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Based on a review of the facility's central log, transfer log, incident report, medical record, interviews, and policies and procedures, it was determined that the facility failed to provide an appropriate medical screening examination for one patient (P)#1 out of 23 sampled patients. Specifically, on 1/13/24 P#1 arrived via EMS from another acute care facility for a radiology procedure to rule out a blood clot. After arrival, the staff and provider explained to P#1 that due to being a worker's compensation case, he may be billed for the ED visit. P#1 was subsequently transported back to the originating facility without being entered into the central log and did not receive a medical screening examination.

Findings:

Cross refer to A2406 as it relates to the facility's failure to ensure that an appropriate medical screening examination was conducted on P#1.

Cross refer to A2408 as it relates to the facility's failure to enter P#1 into the central log and provide an appropriate medical screening examination prior to inquiring about payor status.

Based on a review of the facility's central log, transfer log, incident report, video surveillance, interviews, and policies and procedures, it was determined that the facility failed to register one patient (P)#1 out of 23 sampled patients. Specifically, P#1 was transported via Emergency Medical Services (EMS) from facility (F)#2 to facility (F) #1's emergency department (ED) to receive radiology testing. Once in the ED, physician (MD) GG and registered nurse (RN CC) advised P#1 that there was a lack of in-house staff to conduct testing, he was returned to F#2 by EMS without being registered.

Findings included:

A review of the facility's Central Log dated November 2023 through January 2024 failed to reveal that P#1 was entered on the ED on 1/13/24.

A review of the facility's Transfer Log dated November 2023 through January 2024 revealed that the facility failed to enter P#1 as a transfer patient back to his originating facility (F#2) on 1/13/24.

A review of the incident report #564781 dated 1/13/24 revealed that P#1 arrived in the ED from F#2 via EMS for an ultrasound. The test was not performed because P#1 was not a patient in F#1 and P#1 refused to be registered in the ED because it was a workers compensation case. Patient was alert and capable of making decisions. Patient was not registered.

During a telephone interview with Charge Nurse (CN) CC on 2/6/24 at 2:45 p.m. CN CC stated that she recalled the situation when P#1 was transported from F#2 to F#1 by EMS to get an outpatient venous doppler (a diagnostic test used to check the circulation in the large veins in the legs) of his leg and that it was on the weekend. CN CC stated that an incident report had been written because P#1 had arrived on their property but was not registered. She continued to explain that in order to admit P#1 he would have to be discharged from F#2 and be admitted to F#1 and have all his blood work done all over again. She stated F#2 never called the ED and there was no RN-to-RN report therefore, no one knew about the patient coming to the ED. CN CC continued to explain that P#1 was never supposed to be an ED patient and his injury was a worker's compensation insurance claim and he would have been billed twice from two facilities for two ED visits. CN CC stated that she has received annual EMTALA training.

An interview was conducted with Emergency Department Manager (EDM) FF on 2/7/24 at 1:00 p.m. in the Risk Management conference room. EDM FF stated that she became aware of P#1 and the situation that occurred in the ED during the review of the video surveillance. EDM FF confirmed that although there may have been some confusion with P#1's arrival to F#1 he should have been registered on the ED log.

A review of the facility's policy entitled, "Emergency Medical Treatment and Labor Act (EMTALA)," Policy #11562822, last approved 4/32/22, revealed in
X. Record Keeping
A. The logs from all departments of the hospital where an individual may present for emergency medical services must contain the name of the individual seeking medical treatment and whether the individual was:
a. Was Refused treatment
b. Refused treatment
c. Was transferred
d. Was admitted and treated
e. Was stabilized and transferred
f. Discharged

Based on a review of the central log, incident report, video surveillance, medical records, interviews and policies and procedures, it was determined that the facility failed to conduct an appropriate medical screening examination (MSE) for one patient (P)#1 out of 23 sampled patients. Specifically, P#1 was transported via Emergency Medical Services (EMS) from facility (F)#2 to facility (F) #1's emergency department (ED) to receive radiology testing. Once in the ED, MD GG and RN CC advised P#1 that due to no in-house staff available to conduct testing he was returned to F#2 by EMS without having a medical screening examination.

Findings:

A review of the facility's Central Log dated November 2023 through January 2024 revealed that the facility failed to register P#1 as a patient on 1/13/24 and therefore a medical record was not created.

