The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ADVANCED HEALTHCARE MEDICAL CENTER ROUTE 4, BOX 4269 ELLINGTON, MO March 6, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews the facility failed to follow their policies and procedures when staff:
-did not examine one patient (Patient #10) that presented via ambulance to the hospital emergency department; and did not perform an adequate medical screening examination, within it's capability, to three patients (Patient #13 A, #19 and # 24); and
-did not provide further examination and stabilizing treatment within it's capabilities prior to discharging two patients (Patient # 8 and #13B) of 32 patient records reviewed. These patients presented to the emergency department for treatment from August, 2011 to January, 2012. The hospital sees an average of 210 emergency cases per month.
Findings included.
Record review of the hospital's EMTALA Policy & Procedure Manual, SUBJECT: Medical Screening, Reference #EM-4001 dated 10/16/09 stated, in part:
PURPOSE: To provide guidelines for ensuring that all patients requesting emergency services at Advanced Healthcare Medical Center receive an appropriate medical screening examination.
POLICY: Any patient who comes to Advanced Healthcare Medical Center (AHMC) requesting emergency services is entitled to and will receive a medical screening examination performed by individuals qualified to perform such examinations to determine whether an emergency medical conditions exists.

Page 5 of this policy showed "Medical Screening Examination" is the process required to reach with reasonable clinical confidence whether an emergency medical condition exists. The medical screening examination is an ongoing process and the medical records must reflect continued monitoring based on patient's need and continue until the patient is either stabilized or appropriately transferred.

Page 6 of this policy showed "To Stabilize with respect to an emergency medical condition means to provide such medical treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the facility ..."

Page 8 of this policy showed an individual in a non-hospital-owned ambulance which is on hospital property is considered to have come to the emergency department.

AHMC failed to follow its policy and did not provide Patient # 10 with an examination after he presented on hospital property by ambulance on 1/19/12 at 3:53 PM. Review of the ambulance crew's documentation revealed the Emergency Department (ED) physician went out to the parking lot and requested that the patient be taken to Hospital B.

During an interview on 2/6/12 at 4:30 PM, paramedic C stated that upon arrival to the hospital emergency department (ED) parking lot on 1/19/12, ED physician A came out and requested the patient be taken to Hospital B. Paramedic C stated that ED physician A indicated, "The hospital does not handle psychiatric patients and it would take a long time to find the patient a bed at another hospital." Paramedic C stated that if physician A had not come out to the parking lot he would have taken the patient into the ED but that after physician A came out to the ambulance, Paramedic C did not feel like Patient # 10 was welcome. Refer to tag C2406 for details.

AHMC failed to follow it's policy and did not provide an appropriate examination to three patients (Patient #13A, #19 and #24) after they presented to the ED requesting care.

Patient # 13 A (MDS) dated [DATE] at 3:05 PM and stated he had consumed 45 - 50 tablets of aspirin between 7:00 AM and 1:00 PM and complained of feeling queasy, off balance and ringing in his ears (symptoms suggestive of an aspirin overdose). The ED nurse documented the patient had an elevated heart rate of 137 beats per minute (normal 60 - 100) and elevated blood pressure 139/92 (normal less than or equal to 120/80), and that she requested the patient provide a urine specimen (aspirin overdose is detected through a blood test). Further documentation indicated the patient refused to provide a urine specimen and that the ED nurse documented she "explained" to the patient and his family member they could go to Hospital B if they were not happy. Further documentation indicated Patient # 13 left the ED at 3:39 PM and refused to sign a form indicating he was leaving "against the advice of the attending physician and facility administrator." At 3:58 PM the ED nurse documented Poison Control was contacted and that the information would be kept on hand in case the patient returned. The medical record did not contain evidence that the ED nurse obtained orders for a urine specimen, or that the ED physician was contacted to come and examine the patient, or that Patient # 13 was informed of the risks of leaving before being seen. Refer to tag C2406 for further details.

Patient # 19 (MDS) dated [DATE] at 3:33 PM after her family found her lying on the floor at home without explanation. ED physician A documented the patient's history of diabetes and weakness and asked her if she wanted to be admitted . Further documentation showed the patient agreed and then later changed her mind. The medical record did not contain evidence ED physician A determined the source of patient # 19's weakness or obtained any testing within AHMC's capabilities to determine patient # 19 did not suffer from an infection and/or metabolic derangement as a result of her diabetes. Refer to tag C2406 for further details.

