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 document review and interview it was determined that for 1 of 3 (Pt. #1) records reviewed for pronounced death in the emergency room (ER), the Critical Access Hospital failed to ensure the physician documentation was complete as required per policy.

Findings include:

1. On 04/24/19 at approximately 11:30 AM, the Critical Access Hospital policy titled, "Medical Staff Documentation" dated 12/2/17 was reviewed. The policy included, "Procedure: 1. The health record will contain information to identify the patient; justify diagnoses and treatment results of care or treatment; describe the condition of patient upon discharge; and document instructions to the patient regarding follow-up care, activity levels, and necessary medications."

2. The clinical record of Pt #1 was reviewed on 04/24/19 at approximately 9:30 AM. Pt #1 was a [AGE] year old female who was transferred by ambulance from a local nursing home to the ER on 03/12/19 at 3:57 AM, with a chief complaint of shortness of breath. Pt #1 was pronounced dead on 03/12/19 at 11:20 AM.

- The nursing notes dated 03/12/19 at 3:35 AM by Registered Nurse (RN) (E #5) included, "Physician at bed side examining patient (Pt. #1). Put on CPAP (continuous positive airway pressure) (face mask to improve oxygen saturation) per physician orders. O2sat (oxygen saturation) now 93% (percent) on CPAP, daughter at bed side."

- The emergency room physician (MD #3) notes dated 03/12/19 at 3:57 AM included, "She (Pt. #1) is an obese 97 y.o (year old) with h/o (history of) [DIAGNOSES REDACTED](twitching of heart), HTN (hypertension) and pacemaker (device enabled heart functioning). She (Pt. #1) does not usually use supplementary oxygen. She (Pt. #1) was found by the NH (nursing home) staff to have a low SaO2 (saturation of oxygen) and was sent to ER."

- The transfer record notes dated 03/12/19 at 5:17 AM by RN (E#8) included, "Pt. (Pt. #1) to (tertiary level) Hospital for higher level of care."

- The physician's assessment and certification for transfer notes dated 03/12/19 at 9:09 AM, by MD #3 included, "Pt. (Pt. #1) stable to be transferred based on availability of specialized services, facilities, availability of diagnostic equipment and personnel ..."

- The nursing notes dated 03/12/19 at 10:03 AM by RN (E #8) included, "Heart rate 70 (normal 60 -100); respiration rate 24 (normal 12-28); blood pressure 115/57 (normal 120/80); oxygen saturation 90 (normal 90-100); report given, to be transported to tertiary level Hospital by ambulance." At 10:16 AM, "Pt. (Pt. #1) out to ambulance." At 10:40 AM, "Pt. (Pt. #1) back into ER, oxygen saturation dropping to 60s (normal 90 -100); BP (blood pressure) to 53/28; doctor notified; POA (power of attorney) notified; POA with doctor (MD #3) in pts. (Pt. #1's) room."

- The physician notes (no date, no time) (MD #3) included, "This pt. (Pt. #1) had been stable on CPAP and accepted for transfer to (tertiary level) Hospital. When the transfer team finally arrived to the ER (the documentation indicated Pt. #1 was stabilized in the ER prior to planning transfer to tertiary level Hospital). The transfer team left with the patient around 10:15 AM but then called us to inform us at 10:40 AM that, they were returning the pt. (Pt. #1) because she (Pt. #1) was unstable due to her pulse ox (Oxygen saturation) and blood pressure declining. The pt. (Pt. #1) remained in the ER on CPAP. As she never regained consciousness and her blood pressure continued to gradually decline and the pts. (Pt. #1's) respiratory effort weaken and pulse ox (oxygen saturation) drop, she (Pt. #1) was pronounced deceased at 11:20 AM." The clinical record lacked documentation of physician's discussion with Pt. #1's family regarding the disconnection of CPAP.

3. On 04/25/19 at approximately 10:00 AM, an interview was conducted with the Chief Executive Officer (CEO) (E #1). Upon asking about the Physician documentation regarding CPAP removal, E #1 stated, "I would expect the physician (MD #3) documentation regarding CPAP removal, whoever had the conversation with the family, they should have documented."

4. On 04/25/19 at approximately 2:15 PM, an interview was conducted with the ER Physician (MD #3). MD #3 stated, "I do not recall exactly, probably the family members wanted the CPAP to be removed for the patient (Pt. #1). There was an active DNR (Do Not Resuscitate Advance Directive) present in the chart for this patient (Pt. #1). I do not recall documenting the discussion that I had with the family."