A review of the description of incident report #564781 dated 1/13/24 revealed that P#1 was sent to F#2 from F#2's ED for an outpatient vascular ultrasound of his leg. This was not an ED-to-ED transfer. Was informed by vascular ultrasound tech that this patient's order would need to go through central scheduling and could not be performed until Monday since patient was not an ED patient of F#1 MD GG was notified. MD GG spoke to physician at F#2 and P#1 was sent back to F#2 for further treatment. Patient refused to be seen in F#1 ED due to it being worker's compensation and not wanting a secondary ED visit and/or bill. Patient was alert and oriented and able to make appropriate decisions.

A review of the facility's video surveillance dated 1/13/24 revealed the following:

Video #1
Video Time Stamp 01:59 P#1 enters ED on EMS stretcher accompanied by EMS personnel, wearing gray sneakers, tan colored shorts, blue long-sleeve t-shirt, and a baseball cap. P#1 has a cane with him.
02:11 Paramedics approach nurse at nurses' station and hands her papers
07:27 CN CC is sitting in a chair at the nurses' station on the phone.
Video #2
Time Stamp 00:33 CN CC appears to be speaking to the two paramedics who brought P#1 in
00:53 CN CC hangs up the phone
03:02 CN CC continues speaking with the paramedics; P#1 remains on the EMS stretcher
04:34 P#1 appears to be agitated as he repositions himself on the stretcher
06:10 P#1 continues to reposition himself on the stretcher; a paramedic walks over to assist him in being more comfortable
19:04 MD GG is wearing a white lab coat and walks into the nurses' station and appears to speak with CN CC
19:38 Paramedics move P#1 near a set of chairs in the corner and assist him to a chair to sit down
22:49 MD GG appears to be talking on the phone
23:36 MD GG hangs up the phone and appears to be speaking with CN CC
24:26 MD GG walks over to P#1 and is speaking to him
26:43 P#1 is assisted by the paramedics back onto the EMS stretcher
27:04 MD GG walks away from P#1
28:06 CN CC completes paperwork and returns to paramedics
28:38 P#1 is transported out of ED by EMS paramedics

A review of Patient (P)1's record from Facility (F) #2 revealed that he was seen in the emergency department (ED) at F#2 on 1/13/24 at 9:25 a.m. for pain in right knee. The patient reported increased swelling and pain in the area of the right lower leg emanating from the calf to the ankle. Stated he contacted physician's office and was instructed to come to the emergency department to "check for a deep venous thrombosis." Continued review of F#2's record dated 1/13/24 at 9:52 a.m. revealed a medical screening examination indicated that P#1 presented post op day 4, status post removal of hardware right knee with increased swelling and pain to the right lower leg. P#1's laboratory findings included an elevated D-Dimer with clinical examination demonstrating positive calf tenderness along with the swelling. Ultrasound on call were not available available and based upon a prior arrangement with F#1, P#1 patient was sent to F#1 to get an ultrasound. Continued review of ED course dated 1/13/24 11:36 a.m. bedside report given to EMS staff. P#1 being transported to F#1 for US Venus Doppler RLE (right lower extremity) and then will return. Report acknowledged and care transferred. F#1 Radiology Department notified that P#1 was coming over for an ultrasound. Upon arrival to F#1, was informed after the fact that they (F#1) did not have ultrasound available except for emergent ED patients at their facility (F#1). Subsequently patient was sent back to our facility (F#2). Continued review of ED course dated 1/13/24 at 9:55 a.m. revealed D-Dimer (test can be an indication of blood clots) Assay result of Abnormal: 723 (a normal D-Dimer rest result is generally considered to be below 500).