Patient # 24 (MDS) dated [DATE] at 9:44 AM complaining of abdominal pain and nausea and vomiting that had lasted for one week. ED physician F documented he ordered an abdominal x-ray. Review of the x-ray report revealed nothing to explain patient # 24's complaint of pain and that some areas of the abdomen were excluded from the field of view. The ED physician discharged patient # 24 and instructed him to take half a bottle of magnesium citrate (to relieve constipation) and wrote a prescription for obtaining an ultrasound of the gall bladder. The medical record did not contain evidence that ED physician F obtained any testing within AHMC's capabilities to determine the underlying cause of Patient # 24's pain or to ensure he did not have an emergency medical condition. Refer to tag C2406 for further details.

The hospital failed to follow its policy and did not provide medical treatment to assure within reasonable medical probability that no material deterioration was likely to occur before discharging two patients (Patient # 8 and 13 B) from the ED.

Patient # 8 (MDS) dated [DATE] at 10:00 AM complaining of forgetfulness and confusion for one week. Review of the medical record revealed ED physician G performed an exam and ordered a CT scan (special type of x-ray) of the patient's brain along with blood and urine testing and an EKG (electrical tracing) of the heart. Review of the CT scan report indicated an acute brain injury (acute stroke, an emergency) could not be excluded and that an additional imaging study (Magnetic Resonance - enhanced radiology study) may be helpful for further evaluation. ED physician G documented that patient # 8 had a stroke and that he discharged the patient with instructions to follow up with a neurologist, a primary care physician and a gastroenterologist "for series of testing." The medical record did not contain evidence that ED physician G performed further neurological testing to determine the type, severity or extent of the stroke or that Patient # 8's emergency was stabilized. Refer to tag C2407 for further details.

Patient # 13 B returned to the ED on 11/17/11 at 6:04 PM. Documentation in the medical record revealed patient # 13 had been at the ED earlier in the day complaining of symptoms suggestive of an aspirin overdose and that his symptoms had worsened. ED nurse practitioner E examined Patient # 13 B and documented that he had a laceration to his right wrist that happened "yesterday from a knife in a dish drainer" and that the patient denied suicidal ideation. ED nurse practitioner E sutured the laceration, obtained blood and urine for testing and ordered intravenous fluids after the lab results revealed the patient was significantly dehydrated. At 9:45 PM documentation indicated the patient was "discharged " in "stable condition" and that he refused hospitalization . The medical record did not contain evidence that the patient's dehydration was resolved, or that he received sodium bicarbonate to enhance salicylate (additive found in aspirin) excretion per Poison Control guidelines, or that ED nurse practitioner E contacted Poison Control for direct consultation, or that she explained the risks of refusing hospitalization , or performed a mental health exam to determine the patient's current state of mind, attitude, behavior, mood, affect, thought process, insight or judgement, or a description of the number of aspirin tablets he ingested, or the time period of ingestion or how he lacerated his wrist.

During an interview on 2/23/12 at 7:30 PM, ED nurse practitioner E stated that Patient # 13 refused hospitalization and that she did not request that he complete a form specifying he was "leaving against medical advice" because she knew he had refused to sign the form during a visit earlier that day. Refer to tag C2407 for further details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on interview and record review the critical access hospital (CAH) did not examine one patient (Patient # 10) and failed to perform an adequate examination, within its capabilities, to determine if an emergency existed in three patients (Patient #13 A, #19 and # 24) out of 32 Emergency Department (ED) patient medical records reviewed from August, 2011 to January, 2012. The CAH sees an average of 210 emergency cases per month.

Findings included:
Review of local ambulance service records dated 01/19/12 showed:
-14:58 (2:58 PM) Ambulance was dispatched to patient's (#10) home for a "drug overdose"
-15:15 (3:15 PM) Medics at scene
-15:16 (3:16 PM) Medics at patient's side
-15:53 (3:53 PM) Ambulance arrived at hospital. Documentation showed "Upon arrival at ED, Medic 2 was met by ED Physician A, outside the ED (in the parking lot) who requested the patient not be unloaded and instead be transported straight to Hospital B.

