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Based on record review and interview, the hospital failed to ensure compliance with all Emergency Medical Labor and Treatment Act (EMTALA) requirements under 42 CFR 489.20 and 42 CFR 489.24. The hospital failed to ensure that EMTALA (Emergency Medical Treatment and Labor Act) signage was posted in conspicuous places in the hospital's ED (emergency department) patient waiting areas, in 3 of 3 total waiting rooms observed (main waiting room, family waiting room and children's hospital waiting room) and in 7 of 11 patient treatment rooms observed (triage rooms 1 and 2, treatment rooms 7 and 14 and trauma rooms 1, 2 and 3) in a total of 44 hospital ED treatment rooms. The hospital failed to ensure that medical screening examinations were not delayed, in 1 of 20 patients (Patient #1) presenting to the emergency department.

Findings include:

1) The hospital failed to ensure that EMTALA (Emergency Medical Treatment and Labor Act) signage was posted in conspicuous places in the hospital's ED (emergency department) patient waiting areas, in 3 of 3 total waiting rooms observed (main waiting room, family waiting room and children's hospital waiting room) and in 7 of 11 patient treatment room observed (triage rooms 1 and 2, treatment rooms 7 and 14 and trauma rooms 1, 2 and 3) in a total of 44 hospital ED treatment rooms. (Reference A2402)

2) The hospital failed to ensure that medical screening examinations were not delayed, in 1 of 20 sampled patients (Patient #1) presenting to the emergency department. (Reference A2408)

Based on observation and interview, the hospital failed to ensure that EMTALA (Emergency Medical Treatment and Labor Act) signage was posted in conspicuous places in the hospital's ED (emergency department) patient waiting areas, in 3 of 3 total waiting rooms (main waiting room, family waiting room and children's hospital waiting room); and in 7 of 11 treatment room observations (triage rooms 1 and 2, patient treatment rooms 7 and 14 and trauma rooms 1, 2 and 3) in a total of 44 hospital ED patient treatment rooms.

Findings include:

1) During emergency department waiting room observations, on 9:20 a.m. through 9:45 a.m. on 11/16/17, the EMTALA signage was not conspicuously visible from the registration desk or for seated waiting room patients/families to the right of the registration desk. There was no observed EMTALA signage found in the children's waiting room or the family waiting room.

2) During random observations of the emergency department's patient treatment rooms on 9:20 a.m. through 9:45 a.m. on 11/16/17, there was no EMTALA signage observed in the following rooms:
-triage rooms 1 and 2
-treatment rooms 7 and 14
-trauma rooms 1, 2 and 3

During interview with ED Supervisor N on 11/16/17 at 9:30 a.m., N stated that when patient care treatment rooms are open (available), the patient is brought back to the room immediately without being triaged in available triage rooms. N verified that EMTALA signage was not conspicuously visible in the main waiting area, and was not present at all in the family and children's waiting room areas and the treatment rooms observed.

Based on record review and interview, the hospital failed to ensure that medical screening examinations was not delayed, in 1 of 20 patients (Patient #1) presenting to the emergency department.

Findings include:

Patient #1's medical record review was conducted on 11/15/17 from 11 a.m. through 2:30 p.m. Patient #1's 11/9/17 at 8:03 p.m. through 11/10/17 at 3:09 a.m. ED (emergency department) medical record contained the UW (University of WI Hospitals and Clinic Authority) ED Hospital Encounter (progress and ED notes) and the transferring hospital's "Patient Information" facesheet.

The medical record review of Patient #1's UW "Hospital Encounter" dated 11/9/17 (no time given) revealed a "progress notes" written by RN B at 8:03 p.m. on 11/9/17, and stated "Child (Patient #1) with foreign object in throat...Patient can come ground...".

Continued medical record review revealed that the UW hospital was faxed a "patient information" facesheet from the transferring hospital at 8:08 p.m. on 11/9/17, which contained emergency contact, insurance, allergy, vital signs and x ray information.

The 11/9/17 UW "Hospital Encounter" revealed at 8:18 p.m. that UW RN B contacted UW ED (emergency department) Physician A with information about Patient #1.

Patient #1's "Hospital Encounter's ED Notes" revealed on 11/9/17 at 8:18 p.m. that UW Physician H placed telephone call to transferring hospital and documented "...patient is coming by ground transport to be seen by ENT and possibly go to OR (operating room) for removal...".

Patient #1's "Hospital Encounter progress note" written by UW RN C at 8:50 p.m. on 11/9/17 revealed "Access Center was notified by admissions that the patient's Illinois Medicaid coverage has not been confirmed for patient coverage at the UW Hospital. The UW Access Center contacted the referring facility at CGH (Community General Hospital in Sterling, Ill.) and informed CGH staff in the ED that the patient may not have any insurance coverage if the patient is transferred for care to the UW hospital. The CGH staff expressed understanding and stated that they would communicate the information to the CGH ED physician."

