documentation of ongoing care and treatment by PA-C I but lacked documentation of a call to the on-call physician O.

At 11:12 PM PA-C I pronounced patient # 11 deceased. At 12:40 PM documentation showed on-call physician/Medical Examiner was notified (on-call physician O).

2. Review of Medical Screening and Transfer of Patients to Other Medical Facilities from the Emergency Department, Acute Care", dated 6/22/21, revealed in part, " If an emergency medical condition exists... treatment will be offered... within the capability of [hospital]...provided until the emergency medical condition is resolved, stabilized or an appropriate transfer... "

3. Review of the hospital's "Medical Staff Bylaws, Rules and Regulations" dated 1/26/21 and the hospital policy "Medical Screening and Transfer of Patients to Other Medical Facilities from the Emergency Department, Acute Care", revised 6/22/21 revealed the critical access hospital lacked guidance as to when a PA-C must contact the on-call physician during the care and treatment of patients in the emergency department experiencing an emergency medical condition.

4. During an interview on 2/20/23 at 12:15 PM, PA-C I reported Patient #11 came in with stridor, coughing up thin brownish liquid. Patient #11 told me they were positive for strep, but I am not so sure. It sounded like croup. I was worried about epiglottis (a potentially life threatening condition that occurs when the tissue protecting the windpipe becomes inflamed and can cause swelling which blocks air to the lungs). X-rays didn't show it but I treated the patient for that. It's all in my notes. I knew Patient # 11 might need to be intubated as they were tripoding (putting hands or elbows on knees and leaning forward as one breaths, to help get more air in lungs and easier to breathe), had expiratory stridor (noisy breathing due to obstructed air flow through a narrowed airway), and some inspiratory stridor. I called multiple places to transfer Patient #11 to. I called [hospital W] immediately, [name of system] hotline get's [hospital X] too. One of them had a bed but no ENT (Ears, Nose, and Throat Specialist). Shortly after I called hospital Y and hospital Z. I did not call my back up physician. I was hoping to get Patient #11 transferred within an hour of arrival so I wouldn't have to intubate them. I can intubate without a problem, I have experience. This patient's anatomy was abnormal, vocal cords were tight. That is when things went south.

5. During an interview on 2/15/23 at 2:20 PM, Physician O reported they were the on-call ER physician and the Medical Examiner on 1/1/23. Physician confirmed they had not received a phone call during the care and treatment of Patient #11, Physician O received a phone call from PA-AC I following the death of Patient #11. Physician O reported PA-AC I had a lot of ER experience, didn't always call the on-call physician with emergencies, and physician O was not aware if this was required.



See C2407






Based on document review and staff interviews, the critical access hospital (CAH) failed to ensure the medical staff provided 5 of 21 patients selected for review, an appropriate transfer to another medical facility for an instabilities emergency medical condition (Patient #2, Patient #3, Patient #6, Patient #8, Patient #11)) . Failure to ensure the hospital's advanced practice providers consulted with a physician regarding the risks and benefits of the patient transfer, the physician agreed with the transfer, and subsequently countersigned the certification for transfer could potentially result in a patient transferred without all required stabilizing treatment and result in further deterioration of the patient's emergency medical condition or death. The CAH's administrative staff identified an average of 456 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.


Findings include:


1. Review of the policy, "Medical Staff Coverage to the Emergency Department", dated Reviewed 3/22/2022, revealed in part, "...For patients seen in the Emergency Department by a provider the following may be reported to the...primary or family physician or on-call physician:...Critical condition patients,...Verification for transfer to another facility for appropriate medical specialty or for definitive care beyond the capabilities or capacities of [name of CAH]". The policy lacked a requirement that a physician subsequently counter signed the Advanced Practice Provider (Physician Assistant or Nurse Practitioner) signed certification for transfer.

2. Review of the policy, "Medical Screening and Transfer of Patients to Other Medical Facilities from the Emergency Department, Acute Care", revealed the policy lacked the requirement for an Advanced Practice Provider, (Physician Assistant or Nurse Practitioner), consult with the back-up physician at the time of transfer and that the back-up physician subsequently counter signed the transfer certification form.#2's medical record revealed

3. Review of Patient #2's medical record revealed Patient #2 presented to the CAH's ED by ambulance on 11/29/2022 at 5:33 PM. Patient #2 complained of abdominal pain, nausea, vomiting, generalized malaise, and weakness. Patient #2 was provided a medical screening exam and stabilizing treatment by PA I which included labs, urinalysis, EKG, chest x-ray, CT of abdomen and pelvis, the administration of IV fluids, antibiotics, blood transfusion, and medications to support Patient #2's slow heart rate of 37-40 and low blood pressure of 81/42. PA I diagnosed Patient #2 with septic shock, infected urine, and possible pneumonia. PA I documented consultation with Patient #2's primary provider and arranged for transfer as a direct admit to another hospital's ICU by ground ambulance at 11:25 PM. Patient #2's medical record lacked a physician's counter signature for physician certification of the transfer.

