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.


Based on record review and policy review, the Critical Access Hospital [CAH] did not follow its policy and failed to appropriately transfer a patient (Patient # 10) with an unstable emergency to an acute care hospital out of 20 sampled emergency department patients selected from July to December 2011.

Findings are:

Review of the CAH's policy titled Transfer Policy and Emergency Care, with review date of 6/07 revealed the purpose of the policy was to "provide life saving measures and implement emergency procedures that will minimize further compromise of the condition of any individual."
The policy included:
2. Definition of Emergency Medical Condition as "an acute medical condition that, without immediate medical attention, could reasonably be expected to result in serious jeopardy to the health of an individual ..."
3. Stabilization "is defined to mean no material deterioration of the condition is likely, within reasonable medical probability to result from, or occur during a transfer. Stabilization refers to treatment of the emergency, not treatment of the underlying medical condition."
4. Transfer "If a critical individual must be transferred, Cozad Community Hospital will provide medical treatment to minimize the risk of transfer....The physician will identify to the individual the risks and benefits of transfer, and certify the need for transfer."
7. Appropriate Transfer "An appropriate transfer is one in which:
a) certification is signed by a physician
b) arrangements are made previously with the receiving hospital
c) patient will be accompanied by all required medical records and forms
d) transfer will be conducted with qualified personnel and transportation equipment, including necessary life saving or life support equipment."

Review of Medical Staff Rules and Regulations Attachment A titled Policy and Procedure for Transfer and Emergency Examination, Page 24, outlined the physician's responsibilities for arranging the transfer of a patient with an emergency. The responsibilities included certifying in the medical record the risks and benefits of transfer, contacting the receiving hospital (physician) to confirm acceptance of the transfer and determining the appropriate mode of transportation and qualified accompanying personnel.

Review of CAH's data base information documented the hospital as a designated Level III Trauma Center and has ancillary services that include a clinical laboratory, nuclear medicine services, and diagnostic radiology services.

Review of the emergency department [ED] medical record revealed Patient # 10 (MDS) dated [DATE] at 3:20 PM. The ED nurse documented Patient # 10 arrived with law enforcement under emergency protective custody and that Patient # 10 was lethargic, confused and opened his eyes when stimulated. ED Physician B documented Patient #10 was brought in for "suicidal ideation and alcohol and suspected Phenergan overdose", had been drinking heavily and was holding a shotgun when a family member arrived home and called law enforcement. Documentation revealed Patient #10 had an irregular heart beat and an elevated blood pressure. A 12 lead EKG confirmed that Patient # 10 had an abnormal heart rhythm suggestive of injury or acute infarct (commonly known as a heart attack). At 7:25 PM Patient # 10 was discharged in police custody for transport to Hospital B. There was no evidence in the medical record that to minimize the risks of transfer, ED physician A initiated treatment of patient # 10's abnormal heart condition, or contacted poison control, or arranged transport by an ambulance with the appropriate cardiac monitoring equipment, or that he certified the medical benefits of transfer outweighed the risks. The medical record also did not contain evidence that staff contacted Hospital B to ensure it had the capacity to provide stabilizing treatment, or give report on Patient # 10's condition, or provide copies of the medical record pertaining to his emergency as required by the hospital's Medical Staff Bylaws Rules and Regulations or policies and procedures. Refer to C 2409 for more information.
Based on the Critical Access Hospital's (CAH) report, review of medical records and staff interviews, the CAH failed to appropriately transfer one patient (Patient # 10) with an unstable emergency out of 20 medical records selected for review from July 2011 to December 2011.

Findings include:

Review of the medical record revealed Patient #10 presented to the Emergency Department [ED] on 11/20/11 at 3:20 PM accompanied by sheriff deputies under "emergency protective custody" (EPC) for medical clearance prior to taking patient to Hospital B for care of his psychiatric emergency.

