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Based on medical record review, policy/procedure review, and staff interview, the hospital administrative staff failed to adopt and enforce policies/procedures that ensured patients, insured by Iowa Cares insurance, who presented to the Emergency Room (ER) for a Medical Screening Examination (MSE) received a complete and appropriate MSE for 1 of 35 medical records reviewed (Patient #1). Medical records from June 1, 2011 to September 26, 2011 were selected for review. The hospital administration identified an average of 67 patients per month who present to the ER with Iowa Cares insurance.

Failure to adopt and enforce policies that ensure all patients that present to the ER receive an appropriate MSE and may result in a patient with an emergency medical condition not receiving appropriate care and potentially lead to delay of life saving treatment or death.

Findings include:

1. Review of Patient #1's medical record revealed on 9/19/11 at 9:17 PM, Patient #1 presented to the ER, by ambulance, complaining of a fall due to severe alcohol intoxication. The demographic sheet documented Patient 1's insurance as Iowa Cares.

On 9/19/11 at 10:34 PM, Physician A documented in the History of Present Illness: "Comment: [Patient #1] is a 45 year old with long standing history of alcohol intoxification with history of fall and intracranial bleeding ..., brought to the emergency room by ambulance for severe intoxication. ... Per Emergency Medical Service (EMS), patient had significant mental status changes and was not making any sense. More history is not obtainable at this point secondary to severe intoxication".

Patient #1's medical record revealed laboratory tests were performed and the patient's blood alcohol level (BAL) was 509 milligrams per deciliter (mg/dL). Legal intoxication is defined as 80 mg/dL. A BAL of 509 indicates a possible lethal level of alcohol in the patient's blood.

The medical record indicated that Physician A ordered laboratory tests (including BAL), chest x-ray, CT scan of the head, blood gases, and an Electrocardiogram (EKG). Physician A also ordered Intravenous fluids (IV), folic acid, and thiamine (vitamin B1).

The medical record lacked evidence that Physician A ordered further laboratory tests (such as BAL or blood gases) or treatments (such as intravenous fluids, medications, or oxygen administration) to ensure the medical stability of the patient prior to transfer.

Physician A documented on the Patient Transfer Form on 9/19/11 at 11:52 PM:
"Patient Stable - Patient did NOT come to the Hospital in an Emergency Medical Condition, or did come in such a condition, but is now stable...".

The transfer documentation stated, "Medical Screening - Benefits -patient requested".

2. Review of Patient #1's medical record from Receiving Hospital B revealed the following:

On 9/20/11 at 1:16 AM, Patient #1 presented to the ER, by ambulance, for treatment of alcoholism. "Patient reportedly fell and was taken by ambulance to his local ER. There he was found to be fairly intoxicated with alcohol level of 509 at 10:06 PM. Head CT was negative, Complete Blood Count (CBC), Chem-7, Liver Function Tests (LFT's), coagulation times, and Arterial Blood Gases (ABG) all grossly normal. They transferred the patient here due to reported altered mental status, inability to observe in ER until sober, and patient with Iowa Cares. On arrival patient is alert, in no acute distress. ... He wants to go home and feels he is ready but doesn't know how he'll get home...".

Patient received 2000 mL of IV fluids and was "monitored with no development of symptoms. Patient felt to be clinically sober, able to ambulate around the ER without difficulty...". No other medications, treatments, or interventions required.

Social worker consult: "...Patient transferred to UIHC from Trinity Muscatine. Patient is unsure why he was transferred to UIHC".

Patient discharged to home at 3:20 AM by taxi.

3. Review of policy titled "Transfer Policy", adopted 3/1/10, revealed in part, "... H. Transfer for Detoxification: At Trinity Muscatine, individuals exhibiting symptoms of chemical intoxication shall be provided stabilizing treatment within the capability of the Emergency Department. ...In the event that the individual is rendered incompetent by the chemical intoxication, this finding should be documented in the medical record. ... Without consent of the individual or the authorized representative, the individual should be transferred only in the event that he or she poses a risk of harm to self or others".

4. During an interview on 9/28/11 at 11:20 AM, Physician A stated the following:

"I have cared for the patient numerous times over the past three years. [Patient #1] has a history of severe alcoholism. He presents to the ER severely intoxicated, BAL's of 400 mg/dL or more, but on 9/19/11 he was hallucinating, somnolent, unable to stand, and this was a change from how the patient normally presents. [Patient #1] was taking benzodiazepines [mind altering medication] along with the alcohol and I felt he needed hospitalization".