During a phone interview on 02/06/12 at 4:30 PM Paramedic C (paramedic that transported patient #10), stated that upon arrival to Advanced Healthcare Medical Center (AHMC) ED parking lot on 01/19/12, ED Physician A came out to the ambulance in the parking lot and requested that the patient be taken to Hospital B. Paramedic C stated that ED Physician A indicated, "The hospital does not handle psychiatric patients and it would take a long time to find the patient a bed at another hospital." Paramedic C stated that if Physician A had not come out to the parking lot he would have taken the patient into the ED but that after Physician A came out to the ambulance, Paramedic C did not feel like Patient #10 was welcome at this ED.

During a phone interview on 02/06/12 at 4:50 PM Ambulance Driver B, Emergency Medical Technician (EMT), stated that upon arrival to AHMC ED parking lot on 01/19/12, ED Physician A came out to the parking lot, approached the driver's door and stated, "If this is a psychiatric patient (Patient #10) it's no sense bringing him here, we will just have to transfer him."

Review of local ambulance service records dated 01/19/12 showed ambulance departed AHMC's parking lot and transported Patient #10 to Hospital B where he was triaged into Hospital B's ED.

Review of the AHMC ED log showed five patients were treated on 01/19/12. The ED log did not contain any information about Patient #10 or that he presented to CAH property by ambulance seeking care on 1/19/12 at 3:53 PM.

During an interview on 02/02/12 at 2:00 PM ED Physician A, stated that he was aware that Patient #10 came via ambulance to AHMC ED parking lot on 01/19/12. ED Physician A confirmed he knew the patient very well and they (Physician A and Patient #10) had a long history. ED Physician A stated that he doesn't remember if he went out to meet the ambulance. ED Physician A stated that he couldn't recall if he engaged the paramedic in conversation. ED Physician A stated the he wasn't sure what happened to the patient.

Review of Patient # 13 A's medical record showed:
-Patient # 13 arrived at AHMC's ED on 11/17/11 at 3:05 PM. The triage nursing note showed the patient had a rapid heart rate of 137 beats per minute (normal 60 - 100 beats per minute) an elevated blood pressure of 139/92 (normal is less than or equal to 120/80) and that he "took 45-50 tabs (tablets)" of aspirin 325 mg (milligrams- a unit of measure) throughout the day for a back ache and was feeling queasy, off balance and his ears were ringing (symptoms suggestive of an aspirin overdose). Further documentation showed that Patient # 13 A began taking the aspirin at 7:00 AM and took his last dose at 1:00 PM, and that he refused to provide a urine specimen for testing (aspirin levels are analyzed by testing the blood). The medical record did not contain evidence that the ED nurse notified the ED physician about Patient # 13 A's abnormal heart rate, abnormal blood pressure or symptoms of an aspirin overdose or obtained orders for a urine test.
- The triage nurse documented she "explained" to Patient # 13 and his family member that they could go to Hospital B's emergency room "if they were not happy here but we were not refusing his treatment." Further documentation revealed Patient # 13 left the ED at 3:39 PM and refused to sign a form indicating he was leaving "against the advice of the attending physician and facility administrator." The medical record did not contain evidence that the ED nurse explained the risks of leaving before being seen or contacted the ED physician to explain the risks of leaving before Patient # 13 left the ED.
- At 3:58 PM the triage nurse documented "poison control" was contacted to request information on "acetylsalicylic acid (ASA, aspirin) overdose."
- At 4:11 PM the triage nurse documented the information was received and would be kept "on hand" in case Patient # 13 A returned.

