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Based on staff interviews, policy review, and record review, the critical access hospital (CAH) failed to follow its policy and procedures when it did not provide a Medical Screening Examination (MSE) within its capacity and capability to determine if an Emergency Medical Condition (EMC) existed for three patients (#8, #11 and #19) who presented to the emergency department seeking treatment for a medical condition. The CAH also failed to include patient #19 in its log of patients that presented to the emergency department seeking treatment for a medical condition. The CAH also failed to follow it policies and procedures when it did not properly Triage Patient #8 when Patient #8 came to the ED for treatment of a medical condition. The CAH also did not follow its policy for patients leaving against medical advice (AMA) for Patient #8. Finally, a review of the CAH's EMTALA transfer policies show that it does not not accurately reflect EMTALA requirements. Twenty four medical records from May 2018 to November 2018 were randomly selected for review during the November 16, 2018 onsite investigation.

The CAH's failures place all patients presenting to the ED at risk for deterioration and delays in receiving treatment to stabilize a potential or actual EMC. The CAH's failure to include patient # 19 in its log of patients prevented staff from being able to track whether the patient received treatment for an EMC, whether the patient refused treatment, or whether staff refused to treat the patient.

Review of policy # 1026, titled "EMTALA Transfer Policy," with an effective date of 2/11/2014 specified in part, that if "an individual (or the individuals designated representative) comes to the Hospital's emergency department (ED) requesting (or a prudent layperson observer would assume the individual would be requesting medical care and an EMC is identified, the Hospital must provide an appropriate medical screening examination (MSE)."

However, EMTALA does not require the identification of an EMC before an MSE is performed. Rather, 42 CFR 489.24 (a) requires that if a person comes to the emergency department as that term is defined under 489.24(b), then the hospital must provide a medical screening examination within its capabilities of its emergency department to determine whether or not an EMC exists.

Review of policy #1030, titled "Qualified Medical Personnel Authorized to Perform Medical Screening Examinations; Accompanying Protocols" with an effective date of 2/11/2014 specified in part that Physicians, Advanced Practice Registered Nurses and Registered Nurses are designated and qualified to perform a MSE, sufficient to determine whether or not an EMC exists. The policy specified that if a registered nurse performed the MSE, a physician is responsible for obtaining pertinent information, ordering appropriate diagnostic tests, analyzing the results and determining the patient's disposition. The policy also specified that the qualified medical personnel may not discharge or transfer a patient from the CAH to another facility until he or she has performed a MSE. Lastly, the policy specified that the hospital medical staff shall direct continuous review of medical care to ensure appropriateness of screening examinations, interventions, and patient dispositions.

The CAH did not have a policy or procedure to address information to include in the ED log of patients or how staff must maintain the ED log of patients.

Review of Policy #1096, titled "Triage," effective 1/14/2010 states, in part, that a registered nurse/paramedic will evaluate and categorize each patient upon arrival to the ED into emergent, urgent, and non-urgent categories. RN's must do the assessment. The initial evaluations shall include the patient's name and age, medication and allergies, vital signs, medical and surgical history, subjective-chief complaint, objective nursing observations, tetanus status and LMP, if applicable and weight of pediatric patients. Policy 1096 further defines non-urgent Class III situations to include minor illness and ambulatory such as cough, non productive, minor burns, sprains and strains, minor complaints of pain, and pain for over 36 hours, minor lacerations with bleeding controlled, suture removals, rechecks, medication refills, and chronic back pain without neurological deficits.

Review of Policy #1006, titled, "Patient Leaving Against Medical Advice", effective 1/4/2010, establishes the criteria for documentation of patients leaving Against Medical Advice (AMA). It states, in part, that all patients indicating the desire to leave AMA shall sign an AMA form and that the registered nurse and/or physician shall discussed with the patient and/or family, the potential complications that may occur if this patient leaves prior to the physician discharging the patient, document the patient's desire to leave AMA, conversations on potential complications, and the patient's condition prior to leaving the emergency department. Policy #1006 also requires the CAH to fill out an incident report.