"The first time I called the ER Physician at [Receiving Hospital B], I told the physician I wanted to transfer the patient for detox because he had Iowa Cares insurance. The ER Physician told me I could not transfer the patient only because of Iowa Cares insurance and that the patient had to request transfer". "She also told me that the patient would only receive stabilizing treatment and time to sober up. The [Receiving Hospital] does not admit patients for further detox". "At that time, I went back to [Patient #1] and asked him if he would like to go to [Receiving Hospital B]. [Patient #1] agreed and because the patient had Iowa Cares insurance, I put Patient Request on the transfer form to show the physician at [Receiving Hospital B]". Further Physician A stated the Trinity Muscatine ER had the capability, capacity, and staff to detox Patient #1. Physician A stated he detoxed the patient in the past in the ER. However, from past admission the physician knew that Patient #1's insurance, Iowa Cares, required him to seek care at Receiving Hospital B. Physician A stated he decided to delay Patient #1's continued care until after he transferred him to Receiving Hospital B due to financial considerations.

5. During an interview, on 9/27/11 at 2:35 PM, the Vice President of Patient Care stated "If the patient has Iowa Cares insurance the registration clerk [in the ER the unit clerk] will inform the patient that they will be responsible for the hospital bill. This is an attempt to help the patients and not burden them with the financial responsibilities. This may occur prior to the patient's MSE. The clerk should not be discussing how the patient will pay the bill though, this is the responsibility of the nurse or physician after the MSE and the patient is stabilized".

"We see 60 to 70 Iowa Cares patients a month and end up having to write off the cost of care for these patients. We are seeing more and more of these patients and it does cause a great financial burden." "The hospital is caught in a difficult position but all patients are cared for regardless of insurance or ability to pay."

Based on document review and interviews, the hospital failed to provide further stabilizing treatment within the hospital's capability to an individual (Patient #1), who presented to the Emergency Room (ER) on 9/19/2011 with an emergency medical condition. The deficient practice affected one of 35 medical records reviewed from June 1, 2011 to September 26, 2011. The hospital administration identified an average of 67 patients with Iowa Cares insurance per month who present to the ER seeking emergency medical care.

Findings include:

1. Review of Patient #1's medical record revealed on 9/19/11 at 9:17 PM, Patient #1 presented to the ER, by ambulance, complaining of a fall due to severe alcohol intoxication. Patient #1's demographic sheet documented the patient's insurance as Iowa Cares.

On 9/19/11 at 9:25 PM, Registered Nurse (RN) A documented in the Emergency Room Chart Vitals Signs Data:

9:34 PM Pulse 76 beats per minute (BPM), Respirations 16, Blood Pressure 95/42, O2 Saturation on room air 92 %

11:40 PM (on transfer) Pulse 69 BPM, Respirations 16, Blood Pressure 103/53, O2 Saturation not documented

At 9:25 PM, RN A documented in the Emergency Department Medical (EDM) Record: "Fall Risk/Injury Assessment: Mental Status: Confusion ...No".
Social History: ...Alcohol Use: Yes (6 - 8 beers daily) Alcohol: 2 plus drinks per day

At 10:47 PM, RN A documented in the EDM Patient Record: "IV Initiation":
IV started in the right hand.

23:40 PM 500 mL of intravenous fluids infused by time of transfer

2. On 9/19/11 at 10:34 PM, Physician A documented in the History of Present Illness: "Comment [Patient #1] is a 45 year old with long standing history of alcohol intoxification with history of fall and intracranial bleeding ..., brought to the emergency room by ambulance for severe intoxication. ... Per Emergency Medical Service (EMS), patient had significant mental status changes and was not making any sense. More history is not obtainable at this point secondary to severe intoxication.... Neurologic: Reports history of alcohol withdrawal seizures".

Patient #1's medical record revealed laboratory tests were performed and the patient's blood alcohol level (BAL) was 509 milligrams per deciliter (mg/dL). Legal intoxication is defined as 80 mg/dL. A BAL of 509 indicates a possible lethal level of alcohol in the patient's blood.

The medical record indicated that Physician A ordered laboratory tests (including BAL), chest x-ray, CT scan of the head, blood gases, and an Electrocardiogram (EKG). Physician A also ordered Intravenous fluids (IV), folic acid, and thiamine (vitamin B1).

The medical record lacked evidence that Physician A ordered further laboratory tests (such as BAL or blood gases) or treatments (such as intravenous fluids, medications, or oxygen administration) to ensure the medical stability of the patient prior to transfer.

On 9/19/11 at 11:52 PM, Physician A documented on the Patient Transfer Form :
"Patient Stable - Patient did NOT come to the Hospital in an Emergency Medical Condition, or did come in such a condition, but is now stable...". The transfer form documented "Medical Screening - Benefits -patient requested".

