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Based on interviews, document review, and in the course of a complaint investigation, it was determined that the facility staff failed to comply with the special responsibilities of Medicare hospitals in emergency cases. The facility staff failed to provide evidence of appropriate medical screening examinations for 3 of 30 patients (Patient #21, Patient #27, and Patient #10); and the facility staff failed to ensure 1 of 30 patients (Patient #21) presenting to the emergency department was included on the emergency department log.

The findings include:

Review of Patient #21's 'Prehospital Care Report' completed by ambulance crew members revealed Patient #21 was transported to the critical access hospital (CAH) named in this complaint on 7/14/14. CAH staff members went to the ambulance and informed the ambulance crew members that the CAH was on diversion due to the CT scanner being down and that Patient #21 should be transported somewhere else. While the ambulance crew was waiting on an additional crew member with advanced training, the CAH's RN (registered nurse) and ED Tech (technician) entered the ambulance; the CAH's RN started an IV (intravenous access) on Patient #21 and collect blood samples from Patient #21. The CAH failed to provide an appropriate medical screening examination prior to the patient leaving the facility's campus.

Review of Patient #27's and Patient #10's emergency department clinical records failed to reveal documentation of medical screening exams by the healthcare provider.

As part of the complaint investigation, surveyors requested the Emergency Department (ED) Central Log. The ED Central Log contained no evidence the patient named in the complaint (Patient #21) presented to the ED on 7/14/14.

Please refer to deficiencies cited in this report under §489.20(r)(3) and §489.24(a) for additional information.

Based on interviews, document review, and in the course of a complaint investigation, it was determined the facility staff failed to include on the emergency department central log 1 of 30 patients in the survey sample (Patient #21), who presented to the critical access hospital (CAH) for emergency care.

The findings include:

Patient #21 was not found listed on the emergency department central patient log. Information related to Patient #21's visit referenced in this complaint was found in the personnel file of a registered nurse who had contact with Patient #21 when the patient presented to the CAH via ambulance on the evening of 7/14/14.

The following information was found in the 'Prehospital Care Report' documentation by ambulance crew members providing care for Patient #21 on 7/14/14: "(ambulance) dispatched ... for a (patient identifying information omitted) pt (patient) that had fallen and possibly hit (his/her) head. ... Started transport to (CAH name omitted). ... Called report to (CAH name omitted) ER via radio. ... Arrived at (CAH name omitted) ER. Was greeted by RN-(name omitted) and ED-TECH (name omitted) and RN-(name omitted) stated that (doctor's name omitted) advised that scan was down so EMS need to go elsewhere ... "

The following was found in the written statement of the Registered Nurse (RN #1) who boarded the ambulance and started an IV on Patient #21: "This letter is in reference to the incident that occurred on 7/14/14 regarding a (patient) that was taken to (town/city name omitted). Just before 2300 (11:00pm) on 7/14/14, (ambulance name omitted) called in a pt (patient) report for a (gender omitted) (patient) that had fallen and had an altered mental status. At this time, our CT scanner was down. (Emergency Department (ED) Staff Member #1's and ED Technician (Tech) #1's names omitted) and myself were present in the ED (emergency department). Upon receiving pt (patient) report, I called (doctor's name omitted) in the Doctor's Lounge to alert (him/her) of a pt (patient) report and the possibility of said patient needing a CT. (He/She) instructed me to divert EMS (emergency medical services). I wasn't sure if I should divert EMS, or if (he/she) needed to speak with them. I asked (ED Staff Member #1) and (he/she) was unsure, so I called back to the Doctor's Lounge. (Doctor's name omitted) told me to divert them, and if (he/she) needed to speak with them, (he/she) would. By this time, EMS was pulling in to the hospital, so I had no time to contact them via radio. Myself and (ED Tech #1) went outside to meet the ambulance. When they pulled up to the ED, I alerted the driver to roll down his window and informed (him/her) we were going to have to divert because our CT was down and (doctor's name omitted) said to divert. After telling (him/her) this, (he/she) told me to tell the crew in the back. At this time, myself and (ED Tech #1) boarded the ambulance. On the truck were two attendants, (two ambulance crew member names omitted), last names unknown. I proceeded to inform them that (doctor's name omitted) had instructed us to divert the ambulance use [sic] to CT being down. ... (a third ambulance crew member - name omitted) boarded the ambulance and asked (ED Tech #1) why we were diverting and whom gave permission to divert. (ED Tech #1) informed (the third ambulance crew member) (doctor's name omitted) because the scanner was down. (ED Tech #1) and I stepped off the ambulance and went back inside the ED."

