HospitalInspections.org

Based on policy review, review of the hospital's By-laws Rules and Regulations, medical record review, observation and interview, it was determined the hospital failed to ensure the Dedicated Emergency Department (DED) provided an adequate Medical Screening Examination (MSE) within the capabilities of the hospital DED in order to determine if an emergency medical condition existed and ensure there was no delay in treatment to collect payment information for 18 of 21 (Patients #1, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21) sampled patients.

Based on hospital policy, observation and interview, it was determined the hospital failed to maintain a central log that included each individual who presented to the dedicated emergency department (DED) seeking assistance for a medical condition for 1 of 21 (Patient #21) sampled patients.

The findings included:

1. The Emergency Department's "Records" policy documented, "...it is the policy...to complete an Emergency Department record of every patient who present himself or herself for treatment, who is brought to the Emergency Department for treatment or test of any kind..."

The Emergency Department "COBRA 20 COMMANDMENTS" policy documented, "...Thou Shalt: log in every patient who presents..."

2. Review of the hospital's complaint forms revealed Patient #21 had presented to the DED on 4/5/13 seeking assistance for a medical condition.

3. Review of the hospital's central DED log for 4/5/13 revealed Patient #21's name was not on the DED log.

4. During an interview on 5/6/13 at 6:15 PM Staff #5 stated, "Yes" she was working the night a man brought in another man [Patient #21] who was vomiting. Staff #5 stated, "...I did get a name from the brother [complainant]. But the brother didn't know the date of birth or social security number, didn't have that information..."

During an interview on 5/6/13 at 5:55 PM Staff #3 stated she gets the information to complete the DED log after the patient has been triaged and sometimes after they have been discharged from the DED.

During an interview on 5/7/13 at 3:30 PM the ED Director verified Patient #21 was not on the DED log.

Based on hospital bylaws and guidelines, policy review, medical record review, complaint form review, observation and interview, it was determined the hospital failed to ensure all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition existed for 1 of 21 (Patient #21) sampled DED patients.

The findings included:

1. Review of the hospital By-laws documented, "...Every individual who presents to this facility requesting examination or treatment will receive an appropriate medical screening examination..."

2. The Emergency Department "Emergency Medical Screening" policy documented, "...Every individual who comes to [the hospital's name] Emergency Department will receive an appropriate medical screening examination..."

3. The Emergency Department "Admission of Patients To The Emergency Department" policy documented, "...[Hospital's name] will provide care to all patients who are in need. All patients who present to the Emergency Department, requesting care will be afforded triage and medical screening to determine the presence of an Emergency condition..."

4. The Emergency Department "Cobra Guidelines" policy documented, "...All patients presenting to [Hospital's name] for non-scheduled visit and seeking care must be accepted and evaluated regardless...All patients shall receive a medical screening exam that includes all necessary testing and on-call services within the capability of the Hospital to reach a diagnosis..."

5. The Emergency Department "COBRA '20 COMMANDMENTS..."documented, "...THOU SHALT: Provide a medical screening examination to every person presenting to the hospital..."

6. The Emergency Department "Patient Care Guidelines" documented, "...The Emergency Department personnel shall provide patient care to the patients entering the [Hospital's name] Emergency Department..."

7. The "Patients/Residents" complaints/grievances policy documented, "...The organization will attempt to resolve all complaints as soon as possible...complaint that is made to the facility by a patient/resident, or representative, regarding the patient's/resident's care...or issues related to the facility's compliance...If someone other than the patient/resident complains about care or treatment, contact the patient/resident and ask if this person is the authorized representative before addressing the complaint...If the patient/resident is satisfied with the care and the representative is not, then this is not a grievance..."

8. Review of the hospital's "Complaint Form" documented the Director of Service Excellence (DSE) received a call from the complainant [patient's brother] on 4/5/13 regarding Patient #21. The DSE documented on the complaint form, "...Description of Problem/Complaint...[complainant] brought him [Patient #21] to the ER [DED] last night [4/5/13]" Patient #21 "...had surgery on his throat last week and was bleeding and swallowing blood. The admission's clerk in the ER would not let him in because [complainant's name] could not give SS # [social security number]..."