A review of Patient #8's medical record shows that Patient #8 presented to the ED on 9/6/18 at 7:16 PM complaining of abdominal pain. The CAH did not take Patient #8's vitals, or review medications, allergies, and medical/surgical history. The RN did not document objective nursing observations. Patient #8 Triage Level was documented as III, non-urgent. At 8:30 PM, the record showed that staff escorted patient #8 to ED Room 2 and informed Patient #8 that the the "nurse is discharging another patient and then will return to the patient." At 9:00 PM, nearly 2 hours after presenting to the ED seeking care and 30 minutes after the patient was placed in ED Room 2, the nurse returned to the Patient #8's room and informed Patient #8 that the nurse and physician now need to attend to a critically ill patient and would return as soon as that patient is stable. Patient #8 became upset, reiterating the long wait and the complaint of stomach pain. The nurses stated to Patient #8 that the CAH has a triage process in place and sees patients in order of severity of their presenting complaints. The nurse asked Patient #8 to sign a AMA form, which Patient #8 refused. At 9:21 PM, Patient #8 left the ED without being seen and in an unknown condition. On 9/9/2018, ED physician E created an ER progress note on Patient #8's encounter from September 6, 2018, stating that the patient left AMA without being seen and that the ED was full with critical patients ED physician E also documented in Patient's 8 medicad record that ED physician E examined Patient #8.

A review of the CAH's ED log shows that on September 6 2018, the CAH ED logged a total of 10 patients for the entire day.

Patient #8 left without having received a MSE as required under EMTALA and by CAH policy #1030. Patient #8 was not properly triaged as required by CAH policy #1096. The CAH did not follow its AMA policy #1006 when it did not document the patient's desire to leave AMA, conversations on potential complications for leaving AMA, or note the patient's condition prior to leaving the emergency department. Patient #8's medical record did not contain any documentation indicating a description of the patient's pain, her pain level, the onset or duration of her pain, or any information indicating what if anything relieved her pain. The patient did not sign a form indicating she was leaving (against medical advice) or that staff explained the risks of leaving prior to performing a medical screening examination or any attempts to get the patient to stay for a MSE.

Review of the ED Log showed that Patient # 11 was 35 weeks pregnant, and presented to the ED on 9/9/18 at 1:45 AM complaining of abdominal cramps since midnight that night. An on-duty ED physician E came to the ED window to speak with the woman. The patient left the ED prior to receiving a MSE which was inconsistent with the CAH's policy # 1030.

During an interview on 11/16/18 at 8:30 AM, ED physician E stated that when pregnant patients arrived at the ED, he tells all of them that the CAH does not have the capability to perform ultrasounds. He stated he could not remember whether he told this to patient # 11 when she presented to the ED. After reviewing patient # 11's medical record, ED physician E confirmed that he had not examined patient # 11 or assessed the fetus' viability as required by the CAH's policy # 1030.

Review of Hospital B's medical record showed that patient #19 complained of a headache and nose bleed and presented to the I-70 Community Hospital ED by ambulance on 11/13/18 just prior to arriving at hospital B at 1:53 AM. Documentation in Hospital B's medical record showed that patient #19 stated he was in the I-70 Community Hospital ED on Monday morning on 11/12/18, returned on 11/12/18 at 5:00 PM, and began to re-bleed at 1:30 AM on 11/13/18 and presented to the ED once again. Further documentation showed that when EMS arrived at the I-70 ED staff did not open the doors to allow EMS to bring him into the ED for care. Further documentation showed that staff in the I-70 ED told EMS that they would need to transport patient #19 to a hospital in Columbia or Kansas City, Missouri. EMS subsequently decided to bring patient # 19 to the next closest facility [Hospital B] for evaluation of his nose bleed.

Review of the EMS report contained in Hospital B's medical record showed that patient #19 was coughing up blood while his nose was bleeding. Further documentation showed that EMS transported patient #19 to the I-70 Community Hospital's ED. En route, EMS provided report and was "advised they [I-70 Community Hospital] were on diversion" (a request which may or may not be honored by an ambulance with a patient on board that needs care). Further documentation showed that on arrival, the EMS crew started to take the patient into the ED and found the doors were locked. An EMT went around through the CAH "lobby to speak with staff about coming in." ED nurse F advised that I-70 Community Hospital was on diversion and the EMT could not come in. The EMS crew documented the patient was then transported to Hospital B for examination and treatment.

Review of I-70 Community Hospital's ED log showed no evidence that patient #19 presented to the ED at any time on 11/13/18.