4. Review of Patient #3's medical record revealed Patient #3 presented to the CAH's emergency department on 12/4/2022 at 4:27 PM accompanied by the Patient #2's mother. Patient #2's mother brought Patient #2 in for a psychiatric evaluation and reported Patient #3 voiced suicidal ideation and was concerned for Patient #3's safety. PA AC performed a medical screening exam that included a physical assessment, lab tests and urinalysis and urine drug screen that was positive for cannabinoids.
PA C medically cleared Patient #3 and ordered a psychiatric evaluation. The telehealth psychiatric evaluation was completed at approximately midnight on 12/4.2022 and inpatient psychiatric treatment was recommended. Patient #3 was maintained in the ED on suicide precautions. PA I assumed care of Patient #3 at shift change on 12/5/2022. A behavioral health bed was located the following day, 12/5/2022 and Patient #3 was transferred at 5:48 PM by a secure car service. Patient #3's record lacked documentation of a consultation with a physician regarding the risks and benefits of transfer of Patient #3 in an emergency medical condition and lacked a physician's countersignature for the physician certification.

5. Review of Patient #6's medical record revealed Patient #6 presented to the CAH's ED on 12/6/2022 at 9:32 AM with complaints of severe abdominal pain and a history of abdominal surgery 2 weeks ago at another hospital. PA K provided a medical screening exam that included a physical evaluation, labs, CT angiography of chest and CT of the abdomen and pelvis. PA K discovered that the surgeon who performed Patient #6's surgery was currently at work in the CAH. The surgeon was notified and presented to the ED and evaluated Patient #6. The surgeon voiced concerns about possible post operative surgical complications, reviewed the work up that had already been completed, requested a nasogastric tube be placed in Patient #6, and that Patient #6 be transferred back to the hospital the surgery had been performed at for continued care and evaluation. PA K arranged for the transfer of Patient #6 by ambulance back to the hospital the surgery took place on 12/6/22 at 2:51 PM. Patient #6's record lacked documentation of a consultation with a CAH physician regarding the risks and benefits of transfer of Patient #6 in an emergency medical condition and lacked a physician's countersignature for the physician certification.

6. Review of Patient #8's medical record revealed Patient #8 presented to the CAH's ED on 12/16/2022 at 5:11 PM accompanied by their grandmother. Patient #8's grandmother requested a psychiatric evaluation, reported Patient #8 verbalized suicidal ideation, and that she would not take Patient #8 back home. PA G provided a medical screening exam that included a physical evaluation and lab work. PA G medically cleared Patient #8 and found placement in another hospital's adolescent behavioral health unit for adolescent behavior problems and suicidal ideation. Patient #8's record lacked documentation of a consultation with a physician regarding the risks and benefits of transfer of Patient #8 in an emergency medical condition and lacked a physician's countersignature for the physician certification.

7. Review of Patient # 11's medical record revealed Patient #11 presented to the CAH's ED on 1/1/2023 at 6:21 PM with complaints of difficulty breathing and obvious respiratory distress with stridor. PA I performed a medical screening exam including physical examination, labs, and a soft tissue x-ray of the neck. Labs revealed a normal white blood cell count (typically elevated with an infection), metabolic panel grossly normal, venous blood gases normal. PA I documented Patient #11 clinically appeared to have epiglottis (a potentially life threatening condition that occurs when the tissue protecting the windpipe becomes inflamed) versus laryngeal rachitic (inflammation of the larynx and trachea). The soft tissue x-ray as negative for epiglottis PA I documented need for a higher level of care and attempted to find an accepting hospital for Patient #11 that required ICU level of care due to failed response to treatment and worsening condition. Multiple hospitals contacted for transfer without success. 2 helicopter services contacted reported they were unable to fly due to heavy fog. PA I continued to provide stabilizing treatment and located an accepting hospital with an ICU bed at approximately 9:45 PM, 3-4 hours away. The receiving hospital accepting physician requested Patient #11 be intubated (breathing tube placed) prior to transport due to the lengthy drive and respiratory distress. PA I attempted place an endotracheal tube without success. PA I place a surgical airway. Patient #11 continued to deteriorate. A code was called and life saving measures initiated without success. Patient #11 was pronounced dead at 11:12 PM. Patient #11's medical record lacked documentation of consultation with a CAH physician.

8. During an interview on 2/15/2023 at 8:00 AM, ED Medical Director reported Advanced Practice Providers are to call the back-up physicians for all hospital admissions, Trauma 1 Alerts, and all transfers. The ED physician back-up is provided by the hospital's own medical staff physicians and they would be the ones to countersign the physician certification forms. The ED Medical Director reported they were aware the counter signature was required but was not aware if it took place
in this CAH.

