Amberwell Atchison Association

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51768 Based on document review, video review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure compliance with the Emergency Medical Treatment and Labor Act (EMTALA). Failure to comply with EMTALA guidelines increases patients’ risk of harm. Findings Include: The critical access hospital failed to ensure a patient presenting to the emergency department were listed on the central log. (Refer to Tag A-2405) The critical access hospital failed to ensure a patient presenting to the emergency department received a medical screening exam (MSE) within the capabilities of the hospital’s emergency department (ED). (Refer to Tag A-2506)”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 51768 Based on document review, video review, and record review, the Critical Access Hospital(CAH) failed to ensure a patient presenting to the emergency department was listed on the central log. Failure to maintain an appropriate central log places patients and the hospital at risk. Findings Include: Review of an undated policy titled “EMTALA” showed that the hospital must maintain a central log of all individuals seeking emergency care. Information on the log must include a patient identifier, time of presentation, mode of arrival, and whether the patient refused or was refused treatment, transferred, admitted, or discharged. Review of a hospital document titled “Emergency Room Register” showed that Unregistered Patient 1 was not documented. The hospital failed to document Unregistered Patient 1’s arrival to the emergency department and that Unregistered Patient 1 was refused treatment. Review of a county emergency medical service (EMS) document titled “EMS [emergency medical service] AND FD TIMES 12 YO[F/M] GSW TO ABDOMIN [sic]” dated 04/16/26 showed the following radio communication timeline: 1. On 04/16/26 at 11:46 PM, County EMS was alerted that a 12-year-old female/male, Unregistered Patient 1, had suffered a gunshot wound to the abdomen and was vomiting blood. 2. On 04/17/26 at 12:16 AM, County EMS reported that they are having difficulty obtaining Unregistered Patient 1’s vitals, and Emergency Air Transportation Company suggests the patient be brought into the above-named hospital for management of low blood pressure. County EMS reported that the above-named hospital advised that “ ...there is no point to bring her inside, advised to stay where they (EMS and patient) are ...” Review of security camera video titled “Export ED 20260416” showed that the ED (Emergency Department) nurses’ station area, the area inside the ambulance entrance, and the area outside the ambulance entrance at the above-named hospital from 04/16/26 at 10:59 PM to 04/17/26 at 2:26 AM. The video showed Staff N, Emergency Medical Doctor (MD), accessing the emergency medical radio equipment while talking on 04/17/26 at 12:06 AM and talking on the telephone on 04/16/26 at 11:56 PM, and on 04/17/26 at 12:07 AM and 12:12 AM. On 04/17/26 at 12:11 AM, the video showed an ambulance with emergency lights activated pulling into the parking lot and stopping in the driveway that leads to the ambulance entrance. On 04/17/26 at 12:19 AM, the video showed Staff N walking off camera, toward the ambulance entrance, and EMS Staff A entering the ED through the ambulance entrance, stopping and backing up into the doorway. The video showed EMS Staff A talking and gestured toward the ambulance for approximately 25 seconds before EMS Staff A exited the emergency department, returned to the ambulance, and Staff N walked back into camera view, away from the ambulance entrance. The provided video did not include audio recordings. The provided video did not show Unregistered Patient 1 being assessed or provided medical care by any staff from the above-named hospital, either inside or outside of the facility.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 51768 Based on document review, video review, record review, and interview, the critical access hospital failed to ensure a patient presenting to the emergency department received a medical screening exam (MSE) within the capabilities of the hospital’s emergency department (ED). This failure has the potential to result in an untreated emergency medical condition (EMC), leading to patient harm. Findings Include: Review of an undated policy titled “EMTALA” showed that all persons presenting to the hospital or hospital property requesting emergency services or presenting with a reasonably inferred medical condition will receive an appropriate medical screening examination (MSE) within the hospital’s capability to determine whether or not an emergency medical condition (EMC) exists. If an emergency medical condition is found to exist, the hospital will stabilize or transfer the patient. An MSE, at minimum, must include a brief patient history and physical examination, but may include the need for further diagnostic and procedural interventions to determine if an EMC exists. A physician may authorize a transfer of a patient with an EMC when the physician has certified that the medical benefits to be received at another hospital outweigh the increased risk to the patient. Review of an email from Staff B, Chief Operations Officer, dated 04/23/26 at 4:23 PM, showed the hospital did not have a dedicated policy on hospital diversion or trauma. Review of a county emergency medical service (EMS) document titled “EMS AND FD TIMES 12 YO[F/M] GSW TO ABDOMIN [sic]” dated 04/16/26 showed the following radio communication timeline: 1. On 04/16/26 at 11:46 PM, County EMS was alerted that a 12-year-old, Unregistered Patient 1, had suffered a gunshot wound to the abdomen and was vomiting blood. 