HospitalInspections.org

Based on record reviews, policy review, dispatch log review and staff interviews the Critical Access Hospital (CAH) failed to follow their Emergency Medical Treatment and Labor Act (EMTALA) policies for 2 (Patient (P) 9, and P18 (P18 presented to ED on 3 occasions) of 20 selected Emergency Department (ED) medical records. This failed practice has the potential to cause harm or even death to all ED patients of the CAH. According to facility provided information the ED treats on average 249 patients per month.

Findings include:

See citation C2406 and C2409, that also resulted in C2400 to not be met.

A. Review of facility policy "EMTALA: Medical Screening Exam", effective 8/1/2019 revealed, Patients are to be provided written discharge instructions and discharge education detailing the proper use of any medication they are provided and the potential hazards and side-effects of the medication. Discharge instructions will contain the instructions for the plan of care. The patient will demonstrate improvement in their condition prior to discharge and that improvement will be documented. Where improvement is not achieved, it may be an indication that additional assessment or specialty care is required.
B. Review of medical records from ED-A revealed P18 presenting to the ED on 10/9/24 at 8:22 AM with complaints of shortness of breath, cough and increased oxygen needs. P18 was diagnosed with pneumonia. Discharge instructions included:
- It does appear that you have pneumonia. We have treated you with a dose of Rocephin here in the ER. I have sent a prescription for Augmentin twice daily for 5 days and azithromycin 500mg x 3 days. You may need to increase your usage of your nebulizer treatments as well as your oxygen use until this improves. You may follow-up with your primary care provider if you are not improving or if things worsen.
The medical record lacks orders that include medication, dose, route and frequency of any medication changes desired by NP-B.

Based on policy review, dispatch log review, record reviews, and staff interviews the CAH failed to provide a medical screening exam to 1 (P18B) of 18 ED patient medical records once by cancelling the CAH owned EMS for transport to the Emergecy Department (ED) and, failure to provide a complete MSE when P18B presented to the ED after requesting EMS transport again. This failed practice has the potential to cause harm or even death to all patients treated by the CAH ED. According to facility provided information the ED treats on average 249 patients per month.

Findings include:

A. Review of facility policy "EMTALA: Medical Screening Exam", effective 8/1/2019 revealed, the CAH will provide an appropriate medical screening examination (MSE) to any individual who comes to the emergency department and requests examination or treatment. The MSE must be the same on every individual presenting with comparable conditions.
B. Review of the dispatch log for CAH owned ambulance revealed, 10/9/24 at 20:34:41 (8:34 PM) incident initiated at Nursing Facility -A (NF-A). Caller advised that patient is [gender] with shortness of breath. At 20:55:53 (8:55 PM) PM (CAH) advised NF-A called them and canceled the call. Incident closed.
21:16:07 (9:16PM) NF-A called back and did want the ambulance now. 21:21:41 (9:21PM) Ambulance enroute to NF-A. Ambulance arrived at NF-A 21:22:40 (9:22 PM), 21:40:52 (9:40 PM) Ambulance enroute to ED-A and arrives to ED-A at 21:42:53 (9:42 PM).

C. Review of P19's medical records from NF-A revealed, Res (P19) was having difficulty breathing with respiratory retraction observed. Res (P19) disoriented, voiced seeing people that were not present in the room and reports having double visions. Coarse crackles auscultated to bilateral lungs; skin slightly paler than usual. Vitals: oxygen saturation (SpO2) 92% on 8liters(L) per nasal canula (NC), blood pressure (BP) 169/82, respirations (R) 21, Pulse (P) 89, temp (T) 97.4. P19's daughter was concerned with worsening condition and requested for P19 to go to the ED to be evaluated. The on-call provider for P19's primary care provider (PCP) was notified of patient status. Order received to transport P19 to CAH ED (closest facility). 911 was called by registered nurse A (RN-A) for transport to the ED. RN-A then called the CAH ED to give nurse to nurse report. RN-A was transferred to nurse practitioner B (NP-B) who stated that P19 does not need to be seen since [gender] was already there today and there was not much they could do for resident at ER. Then stated to keep him (P19) at this facility and initiate breathing treatment every 20 minutes x3 and to change prn (as needed) breathing treatment to every 2 hours. NP-B also canceled the EMT (emergency medical technician) transportation to the ER.
Breathing treatments x 2 every 20 minutes were completed. P19 continually stated [gender] shortness of breath was worsening and requested to go to ED-B (CAH facility 25 minutes away) if ED-A would not accept him. RN-A then notified ED-B and spoke with on-call provider who advised that P19's condition is urgent and needs to go to closest ED. RN-A calls ED-A and speaks with NP-B regarding P19's condition worsening and breathing treatments being ineffective. NP-B then gave the okay to transport P19 to ED-A. RN-A again called 911 to request transport to ED-A
RN-A receives call from NP-B at 2215 (10:15PM) to inform nurse that P19's condition is stable for diagnosis of pneumonia, significant COPD (chronic obstructive pulmonary disease - a condition that makes it difficult to breath) and sleep apnea. There is not much they [ED-A] could for him at the ED that this facility [NF-A] can't provide. P19 will be returning to NF-A with no new orders.
P19 returns to NF-A at 2345 (11:45 PM), vital signs on return T 97.8, P114, R22, BP 119/83 SpO2 95% on 4L. P19 vomits upon return to NF-A with continued shortness of breath and respiratory retraction noted. As needed Zofran (medication that helps with nausea) was given.
D. Review of P19's medical records from ED-A revealed, P19 admitted to ED-A via EMS 10/9/24 at 21:46 (9:46 PM) with complaints of worsening symptoms, feeling more short of breath. P19 had completed 2 breathing treatments every 20minutes prior to arrival as ordered. Initial vital signs on admit to the ED were T 97.9, R18, P77, BP 110/56, SpO2 97% on 4L/NC. NP-B arrived at the bedside for assessment at 2158 (9:58PM). Lung sounds documented as faint wheeze bilat upper lobes, bilat diminished lobes on auscultation and percussion, non-labored respiration. NP-B called NF-A at 22:24 (10:24PM) to inform that P19 would be discharged back to NF-A. NF-A will work on finding a ride for P19. NF-A arrived to pick up P19 from ED-A at 2325 (11:25PM) discharge instructions reviewed with P19 who voices understanding of instructions given. Discharge instructions included Patient continues on 4L per nasal cannula sating at 98%. This O2 sat may actually be more than what he is normally used to and could potentially tolerate his 2L per nasal cannula with rest and 4L per nasal cannula with activity which is his baseline. Patient should continue with the antibiotic and nebulizer treatments as prescribed earlier today. No further lab work or imaging was completed at this time. Patient can follow up with his PCP as needed.
The medical record lacks documentation of continued physical assessment monitoring prior to discharge.
E. During an interview on 11/20/24 at 10:55AM, Medical Doctor C (MD-C) revealed that the CAH does not have a policy that allows a provider to cancel a 911 call the ambulance should go and bring the patient to the ED.