The following was the written statement of the CAH's ED (emergency department) physician: "... I received a call from the RN, (RN's name omitted), that there was a call out for an AMS (altered mental status) that would likely require a CT scan, she asked if we should divert, I said yes let them know, as we did not have CT scan available and if there was any problem let me know. After my shift was over I was at my clinic, after 9am, I received a call concerning the above event. I was surprised find [sic] out that the AMS patient was brought to (CAH's name omitted), my facility, and I was not notified of their arrival or departure."

Review of CAH #1 emergency department central log failed to include Patient #21's presentation to the emergency department on 7/14/14.

Based on interviews, document review, and in the course of a complaint investigation, it was determined the facility staff failed to perform and/or document evidence of a medical screening exam for 3 of 30 patients in the survey sample (Patient #21, Patient #27, and Patient #10), who presented to the critical access hospital (CAH) for treatment in the emergency department.

The findings include:

1. Patient #21 arrived at the critical access hospital (CAH) on 7/14/14, via ambulance. The patient was subsequently transferred to a second hospital, without receiving a medical screening exam (MSE) while on the property of the CAH.

The following information was found in the 'Prehospital Care Report' documentation by ambulance crew members providing care for Patient #21 on 7/14/14: "(ambulance) dispatched ... for a (patient identifying information omitted) pt (patient) that had fallen and possibly hit (his/her) head. Arrived on scene and found a (gender omitted) pt laying on (his/her) right side in the fetal position with a pillow under (his/her) head. Asked pt how (he/she) was doing and pt stated fine. Asked pt did (he/she) hurt anywhere and pt stated no. ... Asked pt what was todays [sic] date and pt stated Tuesday 1914. ... Started transport to (CAH's name omitted). O2 states [sic] was reading 58% (at) (room air). (Pt fingernails was covered in dirt) Placed pt onto 15 L (liters) of O2 (oxygen) via nonrebreather. Called report to (CAH's name omitted) ER via radio. While enroute [sic] to (CAH's name omitted) Er [sic], placed 12 Lead ECG pads. Arrived at (CAH's name omitted) ER. Was greeted by RN-(name omitted) and ED-TECH (name omitted) and RN-(name omitted) stated that (doctor's name omitted) advised that scan was down so EMS need to go elsewhere. ... Contacted EMT-I (name omitted) via cell phone and advised (him/her) of our situation. (EMT-I's name omitted) advised that (he/she) would be enroute [sic]. While waiting on (EMT-I's name omitted) arrival, RN-(name omitted) started a 16 G (gauge) IV in the left forearm. (RN's name omitted) obtained a blood drawl. (EMT-I's name omitted) arrived at (CAH's name omitted) Er [sic] and boarded truck. Gave report to EMT-I and released pt care to (EMT-I's name omitted). EMT-I (name omitted), I was contacted by EMT (name omitted) at home. (He/She) advised that they were sitting in the parking lot at (CAH's name omitted) ER and that (doctor's name omitted) had sent (his/her) nurse and tech out and told them they needed to divert to another facility because the CT sca [sic] was down. (He/She) advised me that (he/she) felt (he/she) had a possibly critical (patient) and had gone to the nearest facility but they werent [sic] going to take the (patient) and (he/she) was not comfortable transporting elsewhere without ALS. ... I arrived at unit at (CAH's name omitted) about 14 minutes later. ER tech was on board unit and RN (name omitted) was in unit also. ER staff left as soon as I came aboard. Noted a 16 G (gauge)V [sic] L Forearm with fluids hanging but cut off. ... EMT (name omitted) advised that nurse had started the IV. ... Pt would respond to voice but was extremely confused. (He/She) stated the year was 1940, and that (he/she) was in (his/her) bedroom. Noted 98% on non rebreather switched her to 2L (liters) NC (nasal cannula) and O2 (oxygen saturation) stayed up. HR (heart rate) ranged from 98 to 106 NS (normal sinus) rhythm. ... Report was given to (name of final hospital to which the patient was taken to after leaving the CAH omitted) ... "