3. Review of Patient #1's medical record from Receiving Hospital B revealed the following:

On 9/20/11 at 1:16 AM, Patient #1 presented to the ER, by ambulance, for treatment of alcoholism. "Patient reportedly fell and was taken by ambulance to his local ER. There he was found to be fairly intoxicated with alcohol level of 509 at 10:06 PM. Head CT was negative, Complete Blood Count (CBC), Chem-7, Liver Function Tests (LFT's), coagulation times, and Arterial Blood Gases (ABG) all grossly normal. They transferred the patient here due to reported altered mental status, inability to observe in ER until sober, and patient with Iowa Cares. On arrival patient is alert, in no acute distress. ... He wants to go home and feels he is ready but doesn't know how he'll get home...".

Patient received 2000 mL of IV fluids and was "monitored with no development of symptoms. Patient felt to be clinically sober, able to ambulate around the ER without difficulty...". No other medications, treatments, or interventions required.

Social worker consult: "...Patient transferred to UIHC from Trinity Muscatine. Patient is unsure why he was transferred to UIHC".

Patient discharged to home at 3:20 AM by taxi.

4. During an interview on 9/28/11 at 11:20 AM, Physician A stated the following:

"I have cared for the patient numerous times over the past three years. [Patient #1] has a history of severe alcoholism. He presents to the ER severely intoxicated, BAL's of 400 mg/dL or more, but on 9/19/11 he was hallucinating, somnolent, unable to stand, and this was a change from how the patient normally presents. [Patient #1] was taking benzodiazepines along with the alcohol and I felt he needed hospitalization".

"The first time I called the ER Physician at [Receiving Hospital B], I told the physician I wanted to transfer the patient for detox because he had Iowa Cares insurance. The ER Physician told me I could not transfer the patient only because of Iowa Cares insurance and that the patient had to request transfer". "She also told me that the patient would only receive stabilizing treatment and time to sober up. The [Receiving Hospital] does not admit patients for further detox". "At that time, I went back to [Patient #1] and asked him if he would like to go to [Receiving Hospital B]. He agreed and because the patient had Iowa Cares insurance, I put Patient Request on the transfer form to show the physician at [Receiving Hospital B]".

Physician A reported that a complete MSE was done on the patient when he presented to the ER. "I did not admit the [Patient #1] to our hospital because he had Iowa Cares Insurance. He needed detox so I transferred him to [Receiving Hospital B]. The ER physician repeatedly told me that [Receiving Hospital B] did not detox patients and that they would not care for the patient any differently than I was able to. I still choose to send the patient because of the Iowa Cares Insurance". Physician A stated the ER had the capability, capacity, and staff to detox Patient #1, in fact he detoxed the patient in the past in the ER. However, Physician A stated he knew that Patient #1's insurance, Iowa Cares, required the patient to seek care at Receiving Hospital B. Physician A stated he decided to delay the patient's continued care until after transfer due to financial considerations.

Based on document review and staff interview, the hospital's Emergency Room (ER) administrative staff failed to ensure ER staff did not base Medical Screening Examination (MSE) decisions on a patient's ability to pay for 1 of 35 ER patients that presented to the ER for a MSE, selected for review from June 1, 2011 to September 26, 2011. The ER administrative staff identified an average of 67 patients per month who presented to the ER with Iowa Cares insurance.

A hospital basing MSE decisions on a patient's ability to pay could result in a patient with an emergency medical condition not receiving appropriate care, potentially leading to delay of life saving treatment or death.

Findings include:

1. Review of Patient #1's medical record revealed:

On 9/19/11 at 9:17 PM, Patient #1 presented to the ER, by ambulance, complaining of a fall due to severe alcohol intoxication.

On 9/19/11 at 9:17 PM, Staff D completed Patient #1 registration and updated the demographic sheet with Patient #1's Iowa Cares insurance status.

On 9/19/11 at 10:34 PM, Physician A documented in the History of Present Illness: "Comment [Patient #1] is a 45 year old with long standing history of alcohol intoxification with history of fall and intracranial bleeding ..., brought to the emergency room by ambulance for severe intoxication. ... Per Emergency Medical Service (EMS), patient had significant mental status changes and was not making any sense. More history is not obtainable at this point secondary to severe intoxication.... Neurologic: Reports history of alcohol withdrawal seizures".

The medical record indicated that Physician A ordered laboratory tests (including BAL), chest x-ray, CT scan of the head, blood gases, and an Electrocardiogram (EKG). Physician A also ordered Intravenous fluids (IV), folic acid, and thiamine (vitamin B1).