9. During an interview on 2/16/2023 at 1:00 PM, ED Nurse Manager reported the ED has 24/7 back-up with their local family practice physicians to the contracted ED providers. ED Nurse Manager verbalized they were not aware of a requirement that APP's consult with a physician on all transfers and countersign the physician certification for transfer form. The ED Nurse Manager acknowledged the Medical records of Patient #2, Patient #3, Patient #6, Patient # 8, and Patient # 11 lacked documentation of consultation with the back-up physician and lacked a physician countersignature on the physician certification form.


See C2409

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 2 of 21 patients (Patient #9 and Patient #11) selected for review, who presented to the hospital for emergency care from 12/22/22 through 1/1/23, received all appropriate stabilizing treatment. Failure to provide all appropriate stabilizing treatment at the Emergency Department (ED) resulted in Patient #9 eloping from the ED, which may have resulted in Patient #9 harming themselves or others and potentially averted the death of Patient #11. The CAH's administrative staff identified an average of 456 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings include:

Patient #9:

1. Review of policy, "Abduction and Elopement of Patients/Residents"", reviewed 09/27/2022, revealed in part, "...Purpose...to identify methods in which to keep patients...at risk for ....elopement safe...policy...to maintain the safety of patients..to prevent an unintentional departure from the facility...interventions will be individualized based on the patient risk score...placement in a room close to the nursing station, Use of an alarm system to alert staff...frequent rounding on patient...Documentation of patient's elopement risk will be included in patient's care/treatment plan".

2. Review of policy, "Behavioral Health-Substance Abuse", reviewed 03/22/2022, revealed in part, "...to ensure appropriate evaluation and treatment to patient's presenting to the emergency department for a substance abuse evaluation or that are under the influence of a substance... Provide a safe environment... patient will remain under close observation or 1:1 observation as ordered by the ED Provider...if 1:1 observation is ordered there will be every 15 minute safety checks documented on the patient by the staff member...".

3. Review of policy, "Standard of Practice, Care and Documentation Guidelines-Emergency Department", revised 3/22/2022, revealed in part, "...Elopement: patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety because of legal status...nursing staff will participate collaboratively with ED providers to develop a plan of care for the patient... Nursing staff will anticipate patient clinical, emotional...needs...responsible for ensuring that the plan of care is implemented...


4. Review of Patient #9's medical record revealed:

a. On 12/22/2022 at 11:27 AM Patient #9 presented to the ED accompanied by Patient #9's parents for evaluation of substance use. Patient #9 had just left a substance abuse treatment program a short time ago and parents concerned Patient #9 was using again. RN B documented at 11:42 AM that it was reported that Patient #9 hasn't been acting normally and the parents stated they want to go to the courthouse to have patient #9 committed.

b. PA C medically evaluated Patient #9 at 11:55 AM. PA C talked with Patient #9's parents. PA C ordered screening lab work that included a urine drug screen. The urine drug screen resulted at 12:26 PM and was positive for cannabinoids, amphetamines, and methamphetamine.

c. On 12/22/2022 at 2:29 PM Magistrate A signed a court order for immediate custody and for Patient #9 to be detained in the custody of [name of CAH] or other suitable facility..." Magistrate A's order was based on letters from Patient #9's mother and father who shared information about Patient #9 that made them believe Patient #9 continued to suffer from substance abuse and remained at risk for harm due to continued substance use as well as concerned for own safety.

d. On 12/22/2022 at 3:41 PM RN B documented multiple attempts to find a psychiatric bed unsuccessful and had been told that intake personnel were gone for holiday and would not be returning until Tuesday, 5 days away.

e. On 12/22/2022 at 4:13 PM PA C documented that [name of CAH] is not a suitable facility for a psychiatric patient as the CAH did not provide psychiatric services and that ED staff would endeavor to find a psychiatric bed for Patient #9.

f. On 12/22/2022 at 7:50 PM RN E documented that Patient #9 reported they were going to leave the facility. RN E documented at 7:55 PM they called dispatch and requested the sheriff come watch Patient #9. Paramedic D documented at 7:57 PM Patient #9 stated they want to leave and go to parents house, police can just bring me back if they need to. Provider notified and spoke with Patient #9 that they were committed and cannot leave.

g. On 12/23/2022 at 6:17 AM RN B documented night shift reported Patient #9 had a spell where they wanted to leave and had to be redirected.

h. On 12/23/2022 at 9:56 AM RN B documented multiple calls made to locate a psychiatric bed for Patient # 9, no bed found.

h. On 12/23/2022 at 11:34 AM RN F documented Patient #9's room was empty, search initiated, sheriff's department was called. Patient #9 could not be located in the CAH.

i. Patient # 9's medical record lacked provider orders for frequency of monitoring or 1:1 care, a plan of care and interventions that addressed elopement risks, and lacked documentation that indicated that the patient was under constant surveillance to prevent elopement from the CAH.