ED nurse RN-A documented that upon arrival, Patient #10 was lethargic, confused and opened his eyes to verbal and physical stimulation. ED Physician B examined Patient #10 and documented that while at home, the patient began drinking heavily, told a family member he took a bunch of pills, and that the family member wrestled away a shot gun when he threatened to kill himself before calling law enforcement. Further documentation revealed the family member brought an empty bottle of Phenergan (medication that makes you drowsy and should not be taken with alcohol ) that had been mostly full, 40 tablets were prescribed. Documentation indicated the family member believed that if Patient #10 had taken any of the Phenergan tablets it would have been around 1:30 PM (less than two hours prior to arrival).
ED Physician B documented that patient was brought in for "Suicidal ideation and alcohol and suspected Phenergan overdose" and patient was tachycardic (rapid heart rate) with elevated blood pressure.

ED Physician B ordered one liter of intravenous (IV) fluids, a 12 lead EKG, neurological checks, ongoing monitoring of Patient # 10's vital signs, and laboratory tests including a blood alcohol level though the results would not be available until approximately 20 hours after discharge. ED nurse RN-A documented that Patient # 10 received two liters of IV fluids, and had an abnormally elevated blood pressure (182/125, normal 120/80) from 3:20 PM until 5:10 PM (156/110) and did not document any further blood pressure checks or neurological checks, including at the time of discharge.

An EKG was performed and confirmed Patient # 10 had an abnormal heart rhythm with possible injury or an acute infarct (commonly known as a heart attack). Patient # 10 did not receive treatment for the abnormal rhythm or to protect injury to his heart.

There is no documentation of contact with Poison Control for advice related to Patient # 10's potentially toxic ingestion of alcohol combined with a possible Phenergan overdose.

Further documentation by ED nurse RN-A revealed that Patient #10 was transferred to another area of the hospital (same day surgery) time unknown. The nursing notes revealed that the ED Physician saw Patient #10 at 6:20 PM.

ED Physician B summarized in part Patient # 10's stay in the medical record documenting
"He was observed until around 6:15 PM." "This would be approximately five hours after he would have ingested the Phenergan." "He became more and more awake throughout the entire observation." At 7:25 PM the ED physician discharged Patient #10 for transport by law enforcement vehicle to Hospital B. ED physician's discharge diagnosis was "Alcohol, and Phenergan overdose."

The medical record did not contain evidence that Patient #10's emergency was stable, that ED physician B arranged an appropriate transfer, that the ED physician certified in the medical record the benefits of transfer outweighed the risks, that transport by ambulance to provide ongoing cardiac monitoring was necessary, that Hospital B had been contacted to ensure they had the capacity to stabilize Patient #10's emergency, or that any of the medical records related to Patient #10's emergency condition were sent to Hospital B.

In an interview on 12/30/2011 at 12 noon, ED Physician B said Patient #10 was brought in as an EPC after having tried to kill himself and that the Sheriff had already made arrangements for a psychiatric admission at Hospital B. ED Physician B stated that he realized he should have called the accepting doctor and given a report. ED Physician B said he examined the patient, ordered and reviewed the tests, and had come back in to re-examine him to make sure he was okay for discharge.

Review of an Inmate Medical Clearance Report shows ED Physician B signed the form on 11/20/11 at 6:13 PM, with the following checked for Patient #10, "I have examined the arrestee and find him/her acceptable for admission to the jail. I have no specific suggestions regarding care of this arrestee for the condition for which I have examined him/her." There were no other comments documented regarding the patient's condition. This document was given to the Sheriff deputies who transported Patient #10 to Hospital B.

Review of Hospital B's medical record revealed Patient #10 arrived in their ED at 8:12 PM on 11/20/11. Documentation revealed Hospital B's ED physician ordered medications to reduce Patient # 10's blood pressure, close observation of his heart rhythm, contact with the poison control center, and inpatient admission for further evaluation of the patient's cardiac (heart) status by a specialist prior to treating his psychiatric emergency.