As an ER nurse, I often get patients from skilled facilities who did not need to come to the ER. However, I understand that the nurse responsible for sending them may have limitations on resources. Do you have an in-house physician on-call to advise you? If so, they will be a great resource for you to determine if the patient must be seen. If it is all you, things like chest pain, shortness of breath (if new and there are no breathing treatments or medications available in house), falls with unexplained cause or obvious trauma (facial contusions, shortening), SI/HI, profound mental status change (if mild consider UTI, could be handled in house if timely testing is available), and stroke-like symptoms should be seen promptly.