5. Review of incident report, dated 12/23/2022 11:40 AM, revealed in part, "...pt. here on Court committal for substance abuse, ...was in room near nurses station, [their] coat had been taken from patient and placed in the back of the dept. [Patient #9] served [themselves] coffee and must have seen [their] coat, [Patient #9] was in the room when this writer [RN B] went into another room to care for another Pt. I came out and [Patient #9] was gone, search done in the department and throughout the hospital, unable to find [Patient #9], police called as [Patient #9] is a committal they will be looking for [Patient #9].

6. During an interview on 2/15/2023 at 11:00 AM, PA C reported Patient #9 had been brought in by their parents for help getting Patient #9 into an inpatient substance abuse program and they wanted to get Patient #9 committed. I ordered the typical psychiatric medical clearance screening exam and Patient #9 was medically cleared for a transfer to a psychiatric unit. Usually when there is a court order, someone from the sheriff's department stays with the patient. They are not able to stay 24/7, here all the time, as they may need to leave for an emergency call. I didn't order any special precautions. There are not any special intervals for observation., it depends on the situation. Nurses are constantly there. Room 7 is located where the nurses can easily see from the nurses' station and there is a window in the patient's room door. We certainly try to avoid elopement, if we have the patients we request assistance from law enforcement. I recall the patient required frequent redirection and was having anxiety issues. We let him walk around a bit. We have verbal conversations with nursing staff about precautions that are needed. We don't write orders for precautions and I didn't write any in this situation.

7. During an interview on 2/15/2022 at 2:00 PM, RN B reported they took care of Patient # 9 on both 12/22/2022 and on 12/23/2022. Patient #9 presented to the ED with their mom and dad with a substance abuse issue. The parents wanted Patient #9 committed. Substance abuse cases are hard to place. The parents got Patient #9 committed and we moved Patient #9 into room 7 where we could watch Patient #9 closely. Patient #9 asked what happens if they would leave. I told Patient #9 we would send the police after you. Patient #9 said well I don't want to do that. We try to do an every 15 minute "eyeball" check. RN B acknowledged they could find no documentation that the every 15 minute checks had taken place. RN B reported the morning that Patient #9 eloped, a patient presented to the ED with chest pain. RN F triaged this patient and RN B went in to do the EKG. RN B reported when RN B came out of the room minutes later, Patient # 9 was gone. RN B acknowledged there was no one watching Patient #9 when both RN B and RN F were in the newly arrived patient's room. RN B looked for Patient # 9 for about 5 minutes then called dispatch and filled out a safety form.

8. During an interview on 2/15/2023 at 3:30 PM, RN F reported Patient #9 was sleeping at 6 AM 12/23/2023, the start of RN F's shift. Patient #9 woke up around 9 AM had breakfast then went to the restroom. RN F described Patient #9 as polite and cooperative, not agitated or combative. Around 11:30 a patient presented to the ED with chest pain . RN F transported the new patient into a room and RN B assisted and performed an EKG. RN F reported they came out within 3 to 5 minutes tops and Patient #9 had eloped. RN F acknowledged Patient #9 was an elopement risk but didn't think the risk was high at the time. Patient # 9 had asked what would happen if they left and had been told they would be brought back by the police. Patient #9 accepted that and Patient #9 didn't ask or talk about leaving that morning. RN F reported ED staff routinely screen for suicide and violence on triage assessment but don't routinely do elopement risk screening. Elopement risk screening would have triggered interventions such as putting Patient #9 in paper scrubs, provide chair or door alarms, etc.

9. During an interview on 2/15/2023 at 1:20 AM, PA G reported they took over care for Patient #9 on 12/23/2023 at 7:00 AM. PA G recalled Patient #9 had come in the previous day and was court committed so we kept him here. We try our best to watch patients in these cases. In bigger facilities, they order precautions. Here we are small, we all know what they (patients) are doing. It is such a close unit with good communication. The problem is when they try to leave how do we stop them? I remember Patient #9 asked me what happens when I leave. I believe they did ask for a sitter but none was available. Patient #9 was alert, oriented and cooperative. He wasn't under the influence.

10. During an interview on 2/15/2023 at 10:18 AM RN E reported they worked the ED 12/22/2022 6 PM to 6 AM. Patient #9 was a substance abuse committal. Patient #9 was polite, kind, but anxious and pacing. Patient #9 asked questions that made me think Patient #9 didn't want to stay. I didn't have a good feeling so I called dispatch and asked them to send an officer over. As soon as the officer arrived Patient #9 calmed down, was less anxious. The officer stayed all night and the patient slept. RN E verbalized the staff monitor patients that are court committed by placing the patient in room 7 near the nurses station where they can easily see the patient. The ED staff monitor patients on suicide and homicide precautions every 15 minutes and high risk are 1:1. Patient #9 didn't have suicidal or homicidal ideation.