2. On 04/16/26 at 11:59 PM, County EMS contacted Emergency Air Transport Company. 3. On 04/17/26 at 12:03 AM, Emergency Air Transportation Company accepted the transfer and advised that the estimated time of arrival at the above-named hospital’s helicopter pad would be 34 minutes. 4. On 04/17/26 at 12:07 AM, Staff N, Emergency Department Medical Doctor (MD), contacted County EMS and refused to accept Unregistered Patient 1. Staff N is reported to state they (the above-named hospital) “ ...HAVE NOTHING TO OFFER THIS PATIENT ...” 5. On 04/17/26 at 12:11 AM, County EMS arrived at the above-named hospital’s property. 6. On 04/17/26 at 12:16 AM, County EMS reported that they were having difficulty obtaining Unregistered Patient 1’s vitals, and Emergency Air Transportation Company suggested the patient be taken into the above-named hospital for management of low blood pressure. County EMS reported that the above-named hospital advised “ ...there is no point to bring [him/her] inside, advised to stay where [County EMS] are ...” Emergency Air Transportation Company asked if County EMS had Tranexamic Acid (TXA, a medication to prevent excessive bleeding), and County EMS reported they did not have any available. Review of a County EMS document titled “ACEMS Incident Report Form” signed by EMS Staff A, dated 04/16/26, showed that EMS Staff A sent a radio transmission to the above-named hospital to advise them that the County EMS ambulance was bringing a child there due to a gunshot wound (GSW) to the abdomen and that the child needed stabilization until air medical transport could arrive. When the County EMS ambulance was near the above-named hospital, they received a transmission from the hospital instructing them not to bring the patient there. The patient was declining rapidly, going into shock, and required interventions that were not available on the County EMS ambulance. The Emergency Air Transportation Company crew recommended that the County EMS crew take the patient to the above-named hospital for stabilization. County EMS staff approached the ED to ask for assistance, but the ED provider stood in the doorway, blocking entry. A County EMS staff member stated,” ...will no one help us with the [12 year old female/male] whos bleeding out?!...” ED replied that there was nothing the hospital could do that County EMS had not already done. EMS Staff A reported asking the ED provider if [he/she] was serious, and “ ...if [he/she] was refusing to help...” EMS Staff A reported that the ED provider did not answer the question, and just kept asking “ ...what could they do?...” EMS Staff A returned to the ambulance. Review of a County EMS document titled “ACEMS Incident Report Form” signed by EMS Staff B, dated 04/17/26, showed that Staff N was reported to say “ ...There is nothing that we can do that you guys [County EMS] can’t already do ...” Once the Emergency Air Transportation Company staff arrived on scene, they began supporting County EMS. Emergency Air Transportation Company staff administered TXA, blood products, and performed rapid sequence intubation on Unregistered Patient 1. Review of an Emergency Air Transportation Company document titled “GSW Event Notes from [Emergency Air Transportation Company] Crew” dated 04/22/26 showed that Emergency Air Transportation Company Staff A provided a written statement that the County EMS team had been unable to obtain the patient’s vital signs and did not have TXA to administer to the patient. The document showed that Emergency Air Transportation Company Staff A reported recommending that the County EMS team take the patient into the hospital, and that County EMS radioed that the hospital told them, “there is no point to come inside with the patient.” Review of security camera video titled “Export ED 20260416” showed the ED nurses’ station area, the area inside the ambulance entrance, and the area outside the ambulance entrance at the above-named hospital from 04/16/26 at 10:59 PM to 04/17/26 at 2:26 AM. The video showed Staff N utilizing the emergency medical radio equipment while talking on 04/17/26 at 12:06 AM and talking on the telephone on 04/16/26 at 11:56 PM, and on 04/17/26 at 12:07 AM and 12:12 AM. On 04/17/26 at 12:11 AM, the video showed an ambulance with emergency