The Complaint Form "Follow-Up Notes" documented, "...The admissions clerk says the complainant did not want to give any information out loud. She gave him paper to write the number on and he would not. She claims the complainant got angry at each of the questions, even name, address, and phone number...[the complainant's name] said this is not true. He did not know the information and his brother [Patient #21] was outside throwing up blood. He believes with the severity of the illness and the possibility of his brother [Patient #21] bleeding out, the clerk should have alerted a physician to assess his brother's [Patient #21] condition." The complaint form was forwarded to the admissions supervisor. There was no further documentation of an investigation of the complaint allegations.

9. Observations on 5/6/13 at 1:30 PM in the maintenance office revealed a DED video camera had recorded the DED entrance for the midnight and morning hours of 4/5/13. The Maintenance Director stated the time on the video was off by several minutes, but unsure by how much. Observations of the video revealed at 3:09 AM [video recorded time] 2 males entered the front entrance of the DED. They were the only 2 men to enter through the DED entrance during the time frame in question. Observations revealed 1 male [complainant] went in the direction towards the registration clerk area and 1 male [Patient #21] laid on a chair in the waiting area briefly, then walked towards the registration clerk area. This is where the video recording ended.

10. During a telephone interview on 5/6/13 at 3:06 PM the complainant stated to the surveyor, the hospital would not see Patient #21 because they could not verify his identity. The complainant stated a hospital nurse came into the registration office for a second but didn't say anything. The complainant stated Patient #21 "...couldn't talk because of the pain and vomiting...I was trying to give the information but didn't know it..." The complainant stated they were told by the Director the hospital DED staff "...were following protocol for the emergency department." The complainant stated he took Patient #21 to another hospital (Hospital # 2) in another State and the patient had surgery on 4/6/13 for Esophageal Varices at Hospital # 3.

11. Review of the medical records from Hospital #3 revealed the patient left the Tennessee Hospital (Hospital #1) on 4/5/13 and was driven by a relative to Hospital #2 in Oklahoma. Hospital #2 transferred the patient by ambulance to a higher level of care at Hospital #3 in Arkansas.

The DED medical records from Hospital #3 documented Patient #21 arrived at the DED by ambulance on 4/5/13 at 19:05 PM from Hospital #2. The 19:05 PM DED Physician's note documented the patient was a 48 year old male, presenting with the chief complaint of Gastrointestinal Bleed. The note documented the patient had prior episodes of Esophageal Varices and, "...Reports attempted to be seen at local ER in Tennessee...'we were refused so drove him home [the state of Oklahoma]'..." The patient was admitted as an inpatient at Hospital #3 on 4/5/13 at 21:30 PM.

The History and Physical (H & P) from Hospital #3 documented, "...a known history of esophageal varices..." and the patient had underwent bandings [a procedure to control bleeding] x 7 in the past. The H & P documented the patient reported, "...he started throwing up blood, which was initially dark, later on bright red..." on 4/5/13. The H & P documented, "...Past Medical History Includes...Hepatitis C...Liver cirrhosis...Esophageal varices...Gastritis/duodenitis..." The H & P documented the current assessment as, "...Upper gastrointestinal bleed, likely from the esophageal varices...Condition: Guarded. The patient is at high risk because of the GI bleed..."

The 4/6/13 "Operative Report" from Hospital #3 documented, "...Esophagogastroduodenoscopy...Esophageal exam revealed multiple columns of grade 2 varices with ulcerations x 2 at the old banding site...banding was not performed due to the presence of ulceration..." The recommendations were for Carafate, continue Propranolol, start Proton Pump Inhibitors and check Alpha-fetoprotein and ultrasound.

The 4/7/13 hospital discharge summary from Hospital #3 documented the diagnoses of Upper Gastrointestinal Bleed, Esophageal Varices, Ulceration at banding site and Cirrhosis with Esophageal Varices.