During an interview on 11/15/18 at 2:03 PM, I-70 Community Hospital ED nurse F stated that on 11/13/18 at approximately 12:00 AM she received a phone call from patient # 19's wife asking for medical advice because the patient's nose had begun to re-bleed. ED nurse F stated she advised the spouse that the hospital had treated the patient for a nose bleed three times and suggested they go to a nearby hospital with a physician that specializes in ears, nose and throat (ENT). At approximately 12:50 AM, EMS contacted the ED to provide report on patient # 19. ED nurse F confirmed she referred the call to ED physician E. At approximately 1:02 AM when EMS arrived at the ED, ED nurse F confirmed that the doors were locked and that EMT G requested to bring patient # 19 in to the ED. ED nurse F stated she told EMT G "she was under the impression that EMS would 'complete the patient transfer' to an ALS ambulance (advanced life support equipped) in the parking lot" (for transport to a hospital with an ENT specialist). She did not unlock the EMS doors (in the ambulance bay to inside the ED), so EMT G left. The CAH did not follow its policies and procedures and provide patient # 19 with a MSE after he presented to the ED by ambulance.

Please refer to the 2567 for details.

Based on policy review, record review, and interview, the critical access hospital (CAH) failed to enter into the Emergency Department (ED) log one patient (#19) of 24 patients' medical records reviewed who presented to the hospital's ED seeking care, out of a sample selected from May 2018 to November 2018. This failure had the potential to affect all patients who presented to the ED.

Findings included:

1. Review of the hospital's policy, titled, "EMTALA - Medical Screening Exam and Stabilization Policy", revised 10/27/10, showed no directives for staff to include on the ED log, entry of the person's name, disposition, whether the person refused treatment, was refused treatment by the hospital, transferred, admitted, treated, stabilized, or was discharged, when they presented to the ED seeking care.

Review of the hospital's EMTALA education, revised 04/24/12, showed no directives for staff to include on the ED log, entry of the person's name, disposition, whether the person refused treatment, was refused treatment by the hospital, transferred, admitted, treated, stabilized, or was discharged, when they presented to the ED seeking care.

Review of Patient #19's Emergency Medical Service (EMS) Trip Ticket (Documentation of ambulance transfer) dated 11/13/18, showed the following:

· The patient was immediately transported to I-70 Community Hospital.
· At I-70 Community Hospital, the EMS personal took Patient #19 to the hospital's ED, and the EMS doors were locked.
· Emergency Medical Technician (EMT, EMS certification with scope of practice of basic life support) G, went to the ED's lobby, spoke with Staff F, ED Registered Nurse (RN), who advised EMT G that the ED was on diversion (notification of the hospital ED's inability to care for patients due to high volumes or high acuity of patients), and Patient #19 could not come into the ED.
· Patient #19 was placed back into the ambulance and transferred to a near-by hospital.

Review of the hospital's ED log, dated 11/13/18, showed no evidence of Patient #19's arrival to the ED, that he requested care or that he left the ED without receiving an examination.

During a telephone interview on 11/15/18 at 2:03 PM, Staff F, ED RN, stated that on 11/13/18 at approximately 1:02 AM, EMS arrived at I-70 Community Hospital ED, the EMS doors were locked, and EMT G requested to bring Patient #19 into the ED. She did not place Patient #19 on the ED log.

During an interview on 11/15/18 at 11:25 AM, Staff C, RN, stated that the only patients that were placed on the ED log were the patients that were treated in the ED.

During an interview on 11/16/18 at 9:40 AM, Staff B, Chief Nursing Officer (CNO), stated that every patient that came to the ED should be placed on the ED log.

Based on policy review, record review, observation, and interview, the critical access hospital (CAH) failed to provide a complete Medical Screening Examination (MSE) within its capacity and capability to determine if an Emergency Medical Condition (EMC) existed for three patients (#8, #11 and #19) of 24 patients who presented to the CAH's Emergency Department (ED) seeking care, out of sample selected from May 2018 to November 2018.