lights activated pulling into the parking lot and stopping in the driveway that leads to the ambulance entrance. On 04/17/26 at 12:19 AM, the video showed Staff N walking off camera, toward the ambulance entrance, and EMS Staff A entering the ED through the ambulance entrance, stopping and backing up into the doorway. The video showed EMS Staff A talking and gestured toward the ambulance for approximately 25 seconds before EMS Staff A exited the emergency department, returned to the ambulance, and Staff N walked back into camera view, away from the ambulance entrance. The provided video did not include audio recordings. The provided video did not show Unregistered Patient 1 being assessed or provided medical care by any staff from the above-named hospital, either inside or outside of the facility. Review of a document titled “[Above Named Hospital] *Live* - LAB BBK UNIT LOCATION LIST,” Dated 04/28/26 at 10:47 AM, showed the hospital had available packed red blood cells (PRBCs) on 04/17/26, including: Three (3) O- products, four (4) O+ products, and one (1) B+ product. Review of a document titled “Omni Inventory,” dated 04/23/26 at 1:48 PM, showed the hospital maintains six (6) vials of TXA onsite. Review of Unregistered Patient 1’s medical record from Children’s Hospital 1, dated 04/17/26, showed that while en route, Unregistered Patient 1 had multiple episodes of hematemesis (vomiting of blood), required intubation for airway protection and had multiple episodes of hypotension (low blood pressure) requiring treatment with fluids, 1 unit of packed red blood cells, phenylephrine (a medication that treats low blood pressure) and TXA. Upon arrival, Unregistered Patient 1’s medical record showed the patient required laboratory tests, an ultrasound (a test that uses sound waves to create images of structures within the body), X-ray, and computed tomography (CT) of the abdomen, which showed the need for immediate trauma and surgical intervention. Unregistered Patient 1 was diagnosed with extensive retroperitoneal hemorrhage (the accumulation of blood in an abdominal space) with injuries to the pancreas, small intestine, and spine, causing extravasation (leaking and accumulation of fluids into the body tissue), decreased blood perfusion (passage of blood through the circulatory system to organs or tissues), and cortical fragmentation (small pieces of the vertebrae breaking off). During an interview on 04/28/26 at 8:15 AM, Staff N, Emergency MD, stated that the hospital didn’t have a formal record for Unregistered Patient 1, because they weren’t formally involved with the patient’s care. Staff N stated that the ED team heard a broadcast from dispatch about a 12-year-old patient with a gunshot wound and realized that the hospital could potentially be involved in that case. Staff N reported reaching out to dispatch to discuss how that patient should be handled and strongly encouraged the dispatch operator to send the patient to a level 1 trauma center. Staff N stated that the County EMS ambulance brought Unregistered Patient 1 to the hospital to meet the Emergency Air Transportation service for transport to a trauma center. After waiting in the hospital parking lot for Emergency Air Transportation for approximately 10 minutes, a County EMS team member approached the door and said, “I have this little [boy/girl] bleeding out.” Staff N stated that the County EMS service had been unable to obtain vital signs, which was concerning. Staff N stated that it sounded like the patient needed blood and fluids, and that if the County EMS had those things, the hospital didn’t have much else to offer. Staff N denied being provided enough objective medical information by the County EMS team member to assess if the patient was stable or unstable before that team member returned to the ambulance. Staff N stated that Emergency Air Transportation was about 8 minutes away, and [he/she] believed the patient was hemodynamically stable, so [he/she] determined it was prudent to allow the County EMS to complete the transfer process. Staff N stated that bringing Unregistered Patient 1 inside the hospital could have delayed the patient’s transport to a level 1 trauma center. Staff N stated that if a patient had arrived to the ED by private vehicle with a gunshot wound to the abdomen, the patient’s care likely would have include a primary and secondary survey, starting 2 large bore IVs, having 1 or 2 units of PRBCs ready to infuse if needed, have IV fluids ready to give, and possibly a FAST (Focused Assessment with Sonography for Trauma) exam. If the patient was stable and without free fluid in the abdomen, the hospital might be able to continue monitoring them; if not, they would initiate a transfer as soon as possible. During an interview on 04/29/26 at 9:10 AM, EMS Staff A, Emergency Medical Technician (EMT), stated that the ambulance received a radio call from the above-named hospital that stated, “Do not bring them here. Do not bring the patient in.” while on the way