11. During an interview on 2/15/2023 at 8:15 AM, Paramedic D reported they worked the evening of 12/22/2022. Paramedic D reported Patient #9 had been admitted that afternoon, was court committed, and remained in their regular street clothes. Paramedic D verbalized they were doing checks on Patient #9 all night and recalled a sheriffs deputy was there until Patient #9 went to sleep. Paramedic D reported Patient #9 was not on any precautions. We just generally keep an eye on them.

12. During an interview on 2/14/2023 at 2:13 PM, Sergeant H reported Patient #9's family took Patient #9 to the ED the day before due to Patient #9's substance abuse. A judge had placed a court order for Patient #9 to be held until abed could be found. There had been some bad weather, a snow storm. I came on at 10:00 AM 12/23/2022. I got a call that Patient #9 had left the hospital. The. he police and the sheriffs department had officers out looking for Patient #9. It had been like 45 minutes, it was cold and we were hoping Patient #9 had made it somewhere. Patient #9's dad called the sheriffs office that Patient #9 had arrived at their home. I sent another officer to the hospital to let them know Patient #9 had been located and
that I was taking Patient #9 straight to [Acute Care Hospital] in Waterloo. I picked up Patient #9 at their parents house and drove directly to [Acute Care Hospital. ].I remembered the court committal paperwork in place was worded such that Patient #9 could be kept at [name of CAH] or other suitable place. Well Patient #9 left [name of CAH]. I thought let's bypass [Name of CAH] This [Patient #9] obviously left, it's not suitable. Small hospitals like [name of CAH] aren't set up for this. I knew {Acute Care Hospital] had a ward they could place Patient #9 in and they had psychiatric services this little hospital doesn't have. It was 100% my decision, I did not consult with the [CAH].

13. During an interview on 2/13/2022 at 1:00 PM ED Manager verified Patient #9 had been in the CAH court committed for substance abuse. ED Manager reported this type of committal was very rare. ED Manager acknowledged staff didn't recognize what that exactly meant and Patient #9 did not have elopement precautions implemented with frequency of observations ordered, patient was not placed in paper scrubs and gown belongings were not secured.


Patient #11:

1. Review of Patient #11's medical record revealed the following:

Pt # 11 presented to the ED on 1/1/23 at 6:21 PM complaining of difficulty breathing. At 6:34 PM certified Physician Assistant (PA-C) I documented in the medical record that patient # 11 stated she had had a sore throat for a couple of days. "Seen in urgent care today and tested positive for strep pharyngitis (commonly known as strep throat). She was prescribed antibiotics which she has not picked up yet. Around 2 PM today she started to feel like she was wheezing. She is coughing up phlegm [thick mucous in the airway]." Further documentation showed the patient was "ill-appearing", was in respiratory distress with stridor (abnormal high pitched sound with breathing, a sign that the upper airway is partially obstructed) labored breathing, and was "nervous/anxious." Initial vital signs showed a blood pressure of 122/88, heart rate 123 [normal at rest 60-100 beats per minute] and an Oxygen saturation level of 89% [normal 95 - 100%]. At 6:30 PM, Patient # 11 received a breathing treatment [nebulized (machine that turns the medication into a fine mist) epinephrine] which failed to resolve the patient's respiratory symptoms. At 6:48 PM patient # 11 received intravenous levofloxacin 750 mg [antibiotic] and vancomycin 1500 mg [antibiotic] at 7:15 PM. At 6:54 PM patient # 11 received intravenous ondansetron 8mg [anti-emetic, prevents nausea, vomiting]. At 7:19 PM respiratory therapy placed the patient on a BiPAP machine [noninvasive positive-pressure ventilation] to assist with breathing.

At 7:33 PM patient # 11 received intravenous Lorazepam 1 mg [anti-anxiety], at 7:45 PM hydromorphone .25 mg [narcotic pain medication]. At 7:45 PM staff placed a call to acute care hospital X's helicopter service to arrange transport to an acute care hospital via air ambulance for a "higher level of care." Documentation showed that "they are not flying due to the weather and will put us on the wait list."

At 8:00 PM documentation showed staff placed a call to acute care hospital Y's air ambulance service to arrange for transport to arrange transport to an acute care hospital via air ambulance. At 8:15 PM documentation showed the patient pulled off the bipap machine.

At 8:22 PM documentation showed patient # 11 received a second breathing treatment [nebulized epinephrine] and supplemental oxygen at 4 liters via a nasal cannula [tubing with prongs on the end that insert into the nostrils to deliver oxygen]. At 8:23 PM the patient received intravenous dexamethasone PF 10 mg [anti-inflammatory, reduce inflammation in the respiratory tract]. At 8:36 PM the patient's heart rate was 116 beats per minute, respiratory rate was 20 and oxygen saturation level was 86%. At 8:39 PM staff documented acute care hospital Y's air ambulance service called back and ED staff were told they are not flying due to the weather.