Findings included:

Review of the hospital's policy, titled, "EMTALA - Medical Screening Exam and Stabilization Policy", revised 10/27/10, showed that-

When an individual comes to the I-70 Community Hospital's Emergency Department (ED) and a request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe thathe individual presented with an emergency medical condition, an appropriate Medical Screening Examination (MSE) within the capabilities of the Hospital shall be performed;

An individual must receive an MSE, within the capabilities of the Hospital, to determine whether or not an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor, and whether or not the treatment is expressly for an EMC;

The hospital is obligated to perform the MSE in order to determine if an EMC exists. It is not appropriate to merely "log-in" or triage an individual with a medical condition and not provide an MSE. Triage is not equivalent to a MSE, it merely determines the order in which individuals will be seen, not the presence or absence of an EMC;

The extent of the necessary examination to determine the presence or absence of an EMC is within the discretion of the Qualified Medical Provider (QMP). However, the elements of an appropriate MSE should include log entry with disposition, triage record, ongoing recording of vital signs, oral (verbalized) history; physical exam, use of all available/necessary testing resources, discharge or transfer vital signs, and adequate documentation of all of the above; and

A MSE is required is an individual is in a ground or air ambulance on hospital property for purposes of examination or treatment in the hospital's ED.

Patient #19:

Review of Patient #19's ED medical records showed that on 11/11/18 at 4:25pm , Patient#19 presented to the ED with a complaint of a nosebleed. Patient #19 was examined, treated at the ED (Patient #19 refused packing), and discharged with instructions to, in part, return to the ED if Patient #19 experienced "another nosebleed that you cannot control. On 11/12/18 at 7:03 AM, Patient #19 returned to the ED, with a complaint that the nosebleed restarted. Patient agreed to packing and was discharged with instructions to return for new or worsening condition. On 11/12/18 at 4:00 PM, Patient #19 returned to the ED, after Patient #19 caught the packing string on his coat and yanked the packing out, which caused the bleeding to reoccur. Staff E, ED Physician repacked the nose and discharged Patient #19 at 05:15 PM. Patient #19 denied any active bleeding at time of discharge. Patient was instructed to see primary care physician for packing removal tomorrow and instructed to return for new or worsening condition.

Review of Patient #19's Emergency Medical Systems (EMS, ambulance staff) Trip Ticket (Documentation of ambulance transfer) dated 11/13/18, showed that EMS staff arrived at the scene (fire station) for a 60 year-old male with a nosebleed and coughing up blood. The patient was immediately transported to I-70 Community Hospital by ambulance. EMS staff contacted I-70 Community Hospital to give a report, when ED staff advised EMS staff that the ED was on diversion (notification of the hospital ED's inability to care for patients due to overload). EMS staff spoke with Staff E, ED Physician, and asked if Patient #19 could come into the ED and then transfer the patient by Advanced Life Support (ALS, advance training of life saving measures) ambulance. Staff E agreed to the ALS arrangement. When the ambulance arrived at the hospital, EMS staff unloaded Patient #19 from the ambulance, took him to the hospital's ED, and the EMS doors (entrance to the ED specifically for ambulance patients) doors were locked. Emergency Medical Technician (EMT, EMS certification with scope of practice of basic life support) G went to the ED lobby, spoke with Staff F, ED Registered Nurse (RN), who advised EMT G that the ED was on diversion and Patient #19 could not come into the ED. Patient #19 was placed back into the ambulance by EMS staff, and transferred to Hospital B (nearby hospital).

Review of the hospital's diversion log showed that the hospital was not on diversion on 11/13/18.

During a telephone interview on 11/15/18 at 2:20 PM, EMT G, stated that, when he arrived at the fire station (approximately eight miles from I-70 Community Hospital), they met Patient #19, and "he was choking on his own blood. He loaded Patient #19 in the ambulance and started transport of the patient to I-70 Community Hospital. He feared suctioning Patient #19, because he feared he would block Patient #19's airway (must be unobstructed in order to breathe) with a blood clot. He was a basic EMT, and the only equipment he had to protect an airway was a Combitube (plastic tube to provide an airway to facilitate breathing), which he could not use unless the patient became unconsciousness (no longer able to respond) and EMT G did not want to wait for that to happen. When patient report was provided to the CAH, EMS was informed that the ED was on diversion. He then spoke with Staff F, RN, and told her that he was transporting Patient #19 to the ED. Staff E, ED Physician, told him (during patient report) that if they stopped at I-70 Community Hospital with Patient #19, the ED would have another ambulance transfer Patient #19 to a near-by hospital's ED that had a Ear, Nose, and Throat (ENT, specially trained in treatment of ear, nose, and throat) physician. He questioned Staff E if it would be an ALS ambulance transfer, and Staff E said, "Yes, that would be a good idea." When the ambulance arrived at the ED, they unloaded Patient #19 and went to the EMS doors, but the doors were locked. He left Patient #19 with EMT J at the EMS doors, and went to the ED's lobby to tell the staff to unlock the EMS doors. Staff F told him she believed EMS would transfer the patient from their Basic Life Support (BLS, ambulance with training only on basic life saving measures) ambulance into the ALS ambulance on the hospital property, without ED staff involvement, and did not unlock the EMS doors. He was under the impression that the ED staff would stabilize Patient #19's EMC, and then arrange for an ALS ambulance transfer. He was concerned about Patient #19's unstable airway, so he took Patient #19 to another near-by hospital ED.