12. During an interview on 5/6/13 at 5:45 PM Staff #1 stated, "...When I came in the registration office, the one I believed to be the patient got up and said 'F**k this place' and walked out. I believe his brother [complainant] said something to the effect that 'he needs to stay' and then he got up and left. The registration clerk told me that she was just trying to get all his information. That's all I know"

13. During an interview on 5/6/13 at 6:15 PM Staff #5 stated, "Yes" she was working as the registration clerk the night a man [complainant] brought another man [Patient #21] who was vomiting to the DED. Staff #5 stated, "...I did get a name from the brother [complainant]. But the brother didn't know the date of birth or social security number, didn't have that information. The brother [complainant] seemed scared" When questioned if either man had used curse words, Staff #5 stated, "No" they did not say anything using curse words. Staff #5 stated the hospital supervisor told her, "...the next time just put in the information you can get and get the nurse and put them through..."

14. During an interview on 5/6/13 at 10:55 AM Staff #8, the triage Registered Nurse, stated the "clerk is supposed to get that [identification] verified...not supposed to check in unless they have ID [identification]" If the sticker doesn't match what the patient tells me, they "go back to the clerk...we'd have a problem"

15. Review of the registration clerks' personnel files revealed no documentation of training or orientation for the DED. The registration clerks also perform all the registration for all the hospital services.

During an interview on 5/6/13 at 3:30 PM the Admissions supervisor stated there was no documentation of DED training or orientation.

Based on policy review, medical record review, observation and interview, it was determined the hospital sought and obtained signed verification the patient would be responsible for payment for the provision of services prior to receiving a Medical Screening Examination (MSE) for 1 of 17 (Patients #11) patients observed. Medical record review revealed documentation of signed verifications for 15 of 17 (Patients #1, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19 and 20) patients reviewed.

The findings included:

1. The Emergency Department "Triage" policy documented, "...It is the policy of [hospital name] to provide necessary emergency treatment to all patients in need of such, regardless of ability to pay. Arrangements for payment shall at all times be secondary to the provision of emergency medical care. Under no circumstances shall initial assessment of any patient, or provision of emergency treatment to any patient be delayed in order to inquire about financial arrangements prior to initial assessment or emergency treatment, it must be made clear that the hospital will provide services regardless of ability to pay..."

2. The Emergency Department "Admissions of Patients to the Emergency Department" policy documented, "...will provide care to all patients who are in need. All patients...will be afforded triage and medical screening to determine the presence of an Emergency condition, regardless of financial condition..."

3. The Emergency Department "COBRA '20 COMMANDMENTS..."documented, "...THOU SHALT NOT: Delay the medical screening examination to secure verification or authorization from a third-party payer, nor attempt to influence the patient by drawing payer status issues to the patient's attention prior to screening..."

4. The "AGREEMENT AND CONSENT FOR TREATMENT" form documented, "...Financial Agreement: I understand the hospital account is due and payable at the time of discharge, and now assume responsibility for said payment. Payment arrangements must be made at discharge if not paid in full...I understand that if I do not pay my amount due and have a court settlement against me that I am liable for court costs and reasonable attorney fees...I understand that any health insurance policies under which I am covered are secondary payers to any existing liability policies or any other sources of payment that may or will cover expenses incurred for services and treatment...I hereby appoint the Hospital...any agent...to pursue any claims, penalties, and administrative and/or legal remedies on my behalf for collection against any responsible payer or third party liability carrier of any and all benefits due to me for the payment of charges associated with my treatment...I HEREBY UNDERSTAND AND AGREE WITH THE ABOVE STATEMENTS..."

5. Observations on 5/6/1/13 at 6:10 PM revealed an approximate 5 x 7 framed sign hanging on the wall in the DED patient registration area. The sign had black and red letters and documented, "...IMPORTANT! Please read! Patient payments" in large letters. Under the large letters were smaller letters that documented, "...>If you have insurance, any applicable co-pay is expected at the time of treatment. >If you have no insurance, a deposit of $55 will be required. If you are unable to pay this amount, you may request a charity care application here. >Treatment will be rendered in emergency situations without regard for your ability to pay."

6. Observations in the DED on 5/6/13 at 10:37 AM revealed Patient #11 presented to the DED stating her doctor sent her there because she may possibly be in labor. At the DED registration clerk area, the patient presented her identification information and signed a consent for treatment form. This process took 15 minutes.