The "progress note" written by UW RN D at 11:36 p.m. on 11/9/17 revealed "received call from UW ENT (ear, nose and throat) resident, Physician E, asking when Patient #1 will arrive. Called referring facility to see if they were able to find a facility in Illinois. They stated that Rockford (hospital) had been contacted and they do not have ENT available tonight. Apparently, they call(ed) report on the patient directly to the UW ED. Stated that the ambulance that came to transport the patient to the UW did not feel comfortable transporting patient and the ED staff contacted their flight program to bring child to the UW. Explained that the patient had Illinois Medicaid and they should try to find a facility in Illinois to take the patient since the family could possibly incur the hospitalization cost. Spoke to (transferring hospital) RN E, the charge nurse at the referring facility. I explained that I would have to have administrative approval to bring patient (Patient #1) in."

The "progress note" written by UW RN D at 12:03 a.m. on 11/10/17 revealed "Called UW Access Center Manager F. Explained the situation. Patient is stable, afebrile (temperature not elevated) and not in respiratory distress. Manager F stated need to speak to UW Access Center Director G. Manager F suggested that we reiterate to the referring facility to try to locate a facility in Illinois. (Transferring hospital) charge RN E, asked if we were refusing the patient. Explained it would be better for the family if the patient could be treated in Illinois. Patient condition has not changed since original call."

The "progress note" written by UW RN D at 12:16 a.m. on 11/10/17 revealed "Called Access Center Director G. UW Director G reiterated that the patient should be admitted to an Illinois facility."

The "progress note" written by UW RN D at 12:20 a.m. 11/10/17 revealed "Spoke with UW Physician H, peds (pediatric) ED attending. Explained situation. Would like to make sure that we don't need on-call hospital administrator included in the decision making process. Spoke with Access Director G again and Director G felt that it was not necessary to contact on-call administrator."

The "progress note" written by UW RN D at 12:25 a.m. on 11/10/17 revealed "Contacted referring facility, explained that we were not refusing nor accepting patient. Please try to find a facility in Illinois. If they cannot find another facility, please have the referring MD (medical doctor) call the UW back and we will connect (CGH referring MD) with our (UW) pediatric attending physician."

Patient #1's "Hospital Encounter's ED Notes" revealed that UW RN I contacted transferring hospital on 11/10/17 at 1:40 a.m., and was told by Charge RN E that "patient was still being held at (transferring) hospital".

The "progress note" written by UW RN D at 1:49 a.m. on 11/10/17 revealed "Spoke with referring facility, they have not been able to find an Illinois facility that is able to take patient. Explained to referring facility to have referring MD call to speak with our ED attending (physician)."

The "progress note" written by UW RN D at 3:05 a.m. on 11/10/17 revealed "Contacted referring facility. Patient was sent to Lurie Children's hospital in Chicago", approximately 6 hours after UW's attending physician accepted Patient #1.

The "Hospital Encounter" dated 11/10/17 at 3:09 a.m. revealed under "Discharge Information" that "patient never arrived in ED", but at 3:09 a.m. on 11/10/17 under "Events", the "Hospital Encounter" documented "Patient departed from ED, Patient dismissed."

During interview with UW Physician A on 10/15/17 at 2:50 p.m., A stated that A received a telephone call at home from the Access Center, and was told that there was a "physician on the line" about the possible transfer of Patient #1 to UW. A stated that A told transferring hospital that patient "could come here through ED" and "accepted the patient" for transfer to the UW ED, with arrival "sometime after 10 p.m." A stated A called the hospital ENT resident (physician), who was at the hospital, to inform resident of impending transfer.

The 11/15/17 at 3:15 p.m. record review of hospital procedure "UWHC-AFCH (University of WI Health Care -American Family Children's Hospital) Access Center Standards of Practice Manual, Topic: EMTALA, revised 7/15/16" revealed "...it may be a violation of EMTALA if a ...receiving hospital delays acceptance of the transfer of an individual with an unstabilized emergency medical condition pending receipt or verification of financial information...It is NOT a violation if the receiving hospital delays acceptance of a transfer of an individual with a stabilized emergency medical condition pending receipt or verification of financial information; EMTALA protection no longer applies once a patient is stabilized." This document stated that the Access Center staff should consider the following when taking referrals or transfers: Ask the referring provider if the patient is currently stable and document this. Consider if the injury or illness is life or limb threatening in nature, if so this patient should be made a priority 1. Determine if the level of care being requested is something that the referring facility can not provide.