At 9:11 PM patient # 11 received intravenous magnesium sulfate 2 gm [administered when inhaled short-acting bronchodilators and corticosteroids are ineffective]. Documentation showed the patient was becoming restless and distressed, and pulled off the blood pressure cuff and the oxygen saturation monitor. At 9:51 PM, documentation showed that PA-C I attempted to arrange transfer to Hospital Z in Minnesota using advanced life support equipped ambulance. PA-C I documented "I discussed the case with [name of physician] at [Hospital Z] the intensivist on duty. He did accept the patient, however he requested that we secure the airway prior to transfer. Helicopter ambulance not available due to weather. Patient was observed in the department and did seem to be getting progressively worse. She continued to have significant stridor and appeared to be physically wearing out."

At 10:32 PM the patient received intravenous ketamine 200 mg [dissociative anesthetic, causes amnesia (memory loss) and provides pain relief] and at 10:35 PM rocuronium bromide 80 mg [anesthetic used for rapid sequence tracheal intubation]. Documentation showed PA-C I's first attempt at intubation was unsuccessful and had to perform an emergent cricothyrotomy [incision (cut) made in the larynx (throat) in order to insert a breathing tube]. At 10:38 PM PA-C I initiated cardiopulmonary resuscitation following the advanced cardiac life support algorithm for performing chest compressions and administering life saving medications.

At 11:03 documentation showed patient # 11's heart rate had dropped to 39 beats per minute and respiratory rate was 15, oxygen saturation was 64% and blood pressure was 141/86.

At 11:12 PM PA-C I pronounced patient # 11 deceased. At 12:40 PM documentation showed on-call physician/Medical Examiner was notified (on-call physician O).

2. Review of the hospital's "Medical Staff Bylaws, Rules and Regulations" dated 1/26/21 and the hospital policy "Medical Screening and Transfer of Patients to Other Medical Facilities from the Emergency Department, Acute Care", revised 6/22/21 revealed the critical access hospital lacked guidance as to when a PA-C must contact the on-call physician during the care and treatment of patients in the emergency department experiencing an emergency medical condition.

3. During an interview on 2/20/23 at 12:00 PM, RN P reported they had been the primary nurse for Patient #11. We had a hard time finding a bed in an acute hospital for Patient #11. PA-C I called quite a few places before a bed was located in acute care hospital Z. Patient #11 had received treatment here about 5 hours by that time and was getting fatigued with the effort to breathe. The decision was made to intubate (put a tube down the patient's throat to assist with breathing) since it was almost a 3 hour drive to [hospital Z]. Two different helicopter services had been called but were not flying due to the fog. PA-C I was prepared for the possibility that Patient #11 might need a surgical tracheotomy (an opening made in the front of the neck to insert a breathing tube) due to Patient #11's stridor. PA-C I had everything set out and had marked Patient #11's neck for the possible surgical trach within 15 to 20 minutes of Patient # 11's arrival to the emergency department. We had even moved Patient #11 from exam room 4 to exam room 6 which was about twice the size as room 4 and contained any additional respiratory supplies we might need, just in case.

4. During an interview on 2/20/23 at 12:15 PM, PA-C I reported they called multiple places to transfer Patient #11 to. We knew when Patient #11 came in they would have to go somewhere. I called acute care hospital W immediately. Their hotline number gets Acute Care Hospital X too. I don't remember which hospital that I called, Acute Care Hospital W or Acute Care Hospital V, one of them had a bed but not an ENT (Ears, Nose & Throat Specialist) available. Shortly thereafter I called Acute Care Hospital Y, I was very frustrated as it took a while to find out they had no bed available. No acute care hospital close to us had a bed available. Acute Care Hospital Z had a bed available and accepted Patient #11. (Acute Care Hospital Z is located 137 miles away, approximately 2 1/2 hours drive).

During an interview on 2/14/23 at 3:18 PM, PA-C I acknowledged they did not call on-call physician O during the care and treatment of Patient #11. PA-C I notified on-call physician O by phone after the death of Patient #11. PA-C I reported they had 20 years of emergency experience and did not generally call the on-call physician provider when it was clear that a patient required transfer to a higher level of care as did Patient #11. PA-C I verified they were not aware of any guidelines as to when the ER provider must call the on-call physician regarding the care and treatment of an emergency room patient.

5. During an interview on 2/15/23 at 2:20 PM, Physician O verified they were the on-call ER physician and the Medical Examiner on 1/1/23. Physician O confirmed they had not received a phone call during the care and treatment of Patient #11, Physician O received a phone call from PA-C I following the death of Patient #11. Physician O reported PA-C I had tried to transfer Patient #11 to 2 hospitals in Waterloo, 2 hospital in Cedar Rapids, Iowa City, and Dubuque, IA. No beds were available. PA-C I then called acute care hospital Z in Minnesota when no local bed could be found. Hospital Z accepted Patient #11 and they had to transport by ground ambulance. Physician O reported PA-C I had a lot of ER experience, didn't always call the on-call physician with emergencies, and physician O was not aware if a call to the back up physician was required.