to the hospital with Unregistered Patient 1, an unstable pediatric patient with a gunshot wound to the abdomen. EMS Staff A stated that a medical helicopter from an Emergency Air Transportation Company was en route to the above-named hospital and instructed the County EMS ambulance to take Unregistered Patient 1 into the hospital because the patient was unstable, and County EMS did not have TXA. EMS Staff A reported leaving Unregistered Patient 1 in the ambulance with the remaining County EMS team members and approached the hospital’s ambulance entrance, where Staff N stood in the doorway and said, “Stop. You cannot bring [him/her] in.” EMS Staff A reported saying to the Staff N and the ED staff present, “Will no one help us? There is a 12-year-old [boy/girl] bleeding out in your parking lot.” EMS Staff A stated that Staff N’s reply was, “There is nothing we can do that you haven’t done.” EMS Staff A reported asking Staff N whether they were kidding and repeatedly trying to confirm whether they were refusing to take the patient. EMS Staff A stated that Staff N would not answer the question about refusing to take the patient and only responded by asking EMS Staff A what the ED could do that County EMS could not. EMS Staff A reported saying, “Copy, you are refusing. Got it.” to Staff N and returned to the ambulance. During an interview on 04/23/26 at 12:47 PM, Staff J, Registered Nurse (RN), stated that on 04/17/26, Staff N contacted dispatch and advised EMS not to bring Unregistered Patient 1 to the hospital, and instead advised to use medical air transportation. Staff J stated that a County EMS staff member entered the ED and communicated to the ED staff, “We have a child bleeding out, we don’t know what to do.” Staff J stated that Staff N responded to the County EMS staff, asking about Unregistered Patient 1’s vitals. Staff N then told the County EMS staff that an Emergency Air Transportation helicopter was close and Unregistered Patient 1 needed to go to a trauma center. Staff J confirmed that the Unregistered Patient 1 was not brought into the hospital, and Staff N did not perform an examination. During an interview on 04/27/26 at 2:14 PM, Staff H, RN, reported witnessing Staff N call dispatch twice to tell them not to bring Unregistered Patient 1 to the above-named hospital, and that during the second call, Staff N also told dispatch, “we won’t bring them in.” Staff H reported that an EMT entered the ED, and Staff N told them, “Don’t bring the patient in. I don’t have anything to offer them.” Staff H stated that Staff N told the EMT to just follow their protocols. During an interview on 04/23/26 at 1:03 PM, Staff K, House Supervisor, stated they were notified by an ER nurse shortly before midnight regarding an incoming 12-year-old patient. The nurse advised that Emergency Air Transportation Company had been requested by County EMS and that Staff N had recommended air transport. Staff N stated that the patient should not be brought into our facility, indicating that we are not a trauma center and are not equipped to manage the patient. County EMS later called a Code Red. Staff N spoke directly with dispatch and instructed them not to bring the patient into the hospital. Staff N stated that the hospital was not equipped and did not have radiology available. Staff N advised County EMS to wait outside for the helicopter. EMS Staff A asked how to proceed since the patient was not to be brought inside. Staff N asked County EMS about the patient’s stability, airway status, and condition. Staff N instructed County EMS to use their skills and that there was nothing the hospital could do inside the facility that County EMS could not do outside. Personnel suggested TXA, and County EMS indicated they did not have it available. Staff N was the only individual who communicated directly with County EMS and dispatch regarding not bringing the patient into the facility. During an interview on 04/28/26 at 10:33 AM, Staff E, Emergency Department Medical Director, stated the expectations for a trauma patient requesting to be seen would be to bring the patient into the ER (emergency room). Staff E stated, “Me personally, if I had a patient with a gunshot wound, I don’t know what’s going on in the back of an ambulance; I can’t see that. I want the patient in the ED. You don’t turn the patient away. You need more than vital signs, theoretically, to determine if a patient is stable. Laying eyes on a patient is important.” Staff E reported considering a patient described by County EMS as “bleeding out” to be a patient experiencing an EMC and would constitute a request for help. Staff E reported wanting patients like that inside the ED. Staff E stated that “If at any point, EMS had a patient that is decompensating, even if it is a stand-alone ER with one bed, that is still better than an ambulance.” Staff E stated that transfers always carry the risk of delaying care, but noted that the hospital has a history of quickly executing emergency transfers.”