During a telephone interview on 12/03/18 at 2:06 PM, EMT J, stated that EMS arrived to the fire station and met Patient #19, and he was coughing up blood clots and bleeding from his nose. With the EMS capabilities of BLS, they were concerned of airway obstruction, so they decided to transport the patient to the nearest hospital. Half way (four miles) to I-70 Community Hospital ED, she called the ED to provide report on Patient #19. ED staff (Staff F RN) told her that the ED was on diversion, so EMT G took over the patient's report and said that they needed to bring Patient #19 to the hospital ED. At some point, the ED physician (Staff E) became involved with the patient's report. EMS transported Patient #19 to the ED under the impression that the ED was going to provide stabilizing treatment. When they arrived at the ED, they unloaded Patient #19 and went to the EMS doors, but the EMS doors were locked. They knocked on the doors, but did not see any staff or patients. She stayed with Patient #19 while EMT G left the EMS door area, to find ED staff and tell them to unlock the doors. EMT G returned to the EMS door area, and stated that the ED would not treat Patient #19, so they loaded Patient #19 back into the ambulance and took him to a nearby hospital. The EMS staff were concerned about Patient #19's airway, and wanted to get him stabilized, but the ED would not treat Patient #19, and did not give a reason why.

During a telephone interview on 11/15/18 at 2:45 PM, Patient #19, stated that he was treated three times at I-70 Community Hospital's ED for a nose bleed, and discharged home each time. On 11/13/18, at approximately 12:00 AM, his nose started to bleed again. His spouse called I-70 Community Hospital's ED and the nurse directed them to go to another hospital. While traveling to the near-by hospital in his personal vehicle, he could not breathe, so they pulled over at the fire station and called an ambulance. When EMS staff arrived to the fire station, he was coughing up blood clots, and had trouble breathing, so EMS transported him to I-70 Community Hospital's ED by ambulance. At the ED, EMS removed him from the ambulance and took him to the ED's EMS doors (entrance to the ED specifically for ambulance patients), which were locked. It was cold, he could not breathe, and he could hear the EMS personnel yell, "Open the doors! We need to stabilize this patient!" The ED staff did not open the EMS doors. EMS placed him back into the ambulance and took him to a near-by hospital.

During a telephone interview on 11/15/18 at 2:03 PM and continued on 12/04/18 at 8:30 AM, Staff F, ED RN, stated she received a telephone call from Patient #19's spouse on 11/13/18 at approximately 12:00 AM, asking for medical advice because Patient #19's nose had started to bleed again. She advised Patient #19's spouse that the hospital had treated Patient #19 three times for a nose bleed and suggested that they should go to a near-by hospital that had an ENT physician. No one directed her to suggest the ENT; it was through her many years of experience that she knew Patient #19 needed an ENT. On 11/13/18 at approximately 12:50 AM, EMS called the ED to provide report on Patient #19. Normally, when EMS called the ED with patient report, the ED staff would unlock the EMS doors. During report, EMS asked if the ED was refusing or diverting Patient #19, so she referred the call to Staff E, ED Physician. Staff E took over the EMS call. At approximately 1:02 AM, when EMS arrived to the ED, the EMS doors were locked, and EMT G requested to bring Patient #19 into the ED. She told EMT G that she was under the impression that EMS would complete the patient transfer to an ALS ambulance in the parking lot. She did not unlock the EMS doors, so EMT G left. She then notified Staff E, ED Physician, who was in the physician's sleeping room, that EMS had arrived to the ED with Patient #19.

Review of the hospital's diversion log showed that the hospital was not on diversion on 11/13/18.

Observation on 11/15/18 at 11:10 AM, in the ED, showed EMS doors with no key pad lock (a lock that uses number to unlock instead of a key) to unlock the door. The EMS doors had to be manually opened by ED staff.