Review of Patient # 19's medical record showed:
-Patient # 19 arrived at AHMC emergency department on 10/08/11 at 3:33 PM.
-Triage began at 3:40 PM and the patient was placed in treatment room at 4:25 PM.
-Triage note showed "Client found lying in floor of kitchen (by family). Patient claimed she was cleaning."
-ED Physician A's dictation of evaluation (untimed) showed (in part) that Patient # 19 had a history of lung disease and diabetes. Further documentation showed "Family went to patient's house to visit, patient did not answer the door. When they went into the house they found her on the floor in the kitchen. The patient denied that she fell . She stated that she was just cleaning the floor and then she went to lie down on the floor and was perfectly able to get up on her own but chose to lay on the floor and just rest. Her family did not believe that story because this has happened before where they found her on the floor. They believe she is having episodes of weakness, especially from the knees down and falling." Physician A documented the patient's history and that he asked the patient if she wanted to be admitted , she agreed to admission and then later changed mind. The medical record did not contain evidence that patient # 19 received an examination sufficient to determine whether she had an emergency medical condition. The ED physician did not order any testing to determine she did not suffer from an infection and/or a metabolic derangement as a result of her diabetes prior to discharging patient # 19 home.

-During an interview on 3/06/12 at 4:00 PM, Patient #19's family member stated that they waited a long time in the ED for the doctor to arrive. When ED Physician A arrived he spent a few minutes talking to the patient and then said she would be discharged . Family member stated that she realized no tests were ordered but wasn't familiar with what should have been done so she took the patient home. Family member stated they were still concerned so they took patient to Hospital B's ED on 10/10/11 where the patient was admitted .

- Review of Hospital B's ED medical record revealed Patient # 19 arrived by ambulance in acute distress on 10/10/11 (two days later) at 12:04 PM. The patient was admitted with a potentially life threatening illness to a unit in Hospital B that specialized in treating patients too complex for the regular hospital floor.

Review of Patient # 24's medical record showed:
-Patient # 24 arrived at AHMC's emergency department on 9/18/11 at 9:44 AM.
-Triage began 9:45 AM and showed the patient complained of "nausea/vomiting for one week, complaint of abdominal pain also." History is significant for heart disease, hypertension, and diabetes.
-ED Physician F's untimed evaluation (very difficult to read) showed (in part) "Patient here for abdominal pain, decreases slightly at bedtime", further documentation showed the patient had a history of NIDDM (non insulin dependent diabetes mellitus) and high blood pressure.
-Physician F ordered an X-Ray of Patient # 24's abdomen.
-The radiologist's interpretation of the abdominal X Ray showed, "Grossly non obstructed bowel gas pattern. No etiology seen to explain abdominal pain. Some of the abdomen and bilateral flanks are excluded from the field of view."
-ED Physician F discharged the patient with a diagnosis of abdominal pain, advised him to drink clear liquids and prescribed a bottle of Magnesium Citrate (for constipation) and an ultrasound for abdominal and right upper quadrant pain. Patient # 24 left the hospital at 10:40 AM. The abdominal x-ray did not identify the cause of Patient # 24's abdominal pain. The medical record did not contain evidence blood tests were performed within AHMC's capabilities to determine the underlying cause of Patient # 24's abdominal pain or to determine whether he had an emergency medical condition prior to discharge.
VIOLATION: STABILIZING TREATMENT Tag No: C2407
Based on interview and record review the critical access hospital (CAH) emergency department staff failed to provide further examination and treatment within its capabilities prior to discharging two patients (Patient # 8 and 13 B) with emergency medical conditions out of 32 patient records reviewed from August, 2011 to January, 2012. The CAH's emergency department sees an average of 210 cases per month.

Findings included:
Review of Patient # 8's medical record showed:
-Patient # 8 arrived at AHMC emergency department on 12/07/11 at 10:00 AM.
-Triage began at 10:05 AM and showed that Patient # 8 had been forgetful and confused for one week, that he had a prior myocardial infarction (heart attack) and that his blood pressure was elevated to 159/100 (normal blood pressure is less than or equal to 120/80).
-ED Physician G's untimed evaluation showed (in part) that Patient # 8 had been confused for several days and was "getting worse." Physician G also documented that the patient was a chronic alcoholic, a smoker, and had a history of coronary artery disease (known risks for a stroke, according to the National Stroke Association at www.stroke.org).
- Physician G ordered a CAT scan of the head (special type of x-ray), blood tests including a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Lipid panel (fat in blood), an EKG (tracing of the heart's electrical activity) and a urine analysis.
-The radiological report of the CAT scan showed that, "Acute hypoxic brain injury (acute stroke) cannot be excluded on the basis of this examination." "MR (Magnetic Resonance- enhanced radiology study) scan may be helpful for further evaluation." The report was dictated by the radiologist and faxed to the hospital at 1:59 PM, approximately 25 minutes after Patient # 8 was discharged .
- The medical record did not contain evidence Physician G performed further neurological testing to determine the type, severity or extent of the stroke, or that Patient # 8's emergency was stabilized.
-Physician G discharged Patient # 8 at 1:35 PM and diagnosed him as having a cerebral vascular accident (stroke, an emergency medical condition), altered mental status and anemia (condition in which the body has a low supply of red blood) and instructed him to follow up with 1. Neurology, 2. Primary Care Physician, and 3. GI (Stomach) Specialist "for series of testing."