6. During an interview on 2/20/23 at 12:15 PM, the ED Medical Director acknowledged the back up ER physician should have been notified when it was determined a transfer was needed for Patient #11. The ED Medical Director reported that PA-C I had excellent airway skills and probably better skills than most physicians.
,

Based on document review and staff interviews, the critical access hospital (CAH) failed to ensure the medical staff provided 5 of 21 patients selected for review, an appropriate transfer to another medical facility for an unstabilized emergency medical condition (Patient #2, Patient #3, Patient #6, Patient #8, Patient #11)) . Failure to ensure the hospital's advanced practice providers consulted with a physician regarding the risks and benefits of the patient transfer, the physician agreed with the transfer, and subsequently countersigned the certification for transfer could potentially result in a patient transferred without all required stabilizing treatment and result in further deterioration of the patient's emergency medical condition or death. The CAH's administrative staff identified an average of 456 patients per month who presented to the CAH's dedicated emergency department and requested emergency medical care.


Findings include:


1. Review of the policy, "Medical Staff Coverage to the Emergency Department", dated Reviewed 3/22/2022, revealed in part, "...For patients seen in the Emergency Department by a provider the following may be reported to the...primary or family physician or on-call physician:...Critical condition patients,...Verification for transfer to another facility for appropriate medical specialty or for definitive care beyond the capabilities or capacities of [name of CAH]". The policy lacked a requirement that a physician subsequently counter signed the Advanced Practice Provider (Physician Assistant or Nurse Practitioner) signed certification for transfer.

2. Review of the policy, "Medical Screening and Transfer of Patients to Other Medical Facilities from the Emergency Department, Acute Care", revealed the policy lacked the requirement for an Advanced Practice Provider, (Physician Assistant or Nurse Practitioner), consult with the back-up physician at the time of transfer and that the back-up physician subsequently counter signed the transfer certification form.#2's medical record revealed

3. Review of Patient #2's medical record revealed Patient #2 presented to the CAH's ED by ambulance on 11/29/2022 at 5:33 PM. Patient #2 complained of abdominal pain, nausea, vomiting, generalized malaise, and weakness. Patient #2 was provided a medical screening exam and stabilizing treatment by PA I which included labs, urinalysis, EKG, chest x-ray, CT of abdomen and pelvis, the administration of IV fluids, antibiotics, blood transfusion, and medications to support Patient #2's slow heart rate of 37-40 and low blood pressure of 81/42. PA I diagnosed Patient #2 with septic shock, infected urine, and possible pneumonia. PA I documented consultation with Patient #2's primary provider and arranged for transfer as a direct admit to another hospital's ICU by ground ambulance at 11:25 PM. Patient #2's medical record lacked a physician's counter signature for physician certification of the transfer.

4. Review of Patient #3's medical record revealed Patient #3 presented to the CAH's emergency department on 12/4/2022 at 4:27 PM accompanied by the Patient #2's mother. Patient #2's mother brought Patient #2 in for a psychiatric evaluation and reported Patient #3 voiced suicidal ideation and was concerned for Patient #3's safety. PA C performed a medical screening exam that included a physical assessment, lab tests and urinalysis and urine drug screen that was positive for cannabinoids.
PA C medically cleared Patient #3 and ordered a psychiatric evaluation. The telehealth psychiatric evaluation was completed at approximately midnight on 12/4.2022 and inpatient psychiatric treatment was recommended. Patient #3 was maintained in the ED on suicide precautions. PA I assumed care of Patient #3 at shift change on 12/5/2022. A behavioral health bed was located the following day, 12/5/2022 and Patient #3 was transferred at 5:48 PM by a secure car service. Patient #3's record lacked documentation of a consultation with a physician regarding the risks and benefits of transfer of Patient #3 in an emergency medical condition and lacked a physician's countersignature for the physician certification.


5. Review of Patient #6's medical record revealed Patient #6 presented to the CAH's ED on 12/6/2022 at 9:32 AM with complaints of severe abdominal pain and a history of abdominal surgery 2 weeks ago at another hospital. PA K provided a medical screening exam that included a physical evaluation, labs, CT angiography of chest and CT of the abdomen and pelvis. PA K discovered that the surgeon who performed Patient #6's surgery was currently at work in the CAH. The surgeon was notified and presented to the ED and evaluated Patient #6. The surgeon voiced concerns about possible post operative surgical complications, reviewed the work up that had already been completed, requested a nasogastric tube be placed in Patient #6, and that Patient #6 be transferred back to the hospital the surgery had been performed at for continued care and evaluation. PA K arranged for the transfer of Patient #6 by ambulance back to the hospital the surgery took place on 12/6/22 at 2:51 PM. Patient #6's record lacked documentation of a consultation with a CAH physician regarding the risks and benefits of transfer of Patient #6 in an emergency medical condition and lacked a physician's countersignature for the physician certification.


