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Based on findings from document review and interview, the facility did not have a policy and procedure (P&P) that outlined the duties and responsibilities of a recipient hospital. The facility did not accept a patient with an emergency medical condition without prior insurance authorization. These lapses could lead to untoward patient outcomes.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "EMTALA: Emergency Medical Treatment and Active Labor Act," last revised 8/2015, indicated the facility should not refuse an individual appropriately transferred under EMTALA on the grounds that the facility does not approve of the method of transfer. The P&P does not contain any other recipient hospital responsibilities.

-- Review of Patient #1's medical record (MR) revealed, he was accepted for transfer due to an emergency medical condition, on 6/24/17 at 11:30 pm, by the Nurse Practitioner. However, the transferring facility was instructed by RMH staff that an insurance pre-authorization was required prior to transfer. (See additional findings in Tag 2411)

-- During interview of Staff A, Vice President of Clinical Services/Chief Nursing Officer on 7/19/17 at 10:30 am, he/she acknowledged the above findings.

Based on document review and interview, in 1 of 4 medical records (MRs) reviewed (Patients #1 - #4) of patients with an emergency medical condition requiring transfer to Rome Memorial Hospital (RMH) from another emergency department, the patient's transfer was delayed until insurance authorization was obtained. This delay could place patients at risk for injury and/or inadequate care.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Admissions to the Senior Behavioral Health Unit (SBHU)," last reviewed 8/2015, indicated all appropriate persons are admitted to the SBHU regardless of race, color and/or creed. The P&P does not contain information regarding recipient hospital responsibilities.

-- Review of Patient #1's MR revealed the following:

On 6/24/17 at 11:15 pm, Staff B (Charge Nurse on the SBHU) received a telephone call from Hospital A's Social Worker requesting a transfer for Patient #1. Patient #1 was accepted for admission by the Nurse Practitioner (NP) at 11:30 pm if medically cleared.

On 6/25/17 at 12:45 am, a progress note from Hospital A's ED practitioner, indicated Patient #1 was accepted and medically cleared. However, RMH requested prior authorization from the patient's insurance company. Calls were placed to the nursing supervisor, awaiting call back.

On 6/25/17 at 1:30 am, a progress note from Hospital A's ED practitioner indicated, a call was received from RMH SBHU and they could not answer the insurance question until the morning. Patient #1 had awakened suddenly, was acting very aggressive, threatening staff with fist, given intramuscular Haldol and Ativan.

On 6/25/17 at 9:30 am, Hospital A's ED practitioner was notified by the NP at RMH of the acceptance of the patient. Transfer was arranged, Patient #1 was transported by ambulance to RMH and was admitted at 12:54 pm.

On 6/25/17 at 10:58 pm, documentation by the NP at RMH indicated an 81-year-old male was transferred from Hospital A to SBHU for admission on a DCS (Director of Community Services) involuntary status. Hospital A reported the patient had increased aggressiveness towards family and had a history of dementia. Patient #1's family called 911 after concerns for increasing agitation, confusion and aggression.

-- During interview of Staff B (Charge Nurse SBHU) on 7/18/17 at 3:20 pm, he/she received a telephone call, during report to the next shift, from Hospital A regarding the transfer of a patient to their facility. He/she completed the Inquiry/Assessment form with the information that was provided by the Social Worker from the transferring facility. He/she then contacted the NP on call and provided the information. The NP agreed to accept the patient after he was medically cleared. He/she then informed the NP that the patient had Aetna insurance and per the list in the nurse's station, titled "Insurances that require a Pre-authorization. Any patient coming from an acute hospital unit, i.e., CPEP requires authorization," undated, pre-authorization was required. Staff A indicated that this isn't something that normally happens and he/she can't remember this occurring before. Staff A then stated the NP agreed she should obtain an insurance authorization. This information was then shared with the oncoming charge nurse to facilitate.
When Staff A returned to work the next morning (8 hours later) the patient had not been admitted to the SBHU unit. Staff A then initiated a call to the insurance company to get authorization which was approved.