During an interview on 11/15/18 at 11:25 AM, Staff C, RN, stated that the Emergency Medical Service (EMS, ambulance service) doors were locked at all times for safety reasons, and when EMS contacted ED staff by telephone or radio with the patient's report, the ED staff would manually unlock the EMS doors for EMS entry upon arrival.

During an interview on 11/16/18 at 10:17 AM, Staff A, Chief Executive Officer (CEO), stated that the community had a local ambulance with BLS capabilities who sometimes used the hospital's property to transfer patients into an ambulance with ALS capabilities. When this occurred on hospital property, the ED staff were not involved, and the EMS staff did not request treatment for the patient, nor request entry into the hospital's ED.

During a telephone interview on 11/15/18 at 12:50 PM, Staff E, ED Physician, stated that he spoke with EMT G on 11/13/18, when they attempted to provide a report to the hospital ED staff on Patient #19. He told EMT G that the ED had treated Patient #19 three times, and Patient #19 needed a hospital that had an ENT. He told EMT G that if they stopped with Patient #19, the ED would transfer Patient #19 to another near-by hospital. EMT G asked if they could do an ALS transfer and he said, "That was a good idea." After Staff F notified him about Patient #19, he left the physician sleep room and went to the triage area. He did not physically see or examine Patient #19, but did see the ambulance on the hospital's property and he knew that Patient #19 was in the ambulance.

Review of the ED log, dated 11/13/18 through 11/14/18, showed no evidence of Patient #19's arrival to the ED, that he requested care, or that he left the ED without receiving an examination. The ED log showed no patients presented to the ED, or received care in the ED from 11/13/18 at 11:00 PM through 11/14/18 at 5:50 PM. (At the time of Patient #19's arrival to the ED, there were no patients in the ED for treatment).

During an interview on 11/15/18 at 11:25 AM, Staff C, RN, stated that the only patients that were placed on the ED log were the patients that were treated in the ED.

Even though requested, the hospital could not provide a medical record for Patient #19 that contained adequate documentation of a physical examination, ongoing recording of vital signs, use of all necessary available testing, discharge instruction, a willingness to afford an examination and treatment, and/or documentation of written refusal including risks and benefits, or whether Patient #19 understood the risks and benefits of refusal.

Review of Patient #19's medical record from Hospital B (nearby hospital), showed that Patient #19 presented to the ED on 11/13/18 at 1:36 AM (approximately 30 minutes after leaving I-70 Community Hospital), with a chief complaint of a nose bleed. Patient #19 was treated by the ED Physician and was discharged home on 11/13/18 at 4:05 AM.

During an interview on 11/16/18 at 9:40 AM, Staff B, Chief Nursing Officer (CNO), stated that Staff F, RN, should not have given medical advice over the phone, and the ED staff should have opened the EMS doors to let Patient #19 into the ED for treatment.

During an interview on 11/16/18 at 8:45 AM, Staff H, Chief Medical Officer, stated that she had knowledge of EMTALA, and it was her understanding that anyone who presented, or presented on behalf of a person, should have received a MSE.

Patient #11:

Review of the facility's ED log showed that Patient # 11 presented to the ED with abdominal cramps, 35 weeks pregnant, on 09/09/18 at 1:45 AM. There was no patient name or date of birth obtained. Patient #11 presented to the ED window stating that she was 35 weeks pregnant and had been having abdominal pain since midnight. The patient's obstetrics (OB, a physician who delivers babies) physician was located in a nearby town. Staff E, ED Physician, spoke with the patient at the window. The patient left the facility to go to the nearby town where another hospital was located.

Review of Patient #11's medical record, dated 09/09/18, showed it did not contain adequate documentation of a physical examination, ongoing recording of vital signs, use of all necessary available testing, discharge instructions, a willingness to afford an examination and treatment, and/or documentation of written refusal including risks and benefits, or whether Patient #11 understood the risks and benefits of refusal of care.

During an interview on 11/16/18 at 8:30 AM, Staff E, ED Physician, stated that this facility had the capability to listen to fetal heart tones with a Doppler (a device that uses sound waves to pick up a baby's heart beat) and was capable of performing a pelvic exam on a pregnant female. He informed patients, when they arrive to the ED, that the facility does not have ultrasound capability. He could not recall if he informed Patient #11 of this when he talked with her at the window. After Staff E reviewed Patient # 11's medical record, he could not determine if she had an EMC. He had not performed a pelvic exam or listened to fetal heart tones on this patient.