6. Review of Patient #8's medical record revealed Patient #8 presented to the CAH's ED on 12/16/2022 at 5:11 PM accompanied by their grandmother. Patient #8's grandmother requested a psychiatric evaluation, reported Patient #8 verbalized suicidal ideation, and that she would not take Patient #8 back home. PA G provided a medical screening exam that included a physical evaluation and lab work. PA G medically cleared Patient #8 and found placement in another hospital's adolescent behavioral health unit for adolescent behavior problems and suicidal ideation. Patient #8's record lacked documentation of a consultation with a physician regarding the risks and benefits of transfer of Patient #8 in an emergency medical condition and lacked a physician's countersignature for the physician certification.

7. Review of Patient # 11's medical record revealed Patient #11 presented to the CAH's ED on 1/1/2023 at 6:21 PM with complaints of difficulty breathing and obvious respiratory distress with stridor. PA I performed a medical screening exam including physical examination, labs, and a soft tissue x-ray of the neck. Labs revealed a normal white blood cell count (typically elevated with an infection), metabolic panel grossly normal, venous blood gases normal, PA I documented Patient #11 clinically appeared to have epiglottis (a potentially life threatening condition that occurs when the tissue protecting the windpipe becomes inflamed) versus laryngeal tracheitis (inflammation of the larynx and trachea). The soft tissue x-ray realt negative for epiglottis. PA I documented the need for a higher level of care for Patient #11, who required ICU level of care due to failed response to treatment and worsening condition. Multiple hospitals contacted for transfer without success. 2 helicopter services contacted reported they were unable to fly due to heavy fog. PA I continued to provide stabilizing treatment and located an accepting hospital with an ICU bed at approximately 9:45 PM, 3-4 hours away. The receiving hospital accepting physician requested Patient #11 be intubated (breathing tube placed) prior to transport due to the lengthy drive and respiratory distress. PA I attempted place an endotracheal tube without success. PA I placed a surgical airway. Patient #11 continued to deteriorate. A code was called and life saving measures initiated without success. Patient #11 was pronounced dead at 11:12 PM. Patient #11's medical record lacked documentation of consultation of Patient #11's critical condition with a CAH ED back-up physician.

8. During an interview on 2/14/2023 at 3:18 PM, PA I reported PA I generally called the back-up physician for an admission to the CAH if they had questions regarding capacity. to care for a patient. PA I didn't call the back-up when it was clear the patient needed a higher level of care than we provided here. PA I verified PA I did not call the back up ED physician during the care of Patient #2, Patient #3, and Patient #11. PA I verbalized they didn't know that was an EMTALA requirement.

9. During an interview on 2/15/2023 at 3:04 PM, PA K reported PA K generally contacted the back-up physician with transfer out of the ED and acknowledged a consultation was not documented. PA K verbalized they did not think it was necessary in this case as Patient # 8's surgeon had requested the transfer back to the hospital the surgery was performed at. PA K reported they generally document the consultation in the medical decision making section of the patient's medical record.

10. During an interview on 2/15/2023 at 1:20 PM, PA G reported they usually call or text the back-up physician before they transferred a patient out of the ED. PA G acknowledged the Patient # 8's record lacked documentation of a consultation with the back-up physician prior to transfer.

11. During an interview on 2/15/2023 at 8:00 AM, ED Medical Director reported Advanced Practice Providers are to call the back-up physicians for all hospital admissions, Trauma 1 Alerts, and all transfers. The ED physician back-up is provided by the hospital's own medical staff physicians and they would be the ones to counter sign the physician certification forms. The ED Medical Director reported they were aware the counter signature was required but was not aware if it took place
in this CAH.

12. During an interview on 2/15/2023 at 9:07 AM, Physician L reported Advanced Practice Providers were to call the back-up physician with all transfers but did not know if that consistently happened. Physician L confirmed Physician L had not been consulted in the transfer of Patient #2 or Patient #6 and had not countersigned the physician certification form.

13. During an interview on 2/15/2023 at 9:47 AM, Physician M reported they were not aware the back-up physician needed to be called on all transfers, acknowledged Physician M was not consulted regarding the transfer of Patient #3 and revealed they had never counter signed a physician certification of transfer form.

14. During an interview on 2/15/2023 at 1:00 PM. Physician N reported Advance Practice Providers were supposed to call the back-up physician with all admissions and transfer. Physician N reported APP's are pretty good about doing this but acknowledged Physician M was not consulted on the transfer of Patient #8 and acknowledged the physician certification for transfer form lacked a physicians signature.

15. During an interview on 2/16/2023 at 1:00 PM, ED Nurse Manager reported the ED has 24/7 back-up with their local family practice physicians to the contracted ED providers. ED Nurse Manager verbalized they were not aware of a requirement that APP's consult with a physician on all transfers and countersign the physician certification for transfer form. The ED Nurse Manager acknowledged the Medical records of Patient #2, Patient #3, Patient #6, Patient # 8, and Patient # 11 lacked documentation of consultation with the back-up physician and lacked a physician countersignature on the physician certification form.