-- During interview of Staff C (Charge Nurse SBHU) on 7/19/17 at 10:00 am, he/she revealed that during the shift report, Staff B indicated Patient #1 would be coming from Hospital A and the Social Worker (SW) was supposed to call back with the insurance pre-authorization. He/she was informed the patient had Aetna insurance and per the list in the nurse's station pre-authorization was required. The SW called back and explained he/she could not reach the insurance company, Staff C then told the SW he/she did not know if they could send the patient. Staff C then tried to call Staff B for direction but was unable to reach him/her. The ED practitioner from Hospital A called SBHU and explained that it was an emergent situation and the patient needed placement. Staff C explained to the provider that his/her understanding was that the facility needed insurance pre-authorization. The provider then requested to talk to the Nursing Supervisor and was given the telephone number. Staff C then contacted the Nursing Supervisor to inform her of the situation and to be sure he/she was handling it appropriately. Staff C was told to continue the process and to try to reach out to the Director of SBHU and the evening charge nurse for clarification. He/she was unable to reach either staff member for instruction. When the ED practitioner called her back, he/she explained they would have to wait until the morning to get an answer.

-- During interview of Staff D (NP SBHU) on 7/18/17 at 3:10 PM, Staff D was contacted regarding Patient #1 and agreed to accept the transfer after he was medically cleared. He/she only reviews the clinical presentation and makes the decision to admit if the criteria are met. In regards to Emergency Department (ED) admissions he/she is not involved with insurance and he/she is not sure how the facility handles it. Staff D was not aware of any insurance issues. He/she expected to be notified during the night of the patient's admission to write the orders. Staff D indicated there was a bed available on the unit.

-- During interview of Staff E (Nursing Supervisor) on 7/19/17 at 9:30 am, Staff E indicated he/she does not get involved with the admissions to the SBHU, they take care of their own admissions. He/she assists the unit if they need staff or need relief for breaks. Staff E did receive a call from the transferring facility, from a male, who did not identify himself. He/she referred him back to SBHU regarding the admission. Staff E stated the call did not send up any red flags, he/she did not feel it was urgent and no call was made to the Administrator on Duty. Staff E stated he/she does not get involved with any insurance issues. When he/she made rounds that night staff on the SBHU informed him/her that the patient would be coming in the morning.

-- During interview of Staff F (Director SBHU) on 7/18/17 at 12:35 pm, he/she indicated that if the patient meets the emergency standards of the Office of Mental Health (OMH) then they should accept the patient regardless of insurance. Nurses should not hold up an admission due to insurance. He/she indicated there are no policies related to obtaining pre-authorization prior to transfer acceptance.

-- Review of the facility's policy and procedure (P&P) titled "Nursing Admission Procedures," last reviewed 8/2015, indicated insurance pre-certification is completed by the clinician completing pre-admission assessment when necessary or by the business office during regular business hours.

-- Review of the facility's self learning module titled "2016 Mandatory Annual Education," undated, contained the following statement, EMTALA is a federal law requiring Emergency Departments (ED) to provide medical screening exams by a qualified medical provider, stabilizing treatment, and safe patient transfer to a higher level of care, if necessary, to any patient regardless of their illness or ability to pay.

-- Review of the facility's education titled "General Orientation for New Employees," dated 3/2017, contained the following information:
- Rome Memorial Hospital (RMH) must provide emergency care to any patient requesting treatment without regard to the individuals race, ethnicity, age, sex, national origin, pre-existing medical conditions or handicaps, or other disabilities, insurance status or ability to pay.
Emergency care includes:
* A medical screening exam by a qualified provider
* Stabilization of any emergency condition within the capabilities of the RMH ED
* Safe patient transfer to another healthcare facility if the physician certifies that the medical benefit out weigh the risks or RMH

-- The above educational material provided to facility staff, lacked instruction pertaining to recipient hospital responsibilities. This lack of education was confirmed by Staff A (Vice President of Clinical Services/Chief Nursing Officer) on 7/19/17 at 10:30 am.