During a telephone interview with Charge Nurse (CN) CC on 2/6/24 at 2:45 p.m. she stated that as CN it is her responsibility to ensure that the flow of the ED is running smoothly, and the patients were triaged appropriately. She continued to explain that if the patient was critical or unstable, a provider came in to assess the patient. CN CC continued to say that they will accept incoming reports from the emergency medical services (EMS) or other facilities that are transferring patients to the ED. CN CC stated that when an ED-to-ED transfer occurs, the call was facilitated by the transfer center. She continued to explain that the ED physician from the referring facility spoke with the ED physician at F#1 to determine if a patient was appropriate for transfer. CN CC recalled the situation when P#1 was transported from F#2 to F#1 by EMS to get an outpatient venous doppler (a diagnostic test used to check the circulation in the large veins in the legs) of his leg and it was the weekend. She continued to explain that someone from F#2 called F#1 and spoke to someone in the imaging department, who said it was ok to send P#1 over with his paperwork to have the test done. She continued to explain that MD GG spoke to the ED physician at F#2 and confirmed that P#1 was sent to rule out the possibility of a blood clot because his leg was swollen to the touch, but they agreed to send P#1 back to F#2. She continued to explain that MD GG performed a medical exam and assessment. She stated that an incident report was completed due to P#1 not being entered on the central log and registered. She continued to explain that in order to admit P#1 he would have to be discharged from F#2 and be admitted to F#1 and have all his blood work done all over again. She stated F#2 never called the ED and there was no RN-to-RN report therefore, no one knew about the patient coming to the ED. CN CC continued to explain that P#1 was never supposed to be an ED patient and his injury was a worker's compensation insurance claim and he would have been billed twice from two facilities for two ED visits.


An interview was conducted with Medical Doctor (MD) GG on 2/7/24 at 1:40 p.m. in the Risk Management office. MD GG stated after reviewing incident report #564781 entered by RN CC he did recall the incident that involved P#1. MD GG stated that he did recall speaking with the ED physician at F#2 shortly after P#1 arrived at the ED. He continued to explain that the F#2 ED physician explained that P#1 was sent to F#1 post op (after operation) knee surgery but woke up with swelling. MD GG continued to explain that F#2's ED physician stated that he sent P#1 over to have a doppler study to make sure he did not have a DVT (a blood clot in a deep vein, usually in the legs) and they called the radiology department who said it was okay to send him. MD GG continued to explain that the person in radiology did not know that the radiology staff do not work on the weekends, and they would need to be called in. He continued to explain; however that radiology would not come in to do an outpatient test on the weekend for a non-inpatient, non-emergency patient. MD GG stated that when he spoke to the ED physician at F#2 he explained the situation with the vascular staff not on-site on a weekend but if they accepted the patient, they would need to draw more blood and make him an inpatient at F#1 then we could call in the vascular staff to perform the doppler study. He continued to explain that the ED physician at F#2 stated that he did not want to have all the extra work done to P#1 and that they can treat P#1 at F#2. MD GG continued to explain that he spoke to P#1 and apologized for the miscommunication and stated that F#1 could treat him, but they would need to admit him as an inpatient, draw more blood, and then call in the vascular team to perform the test. He continued to explain that he advised P#1 that he will end up with two hospital bills and he was not sure how his worker's compensation insurance handle it. MD GG stated after his conversation with P#1 and the ED physician at F#2, P#1 decided to return to F#2. MD GG stated that he is a part of a contracted physician group and not an employee of F#1.

During a telephone interview with the complainant, P#1, on 2/6/24 at 8:45 a.m. revealed that on Saturday 1/13/24 he woke up to a swollen and painful right knee and he called his physician in Phenix City, Alabama immediately, who advised him to go to the ED to rule out a blood clot post knee surgery a few days earlier. He continued to explain that once he arrived at F#2 he was advised by the ED physician that the facility did not have the capability to conduct the ultrasound he needed, and they were going to send him to F#1 for the test. P#1 continued to say his right knee was swollen and he was in pain when he presented to both Emergency Departments. He continued to explain that the ED doctor at F#1 did not assess his leg or knee. P#1 recalled that the ED physician told him that he (P#1) would incur additional costs because of having to be discharged from F#2 and admitted to F#1. P#1 stated that he felt discouraged about the test after speaking with the doctor. He continued to explain that the ED nurse inquired about his insurance, that is how she knew his injury was related to Workers Comp. He continued to say that the ED nurse advised him that the staff needed to conduct the test were not at the facility and they can only be called to come in for an emergency patient admitted to their facility (F#1). P#1 stated that he did not know what to do or say so he agreed to go back to his original facility, F#2.

A review of the facility's policy entitled, "Medical Screening of Emergency Department Patients," Policy #14296921, last revised 9/5/2023 revealed Purpose. The purpose of the triage process is to provide a quick assessment (triage) of patients presenting to the Emergency Department and to appropriately facilitate patients to a suitable area for treatment in a time frame appropriate to their presenting symptomatology. All patients will then receive a medical screening exam (MSE) by a Mid-Level provider (PA, APNP) or physician. A disposition will be made after the medical screening exam is complete.