The 11/15/17 at 3:15 p.m. record review of hospital procedure "UWHC-AFCH (University of WI Health Care -American Family Children's Hospital) Access Center Standards of Practice Manual, Topic: Transfer process: Administrative Considerations, revised 7/8/17" revealed "Factors that are to be considered in the transfer process include but are not limited to the following: Patient Medical Condition, Priority 1: Priority 1 transfers are considered critical in nature. Critical transfers are necessary when the referring facility does not have the capacity or capability to stabilize the patient, and the benefits to the patient of the transfer outweigh the risks. Transfers should be considered a priority 1 when UW has specialized capabilities or facilities that cannot be received at the referring facility. For Priority 1 transfers, it is not appropriate to delay the transfer to obtain insurance/payment information. Priority 2: Priority two transfers are considered non-critical, the patient is in stable condition, and the transfer is not considered emergent in nature. A referral may be considered a priority 2 when that care requested is not considered specialized in nature and is not emergent or life/limb threatening. Priority 2 referrals are for services that can be received elsewhere and are not unique to UW. It is appropriate to obtain insurance verification and approval prior to acceptance for Priority 2 transfers.

During interview with RN D on 11/16/17 at 11:45 a.m., D stated that the access center's role was to link transferring physician to appropriate UW physician service, field phone calls for admission to UW and provide triage services for appropriate UW MD contact. D verified the documented information written for Patient #1 on 11/9/17 and 11/10/17 in the "hospital encounter's progress notes". D stated D spoke to the transferring hospital "3-4 times about financial issues", and stated "I did not refuse patient", but thought it "was better to treat child in Illinois rather that incur expenses". D stated that D talked to transferring hospital's RN E about stability of patient and was told that patient was "stable", and needed "emergent" care. D stated that "I know with Illinois Medicaid patients, there can be a huge out of pocket expense". D stated "admission is based on stability and whether we (UW) can take patient." D stated that Patient #1 was classified as a "P2 (priority 2)". D told of previously receiving work emails from supervisors about how to handle out-of-network patients and Illinois Medicaid patients. D stated that D was told that these out-of-network and Illinois Medicaid patients needed prior authorization before being brought into the UW ED unless they were P1 (Priority 1). D stated that D was told that "it would be better if they find a facility in Illinois", and stated "in the past we took every child, this (practice of prior authorization) started within past year". D talked about out-of-network authorization, stating "sometimes this is a challenge at night because there is no one to check out-of-network payer status". D stated "these patients can be held at other (transferring) facilities till morning when (UW) staff come in." When asked if D could identify other medical records where out-of-network patients were "held" due to authorization of out-of-network payer status. D told of not remembering any patient names, and stated "it would be almost impossible" to try to identify these patients through a patient log.

The 11/17 17 at 8:30 a.m. record review of the transferring hospital's medical record dated 11/9/17 through 11/10/ 17 for the ED stay for Patient #1 revealed an "ED progress note" written by RN J at 12:26 p.m." ... RN D from UW Madison (called) stating they were concerned about whether or not they would receive payment for their services due to patient having Illinois Medicaid. RN D stated that D did not know if Illinois Medicaid would cover the cost of the transfer. Physician note reviewed and RN D informed that (transferring) Physician K had already attempted to have patient transferred to Rockford Memorial Hospital (RMH) and RMH refused to take patient. Patient is currently stable in no respiratory distress. Physician L aware of situation, and entered a room to speak/update patient's family and flight crew on status of transfer. Health unit coordinator now attempting to transfer to another facility per Physician L".

The transferring hospital's ED stay for Patient #1, dated 11/9/17 through 11/10/17, revealed that the nursing triage status was a "4= less acutely ill patient)" at 8:37 p.m. on 11/9/17. The "ED progress note" signed by Physician K at 11/9/17 at 8:24 p.m. and by Physician L on 11/10/17 at 2:20 a.m., stating "Addendum: ...When ambulance arrived to transfer the patient to UW at Madison (WI) they (ambulance personnel) were concerned about possible decompensation (worsening of condition) so they did not feel safe transferring the patient on the ground and recommended air transport. Air transport was contacted and when they arrived and strapped the patient to the bed, we received a call from the UW in Madison who declined acceptance of the patient with recommendations on attempting to transfer the patient to a facility in Illinois for insurance purposes. We attempted Saint Francis (in) Peoria (Illinois), however they did not have a pediatric ENT Physician on-call. I contacted children's hospital in Chicago... After reviewing imaging, the patient has been accepted at the children's hospital in Chicago with accepting physician being Physician M. They are agreeable that air transport is indicated." The transferring hospital's "transfer record" revealed that Patient #1 left the transferring hospital's ED at 2:30 a.m. for Lurie Children's Hospital in Chicago, Illinois. Record review of the "physician assessment and certification form" dated 11/10/17 at 2:14 a.m. (signature illegible) revealed that Patient #1 was in "stable condition".