The medical record lacked evidence that Physician A ordered further laboratory tests (such as BAL or blood gases) or treatments (such as intravenous fluids, medications, or oxygen administration) to ensure the medical stability of the patient prior to transfer.

Physician A documented on the Patient Transfer Form on 9/19/11 at 11:52 PM:
"Patient Stable - Patient did NOT come to the Hospital in an Emergency Medical Condition, or did come in such a condition, but is now stable...". "Medical Screening - Benefits -patient requested".

3. Review of Patient #1's medical record from Receiving Hospital B revealed the following:

On 9/20/11 at 1:16 AM, Patient #1 presented to the ER, by ambulance, for treatment of alcoholism. "Patient reportedly fell and was taken by ambulance to his local ER. There he was found to be fairly intoxicated with BAL of 509 at 10:06 PM.... They transferred the patient here due to reported altered mental status and inability to observe in ER until sober and patient with Iowa Cares...".

4. During an interview on 9/28/11 at 11:20 AM, Physician A stated the following:

"I have cared for the patient numerous times over the past three years. [Patient #1] has a history of severe alcoholism. He presents to the ER severely intoxicated, BAL's of 400 mg/dL or more, but on 9/19/11 he was hallucinating, somnolent, was unable to stand, and this was a change from how the patient normally presents. [Patient #1] was taking benzodiazepines [mind altering medication] along with the alcohol and I felt he needed hospitalization".

"The first time I called the ER Physician at [Receiving Hospital B], I told the physician I wanted to transfer the patient for detox because he had Iowa Cares insurance. The ER physician told me I could not transfer the patient only because of Iowa Cares insurance and that the patient had to request transfer". "The ER Physician also told me that the patient would only receive stabilizing treatment and time to sober up. The [Receiving Hospital] does not admit patients for further detox". "At that time, I went back to [Patient #1] and asked him if he would like to go to [Receiving Hospital B]. He agreed and because the patient had Iowa Cares insurance, I put Patient Request on the transfer form".

Physician A stated the ER had the capability, capacity, and staff to detox Patient #1 and he detoxed the patient in the past in the ER. However, from past admission the Physician knew that Patient #1's insurance, Iowa Cares, required him to seek care at Receiving Hospital B. Physician A decided to delay Patient #1's continued care until after he transferred Patient #1 to Receiving Hospital B due to financial considerations.

5. Review of the policy titled "Transfer Policy", adopted 3/1/10, revealed in part, "... H. Transfer for Detoxification: At Trinity Muscatine, individuals exhibiting symptoms of chemical intoxication shall be provided stabilizing treatment within the capability of the Emergency Department. ...In the event that the individual is rendered incompetent by the chemical intoxication, this finding should be documented in the medical record. ... Without consent of the individual or the authorized representative, the individual should be transferred only in the event that he or she poses a risk of harm to self or others".

6. Review of the policy titled "Transfer Policy", adopted 3/1/10, revealed in part, "General Procedures: ...A. No Delay in Treatment - Provision of the medical screening examination and further examination and treatment may not be delayed in order to inquire about the individual's method of payment or insurance status".

7. Review of Medical Staff Rules and Regulations, dated 6/24/11, lacked evidence of rules or regulations related to the responsibilities of the ER physician for the appropriate provision of medical screening, stabilizing treatment and when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care.

8. During an interview, on 9/27/11 at 2:35 PM, the Vice President of Patient Care stated "If the patient has Iowa Cares insurance the registration clerk (the ER unit clerk) will inform the patient that they will be responsible for the hospital bill. This is an attempt to help the patients and not burden them with the financial responsibilities. This may occur prior to the patient's MSE. The clerk should not be discussing how the patient will pay the bill, this is the responsibility of the nurse or physician after the MSE and the patient is stabilized".

"We see 60 to 70 Iowa Cares patients a month and end up having to write off the cost of care for these patients. We are seeing more and more of these patients and it does cause a great financial burden". "The hospital is caught in a difficult position but all patients are cared for regardless of insurance or ability to pay".

9. During an interview, on 9/27/11 at 10:45 AM, Unit Clerk C reported "I go in to see the patient to verify their insurance status after the patient is seen by the nurse. If the patient has Iowa Cares insurance I will explain to the patient that the visit to the ER will not be covered because of their insurance. I also tell the patient that they can stay and be treated but that they will pay for the bill. I will then report to the physician and/or nurse that the patient has Iowa Cares. I may have this conversation with the patient prior to the medical screening exam by the doctor. The doctor needs this information to help make decisions on where to transfer the patient. The doctor discusses the options to the patient, then the patient can accept transfer or refuse".