Review of Patient # 13 B's medical record showed:
-Patient # 13 returned to the Emergency Department on 11/17/11 at 6:04 PM (the patient left before receiving an examination earlier in the day).
- Triage began at 6:15 PM and showed that Patient # 13 complained of worsening stomach pain, achy, trouble breathing, and ringing in his ears (symptoms of an aspirin overdose). The ED nurse documented the patient had a rapid heart rate, 140 beats per minute (normal 60 - 100 beats per minute at rest) and a below normal temperature of 97.5 degrees Fahrenheit (normal is 98.6 degrees Fahrenheit). The medical record did not contain evidence of ongoing monitoring of the patient's vital signs within the hospital' s capabilities.
-ED Nurse Practitioner E's untimed evaluation showed (in part) that Patient # 13 complained of back pain and had taken 2 - 3 aspirin tablets at a time, every couple of hours throughout the day for the pain. Further documentation showed, "He has a laceration in his right wrist that happened yesterday from a knife in a dish drainer." "Pt (patient) denies intentional overdose of ASA (aspirin) or suicidal ideation." The medical record did not contain evidence that ED Nurse Practitioner E performed a mental health exam to determine the patient's current state of mind, attitude, behavior, mood, affect, thought process, insight or judgment, or a description of the number of ASA tablets ingested, the time period of ingestion, or evidence of direct consultation with Poison Control for assistance in treating Patient # 13's ASA overdose.
- ED Nurse Practitioner E documented the patient's right wrist laceration was 4 centimeters (1.6 inches) long and required 4 stitches. Nurse Practitioner E ordered lab work including a CBC (complete blood count), CMP (comprehensive metabolic panel), Urine Analysis, and a Urine Drug of Abuse Screen. An Aspirin level was obtained but sent to an outside laboratory for analysis. At 7:07 PM the complete blood count revealed Patient # 13 was dehydrated (high concentration of white and red blood cells, and platelets). A repeat test at 7:40 PM revealed little change. At 8:30 PM the patient received 1 liter of intravenous fluids without follow up blood testing. The medical record did not contain evidence the patient received urine alkalinization (intravenous administration of sodium bicarbonate) to enhance excretion of salicylate (additive in aspirin) or that the amount of his urine was monitored as recommended in Poison Control's standard treatment outline for ASA Overdose.
- ED Nurse Practitioner E, noted "Patient refused hospitalization " and that he was "discharged " at 9:45 PM in "stable" condition. The medical record did not contain evidence that the patient was stable or that ED Nurse Practitioner E explained the risks of refusing hospitalization , or the seriousness of the abnormal lab results or discussed transfer to another hospital capable of providing a higher level of care, or that Patient # 13 signed a form indicating he understood the risks of leaving prior to stabilization.
-ED Nurse Practitioner E diagnosed Patient # 13 with a urinary tract infection, Leukocytosis (elevated white blood cell count), back pain, laceration to the right wrist area, accidental ingestion of Aspirin, and dehydration.

-During an interview on 2/23/12 at 7:30 PM ED Nurse Practitioner E stated that the patient refused hospitalization and that she did not request that he complete a leaving "Against Medical Advice" form because she knew he had refused to sign the form during a visit earlier that day.

-Further review of the medical record revealed the hospital received the Salicylate level blood test results on 11/21/11 at 4:01 PM which indicated a level of 94 mg/dl. The report indicated a value greater than 30 mg/dl was considered "Toxic."