Review of the paperwork obtained during the registration of Patient #11 revealed the following:
An "Agreement and Consent for Treatment."
A face sheet/demographic sheet that documented the patient was unemployed, had TennCare insurance and was the "Guarantor."
A copy of the patient's drivers license.
A front and back copy if the patient's BlueCare insurance card.
A TennCare Eligibility page with the print date of 5/6/13.
A Bureau of TennCare page with the print date of 5/6/13.
A Blue Cross Blue Shield of Tennessee BlueCare Eligibility page with the print date of 5/6/13.

During an interview on 5/6/13 at 10:52 AM Staff #7 (registration clerk who registered Patient #11) stated, "...I did not ask for any insurance or anything...I get a copy of ID [identification]...I used everything we have on file for her. She was just in here the 15 th of April..."

During an interview on 5/6/13 at 10:53 AM Staff #6 registration clerk stated, "we can ask for ID [identification] first...driver's license, anything with a picture ID" or "social security card" we "have to have something to verify" identification. Staff #6 stated they also get a "consent for treatment" signed during the initial registration process.

7. Medical record review for Patient #1 documented the patient presented to the DED on 3/5/13 at 9:25 AM with the complaint of "having difficulty swallowing."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

8. Medical record review for Patient #4 documented the patient presented to the DED on 4/5/13 at 20:00 PM with the complaint of "RLE [right lower extremity] wound/pain."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

9. Medical record review for Patient #5 documented the patient presented to the DED on 4/5/13 at 01:17 AM with the complaint of pain to the foot post motor vehicle collision.

The 3/20/13 triage note documented at 19:20 PM "...eloped prior to triage..."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

10. Medical record review for Patient #7 documented the patient presented to the DED on 3/20/13 at 17:39 PM with "unknown complaint."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

11. Medical record review for Patient #8 documented the patient presented to the DED on 2/25/13 at 20:45 PM with the complaint of "fall...[right] arm pain..."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

12. Medical record review for Patient #9 documented the patient presented to the DED on 4/6/13 at 13:04 PM with the complaint of increased "...confusion, friend reports trashed apartment couple days ago..."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

13. Medical record review for Patient #10 documented the patient presented to the DED on 4/5/13 at 00:17 AM with the complaint of "mouth pain..."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

14. Medical record review for Patient #12 documented the patient presented to the Dedicated Emergency Department on 5/6/13 at 09:55 AM with the complaint of "toothache."

Review of face sheet/demographics sheet revealed the registration clerk had documented the patient's name, address, phone number, birth date, employer, emergency contacts for 2 people, Guarantor and Guarantor's employer and the patient was unemployed. The face sheet/demographic sheet was dated and timed the exact time the patient presented to the DED prior to receiving a MSE.

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

15. Medical record review for Patient #13 documented the patient presented to the DED on 4/4/13 at 22:59 PM with the complaint of left lower quadrant pain.

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

16. Medical record review for Patient #14 documented the patient presented to the DED on 4/4/13 at 23:03 PM with the complaint of chest pain.

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

17. Medical record review for Patient #15 documented the patient presented to the DED on 4/4/13 at 23:30 PM with the complaint of "fall [with left] hip pain."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

18. Medical record review for Patient #16 documented the patient presented to the DED on 4/5/13 at 10:19 AM with the complaint of nausea and abdominal pain.

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

19. Medical record review for Patient #17 documented a presented to the DED on 5/5/13 at 20:56 PM with the complaint of "irregular breathing."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record. The patient was documented to have "eloped" after triage.

20. Medical record review for Patient #18 documented the patient presented to the DED on 5/5/13 at 12:17 PM with no complaint documented. The patient was documented as having "eloped."

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

21. Medical record review for Patient #19 documented the patient presented to the DED on 5/4/13 at 11:42 AM with the complaint of "pain to neck...[left] shoulder." The patient was documented as leaving Against Medical Advice.

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.

22. Medical record review for Patient #20 documented the patient presented to the DED on 5/4/13 at 15:46 PM in police custody after a motor vehicle collision.

The patient had an "AGREEMENT AND CONSENT FOR TREATMENT" form signed in the medical record.