The following was the written statement of the RN who boarded the ambulance and started and IV on Patient #21: "This letter is in reference to the incident that occurred on 7/14/14 regarding a (patient) that was taken to (town/city name omitted). Just before 2300 (11:00pm) on 7/14/14, (ambulance name omitted) called in a (patient) report for a (gender omitted) (patient) that had fallen and had an altered mental status. At this time, our CT scanner was down. (Emergency Department (ED) Staff Member #1's and ED Technician (Tech) #1's names omitted) and myself were present in the ED (emergency department). Upon receiving (patient) report, I called (doctor's name omitted) in the Doctor's Lounge to alert (him/her) of a (patient) report and the possibility of said patient needing a CT. (He/She) instructed me to divert EMS (emergency medical services). I wasn't sure if I should divert EMS, or if (he/she) needed to speak with them. I asked (ED Staff Member #1) and (he/she) was unsure, so I called back to the Doctor's Lounge. (Doctor's name omitted) told me to divert them, and if (he/she) needed to speak with them, (he/she) would. By this time, EMS was pulling in to the hospital, so I had no time to contact them via radio. Myself and (ED Tech #1) went outside to meet the ambulance. When they pulled up to the ED, I alerted the driver to roll down (his/her) window and informed (him/her) we were going to have to divert because our CT was down and (doctor's name omitted) said to divert. After telling (him/her) this, (he/she) told me to tell the crew in the back. At this time, myself and (ED Tech #1) boarded the ambulance. On the truck were two attendants, (two names ambulance crew omitted), last names unknown. I proceeded to inform them that (doctor's name omitted) had instructed us to divert the ambulance use [sic] to CT being down. At that time they were performing a 12 lead EKG and repeating vital signs. They said they would have to call (a third ambulance crew member's name omitted) for ALS (advanced life support). (Ambulance crew name omitted) called (name omitted of individual being called for ALS) from his cell phone. ... I then told them that I would help (the third ambulance crew member) out by starting an IV and drawing blood. The (patient's) blood pressure was 168/88 and heart rate was 115. I remember these vital signs because they had initially stated the (patient) was hypotensive, so they repeated the blood pressure twice. About five minutes after starting the IV, (the third ambulance crew member) boarded the ambulance and asked (ED Tech #1) why we were diverting and whom gave permission to divert. (ED Tech #1) informed (the third ambulance crew member) (doctor's name omitted) because the scanner was down. (ED Tech #1) and I stepped off the ambulance and went back inside the ED."

The following was the written statement of the CAH #1's ED (emergency department) physician: "(At the start of the shift a call was placed to (individual's name omitted) and broadcast over the scanner to (county name omitted) rescue that our CT scanner was down and to divert strokes, traumas or patients that would likely need CT scan if possible.) I received a call from the RN, (RN's name omitted), that there was a call out for an AMS (altered mental status) that would likely require a CT scan, (he/she) asked if we should divert, I said yes let them know, as we did not have CT scan available and if there was any problem let me know. After my shift was over I was at my clinic, after 9am, I received a call concerning the above event. I was surprised find [sic] out that the AMS patient was brought to (CAH name omitted), my facility, and I was not notified of their arrival or departure."

2. Patient #27's documentation for an emergency department visit on 4/1/15 failed to include documentation of the provider's medical screening exam.

The emergency department central log provided to the survey team included evidence that Patient #27 presented to the emergency department on 4/1/15 and only received a medical screening exam.

A copy of an untitled form, which was found in Patient #27's emergency department documentation for the 4/1/15 visit, included the following information that was signed by a nurse practitioner (NP): "The Emergency Department physician/FNP has completed a medical screening as required by the Emergency Medical Treatment and Active Labor Act (EMTALA.) Based on this medical screening, the physician/FNP has determined that your condition is: ... Non-Urgent and does not meet the criteria of an emergency medical condition". The NP's signature was noted after the aforementioned statement but the area for a time and date to indicate when the NP signed the statement was left blank.

Patient #27's electronic medical record for an emergency department visit on 4/1/15 was reviewed with the facility's director of nursing (DON) on 5/12/15 at 4:40 PM. The electronic medical record did not contain documentation of the medical screening exam (MSE). After requesting a search of the electronic record by medical record's personnel, the DON acknowledged they were unable to find a MSE and stated, "I can't explain it."

During an interview on 5/13/15 at 9:25AM, the facility's DON reported that NP documentation of the MSE was not found.

3. Patient #10's documentation for an emergency department visit on 3/4/15 failed to include documentation of the provider's medical screening exam.

The emergency department central log provided to the survey team included evidence that Patient #10 presented to the emergency department on 3/4/15 and only received a medical screening exam.

A copy of an untitled form, which was found in Patient #10's emergency department documentation for the 3/4/15 visit, included the following information that was signed by a nurse practitioner (NP): "The Emergency Department physician/FNP has completed a medical screening as required by the Emergency Medical Treatment and Active Labor Act (EMTALA.) Based on this medical screening, the physician/FNP has determined that your condition is: ... Non-Urgent and does not meet the criteria of an emergency medical condition". The NP's signature was noted after the aforementioned statement but the area for a time and date to indicate when the NP signed the statement was left blank. No documentation of a medical screen exam was found in Patient #10's clinical record.

Patient #10's clinical record was reviewed with the facility's Director of Nursing (DON) on the afternoon of 5/12/15. The facility's DON was asked for Patient #10's medical screening exam. The DON consulted with a Medical Records employee (MR #1); MR #1 reported to the surveyor that documentation of Patient #10's medical screening exam was not found.

This is a complaint deficiency.