10. During an interview, on 9/28/22 at 2:05 PM, RN A stated "I was not present when [Physician A] discussed the transfer with [Patient #1]. The unit clerks do the registration and ask the patients about their insurance. This may be done prior to the MSE. The unit clerk will tell the patient about the hospital bill but I usually don't stay in the room. It is up to the doctor to discuss transfer or payment options with the patient or family. I have never heard a patient pressured to agree to transfer but, I have heard patients decide to go to [Receiving Hospital B] because they were told that Iowa Cares would not pay for further treatment".

Based on document review and staff interview, hospital administration failed to ensure that patients identified with an unstabilized emergency medical condition (EMC) are not transferred until the hospital has provided medical treatment within its capacity and minimized the risks to the 1 of 35 ER patients that presented to the ER for a MSE, selected for review from June 1, 2011 to September 26, 2011. The ER administrative staff identified an average of 67 patients per month who presented to the ER with Iowa Cares insurance.

Failure to stabilize and arrange for an appropriate transfer for a patient with an unstabilized emergency medical treatment has the potential to result in delay of life saving treatment or death to the patient.

Findings include:

1. Review of Patient #1's medical record revealed on 9/19/11 at 9:17 PM, Patient #1 presented to the ER, by ambulance, complaining of a fall due to severe alcohol intoxication.

Physician A ordered lab tests, chest x-ray, CT scan, EKG, an intravenous infusion of normal saline, administration of folic acid and thiamine (vitamin B1). Physician A, reviewed Patient # 1's lab results and performed a physical examination. Physician A documented the patient's blood alcohol level (BAL) was 509 milligrams per deciliter (mg/dL). Legal intoxication is defined as 80 mg/dL. A BAL of 509 indicates a possible lethal level of alcohol in the patient's blood. The patient was severely intoxicated and had a history of alcohol withdrawal seizures.

The medical record lacked evidence that Physician A ordered further laboratory tests (such as BAL or blood gases) or treatments (such as intravenous fluids, medications, or oxygen administration) to assess Patient #1 for the presence of an EMC (Emergency Medical Condition) or to ensure the medical stability of the patient prior to transfer.

On 9/19/11 at 11:52 PM, Physician A documented on the Patient Transfer Form :
"Patient Stable - Patient did NOT come to the Hospital in an Emergency Medical Condition, or did come in such a condition, but is now stable...". "Medical Screening - Benefits -patient requested".

Physician A arranged for Patient #1 to be transferred to Receiving Hospital B where Iowa Care insurance would cover the cost of the further detoxification treatment necessary to stabilize his emergency medical condition.

2. Review of hospital ER physician/nursing schedules and ER census reports, available to Physician A, for 9/19/11 revealed that the ER had the capability, capacity, and staff to detox Patient #1. On interview; 9/28/11 at 11:20 AM, Physician A stated he detoxed the patient in the past in the ER. However, from past admission he knew that Patient #1's insurance, Iowa Cares, required the patient to seek care at Receiving Hospital B. Physician A stated he decided to delay Patient #1's continued care until after he transferred Patient #1 to Receiving Hospital B due to financial considerations.

3. During an interview on 9/28/11 at 11:20 AM, Physician A stated the following:

"I have cared for the patient numerous times over the past three years. [Patient #1] has a history of severe alcoholism. He presents to the ER severely intoxicated, BAL's of 400 mg/dL or more, but on 9/19/11 he was hallucinating, somnolent, unable to stand, and this was a change from how the patient normally presents. [Patient #1] was taking benzodiazepines along with the alcohol and I felt he needed hospitalization".

"The first time I called the ER Physician at [Receiving Hospital B], I told the physician I wanted to transfer the patient for detox because he had Iowa Cares insurance. The ER physician told me I could not transfer the patient only because of Iowa Cares insurance and that the patient had to request transfer". "She also told me that the patient would only receive stabilizing treatment and time to sober up. The [Receiving Hospital] does not admit patients for further detox". "At that time, I went back to [Patient #1] and asked him if he would like to go to [Receiving Hospital B]. [Patient #1] agreed and because the patient had Iowa Cares insurance, I put Patient Request on the transfer form to show the physician at [Receiving Hospital B]".

Physician A reported that a complete MSE was done on the patient when he presented to the ER. "I did not admit [Patient #1] to our hospital because he had Iowa Cares Insurance. He needed detox so I transferred him to [Receiving Hospital B]. The ER physician repeatedly told me that [Receiving Hospital B] did not detox patients and that they would not care for the patient any differently than I was able to. I still choose to send the patient because of the Iowa Cares Insurance".