Based on a review of the central log, incident report, interviews and policies and procedures, it was determined that there was a delay in treatment after staff identified Patient #1 (P#1) payment status, therefore, the facility failed to conduct an appropriate medical screening examination (MSE) for one patient (P)#1 out of 23 sampled patients. Specifically, P#1 was transported by Emergency Medical Services (EMS) from facility (F)#2 to facility (F) #1's emergency department (ED) to receive radiology testing. Once in the ED, RN CC inquired about P#1's insurance and advised P#1 that due to his Worker's Comp insurance the ED visit may be double billed.


Findings:

A review of the facility's Central Log dated November 2023 through January 2024 failed to reveal that P#1 was entered on the ED on 1/13/24.

A review of the incident report #564781 dated 1/13/24 revealed that P#1 arrived in the ED from F#2 via EMS for an ultrasound. The test was not performed because P#1 was not a patient in F#1 and P#1 refused to be registered in the ED because it was a workers compensation case. Patient was alert and capable of making decisions. Patient was not registered.


During a telephone interview with Charge Nurse (CN) CC on 2/6/24 at 2:45 p.m. CN CC stated that she recalled the situation when P#1 was transported from F#2 to F#1 by EMS to get an outpatient venous doppler (a diagnostic test used to check the circulation in the large veins in the legs) of his leg and that it was on the weekend. CN CC stated that an incident report had been written because P#1 had arrived on their property but was not registered. She continued to explain that in order to admit P#1 he would have to be discharged from F#2 and be admitted to F#1 and have all his blood work done all over again. She stated F#2 never called the ED and there was no RN-to-RN report therefore, no one knew about the patient coming to the ED. CN CC continued to explain that P#1 was never supposed to be an ED patient and his injury was a worker's compensation insurance claim and he would have been billed twice from two facilities for two ED visits. CN CC stated that she has received annual EMTALA training.

An interview was conducted with Medical Doctor (MD) GG on 2/7/24 at 1:40 p.m. in the Risk Management office. MD GG stated after reviewing incident report #564781 entered by RN CC he did recall the incident that involved P#1. He continued to explain that he looked at the patient and he appeared to be comfortable, sitting in a chair, and not in distress. MD GG continued to explain that he spoke to P#1 and apologized for the miscommunication and stated that F#1 could treat him, but they would need to admit him as an inpatient, draw more blood, and then call in the vascular team to perform the test. He continued to explain that he advised P#1 that he will end up with two hospital bills and he was not sure how his worker's compensation insurance handle it. MD GG stated after his conversation with P#1 and the ED physician at F#2, P#1 decided to return to F#2. MD GG stated that he is a part of a contracted physician group and not an employee of F#1. He continued to say that he has completed his annual EMTALA training.


During a telephone interview with the complainant, P#1, on 2/6/24 at 8:45 a.m. revealed that on Saturday 1/13/24 he woke up to a swollen and painful right knee and he called his physician in Phenix City Alabama immediately, who advised him to go to the ED to rule out a blood clot post knee surgery a few days earlier. He continued to explain that once he arrived at F#2 he was advised by the ED physician that the facility did not have the capability to conduct the ultrasound he needed, and they were going to send him to F#1 for the test. P#1 continued to say his right knee was swollen and he was in pain when he presented to both Emergency Departments. He continued to explain that the ED doctor at F#1 did not assess his leg or knee. P#1 recalled that the ED physician told him that he (P#1) would incur additional costs because of having to be discharged from F#2 and admitted to F#1. P#1 stated that he felt discouraged about the test after speaking with the doctor. He continued to explain that the ED nurse inquired about his insurance, that is how she knew his injury was related to Workers Comp. He continued to say that the ED nurse advised him that the staff needed to conduct the test were not at the facility and they can only be called to come in for an emergency patient admitted to their facility (F#1). P#1 stated that he did not know what to do or say so he agreed to go back to his original facility, F#2.


A review of the facility's policy entitled, "Emergency Medical Treatment and Labor Act (EMTALA)," Policy #11562822, last approved 4/32/22, revealed that it was the policy of the facility to provide a medical screening examination to individuals seeking emergency services regardless of their ability to pay, race, ethnicity, religion, national origin, citizenship, age, sex, preexisting medical condition, physical or mental handicap, or insurance status.