Based on policy review, record reviews, and staff interview the CAH failed to provide stabilizing medical treatment within its capabilities to 1 (P9) of 5 transferred patients. This failed practice has the potential to cause harm or even death to all ED patients treated at the CAH. According to facility provided information the ED transfers on average 19 patients per month.

Findings include:

A. Review of facility policy "EMTALA: Emergency Treatment and Transfer Policy", effective date 8/1/2019 revealed, individuals with an emergency medical condition must be stabilized or, if the medical benefits exceed the risks, transferred to an appropriate alternative facility according to the prescribed processes.
- Alternate facility must have special or additional resources and capabilities not available at this facility.
- The provider (physician or non-physician certifying/ordering the transfer) will explain the risks and benefits of transfer to the individual.
- The individual will be treated within the capabilities available to the emergency department prior to transfer to minimize, to the extent possible, the risks of transfer.
- A physician will certify the need for transfer.
- Qualified personnel, appropriate equipment and vehicle will be utilized to effect transfer.
B. Review of ED-A's medical record revealed, P9 presented to the ED on 8/20/24 at 7:25PM with a complaint of choking on some food and now is having trouble swallowing. P9 states that [gender] was eating a piece of pork tenderloin and felt like it got stuck in [gender] throat. Attempted to drink water but was unable to swallow water. Now feels like it is stuck mid chest. Admits to having pain/difficulty breathing and is not able to swallow much saliva. Patient has been constantly spitting up saliva and phlegm. Inspiratory stridor (a sound made when breathing in that indicates a partial obstruction in the upper airway.) noted on physical exam by Physician Assistant D (PA-D). PA-D ordered a cat scan of chest high resolution without contrast (imaging test that uses a higher dose of x-rays to produce detailed images of the lungs) and Toradol 30mg (pain medication) intramuscular (IM) for pain control.
CT report revealed a dilated fluid-filled esophagus with concern for possible impacted food bolus in the mid esophagus and they are recommending endoscopy to further evaluate (the tube that goes from mouth to stomach is filled with liquid and a suspicion that a piece of food is stuck in the middle section that could be blocking the tube).
P9 did admit to feeling a little better after the Toradol. P9 thought [gender] might have coughed it up. Attempted to give P9 some fluids but P9 was still unable to swallow them.
PA-D consulted with surgeon MD-E regarding P9. The MD-E felt P9 needed to present to the ED at Acute Care Facility-D (ACF-D) as soon as possible. MD-E stated he is okay with the P9 driving themselves, noting stable vital signs. MD-E did advise that P9 not stop prior to coming. MD-E wanted alerted to when the patient would be 30 minutes out and he would meet P9 in the ED at ACF-D.
The patient transfer form was completed. The patient condition is marked as the patient may be at risk for deterioration from or during transport. The mode of transport is marked as private vehicle. P9 signed consent to transfer and refusal of ambulance transport. On P9's discharge instructions included statement: It is imperative that you go to the ED at [name of ACF-D]. Do not stop along the way. If there are any concerns during your drive continue towards the hospital and call 911.
The medical records lack documentation to attempt to treat the food bolus in the ED. Glucagon available and noted during ED tour.
C. Review of ED-A's medical record revealed, P18C presented to ED-A 10/10/24 at 6:18AM via EMS after going unresponsive at NF-A and having CPR (cardiopulmonary resuscitation) initiated prior to 911 call. Upon arrival to the ED P18C was in ROSC (return of spontaneous circulation). P18C was evaluated by NP-B and decision to transfer was made. NP-B completed the patient transfer form indicating that P20 may be at risk of deterioration from or during transport. NP-B had a physician backup of MD-F.
D. During an interview on 11/20/24 at 10:40AM, MD-C revealed that P9 did have an EMC on dismissal/transfer to ACF-D. MD-C did agree that the medical record lacked documentation of if pharmacological intervention was discussed or if it should be attempted prior to transfer.
E. During an interview on 11/20/24 at 12:40PM, MD-F revealed that NP-B did not notify her of the code or transfer of P18C that morning.