During an interview on 11/16/18 at 9:40 AM, Staff B, CNO, stated that her expectation of staff in the ED was to triage and provide a medical exam to all pregnant women that enter the ED requesting help. The facility had the capability to check for fetal heart tones, perform pelvic exams, lab work and offer to call the patient's OB physician. Staff B added that it was inappropriate to tell the patient that the facility did not have OB ultrasound and send them away without a MSE.

Patient #8:

Review of the hospital's policy, titled, "Triage", revised 01/14/10, showed that the RN/Paramedic will evaluate and categorize each patient upon arrival to the Emergency Department into three Classes. Class I, Emergent (immediate care, life threatening). Class II, Urgent (major illness or injury, but stable). Class III, Non-Urgent (minor injury or illness and ambulatory). The initial evaluation shall include the: Patients name and age, Medications and allergies, Vital signs; Medical and surgical History, Subjective chief complaint, Objective nursing observations; and, Tetanus (bacteria that causes tightening of the muscles all over the body) immunization status and last menstrual period (LMP). In the event the RN or Paramedic is unable to do triage, a call can be placed to the ED nurse manger to assist with triage until the RN is available.

Review of Policy #1006, titled, "Patient Leaving Against Medical Advice", effective 1/4/2010, establishes the criteria for documentation of patients leaving Against Medical Advice (AMA). It states, in part, that all patients indicating the desire to leave AMA shall sign an AMA form and that the registered nurse and/or physician shall discussed with the patient and/or family, the potential complications that may occur if this patient leaves prior to the physician discharging the patient, document the patient's desire to leave AMA, conversations on potential complications, and the patient's condition prior to leaving the emergency department. Policy #1006 also requires the CAH to fill out an incident report.

Review of the facility's ED log showed that Patient #8 presented to the ED with abdominal pain on 09/06/18 at 7:16 PM.

A review of Patient #8's medical record shows that Patient #8 presented to the ED on 9/6/18 at 7:16 PM complaining of abdominal pain. The CAH did not take Patient #8's vitals, or review medications, allergies, and medical/surgical history. The RN did not document objective nursing observations. However, the CAH documented Patient #8 Triage Level as III, non-urgent. At 8:30 PM, the record showed that staff escorted patient #8 to ED Room 2 and informed the patient that the the "nurse is discharging a patient and then will return to the patient." At 9:00 PM, nearly 2 hours after presenting to the ED seeking care and 30 minutes after the patient was placed in ED Room 2, the nurse returned to the patient's room and informed Patient #8 that the nurse and physician now need to attend to a critical ill patient and would return as soon as the patient is stable. The patient became upset, reiterating the long wait and the complaint of stomach pain. The nurses stated to Patient #8 that the CAH has a triage process in place and see patients in order of severity of their presenting complaint and system. The nurse asked the patient to sign a AMA form, which the patient refused. At 9:21 PM, Patient # 8 left the ED without being seen and in an unknown condition. The Against Medical Advice (AMA) release showed no name of the person who explained the potential risks and benefits which could arise from refusal of medical care. Patient # 8 did not sign the AMA release form. On 9/9/2018, ED physician E created an ER progress note on Patient #8's encounter from September 6, 2018, stating that the patient left AMA without being seen and that the ED was full with critical patients However, ED physician E further states that ED physician E has examined the patient.

Patient #8's medical record did not contain any documentation indicating a description of the patient's pain, her pain level, the onset or duration of her pain, or any information indicating what if anything relieved her pain. The patient did not sign a form indicating she was leaving (against medical advice) or that staff explained the risks of leaving prior to performing a medical screening examination or any attempts to get the patient to stay for a MSE. Patient #8's medical record did not contain adequate documentation of a physical examination, ongoing recording of vital signs, use of all necessary available testing, discharge instructions and a willingness to afford an examination and treatment.

During an interview on 11/16/18 at 8:30 AM, Staff E, Ed Physician, stated that he did not perform a MSE on Patient #8 and had no interaction with the patient.

During an interview on 11/16/18 at 9:40 AM, Staff B, CNO, stated that her expectation of staff in the ED was to triage patients in 30 minutes or less, and that it was inappropriate to document a triage level with no assessment of vital signs, pain or medical history. Staff B added that the medical unit nurses were available to help with triage, if needed, when the ED was busy.


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