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Based on observation and interviews the facility staff failed to post in conspicuous places in the Emergency Department and waiting areas of the Emergency Department (ED) a sign specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor; and to post information indicating whether or not the hospital participates in the Medicaid program.

The Findings Include:

On 1/22/10 at approximately 10:30 A.M. a tour of the waiting area and ED was completed by the two (2) Medical Facilities Inspectors (MFI) with the following hospital staff; Director of Patient Care Operations, Director of Med Surg. and the Emergency Department Nurse Manager. Initially no signs indicating the right of a patient to be treated could be located by the MFI. The hospital staff were asked to locate the appropriate signage indicating the right to treatment by a patient. The staff appeared to have some difficulty in locating the signage but eventually located one sign approximately 12 inches by 18 inches in a pale green with slightly darker lettering between two other signs. A second sign approximately 8 inches by 11 inches was located beside the door leading to the ED area. The facility staff agreed the signs needed to be more conspicuous.

Once inside the treatment areas no signs regarding the right to treatment could be located.

Based on review of hospital Emergency Medical Treatment and Active Labor Act (EMTALA) policies and procedures, observation and interviews, it was determined that the hospital failed to comply with their policy to provide triage and a medical screening examination to all patients who are in need of emergency treatment that can not be provided by the initial treating hospital.

On the evening of 12/11/09 this hospital (will be identified as Nearby Alternate Hospital in this report, a Level 2 trauma center) Transfer Center Registered Nurse (RN) questioned the Emergency Department (ED) referring physician at Hospital (identified as Transferring Hospital) and a family member as to the type of insurance the patient had before accepting, treating and stabilizing the patient (Patient #1).

During the investigation it was discovered that the Nearby Alternate hospital Transfer Center Registered Nurse on 11/29-30/09 (Patient #2) and 12/13/09 (Patient #3) again asked about the type of insurance coverage potential patients had prior to accepting, treating and stabilizing the patients in need of care. It was also discovered that one patient potentially endured a delay in treatment and was transferred unnecessarily on 8/31/09 (Patient #4).

The Findings Included:

REVIEWED at Nearby Alternate Hospital, a Level 2 trauma center:
1. The Emergency Log.
2. Twenty (20) Emergency Department medical records from July 2009 through January 2010, chosen by the surveyors from the Emergency Log.
3. Nurse staffing schedules for the Emergency Department (ED) for the months of September - December 2009 and January 2010.
4. Emergency Department Physician schedules for 2009.
5. Attending physician on-call schedules for September - December 2009 and January 2010.
6. Eleven Emergency Department nurse, technician, unit clerk and customer service assistant (CSA) personnel files and 4 Transfer Center nurses personnel files.
7. Hospital EMTALA policies and procedures.
8. Policies and procedures for Emergency Department orientation and continued education, including for EMTALA.
9. Critical Care/Emergency Department Meeting minutes for 2009.
10. Medical Executive Committee Meeting minutes for 2009.
11. Quality documents and meeting minutes for 2009.
12. Job Description for Resource Nurse (Transfer Center Nurse)
13. Copy of written statement of events dated September 1, 2009 provided by Orthopedic Surgeon on Call 8/31/09
14. Copy of Physician Dictated Concern by Orthopedic Trauma Specialist

INTERVIEWED at Nearby Alternate Hospital:
1. Director of Patient Care Operations
2. Director of Med Surg.
3. Chief Nursing Officer
4. Emergency Department Nurse Manager
5. Director Customer Relations Management (Transfer Center Director)
6. CSA (Registration clerk)
7. Medical Director of the Emergency Department
8. Orthopedic Surgeon on Call 8/31/09
9. Orthopedic Trauma Specialist
10. Senior Vice President/Administrator
11. Director of Human Resources
12. Vice President Trauma and Emergency Services
13. Emergency Department Physician on duty 8/31/09

INTERVIEWED at Transferring Hospital:
1. Emergency Department Attending Physician on the evening of 12/11/09
2. Administrator

INTERVIEWED at Level I Trauma Center Hospital:
1. Vice President of Medical Affairs
2. Medical Director of the Emergency Department
3. Patient Safety Specialist/Accreditation Operations Manager
4. Clinical Nurse II, ED
5. Team Coordinator for ED
6. Chairperson for Ophthalmology
7. Ophthalmology Physician - Resident
8. Ophthalmologist on call for 12/11/09 - Attending

OBSERVED at Nearby Alternate Hospital:
1. The Emergency Department physical facilities. The clinical and waiting areas of the Emergency Department

REVIEWED at Nearby Alternate Hospital:
1. Three taped conversations with the Transfer Center Nurse and various emergency department physicians and or physicians on call for various specialities

On the evening of 12/11/09 the Nearby Alternate Hospital Transfer Center Registered Nurse was contacted by the referring physician at the Transferring Hospital regarding a Patient #1 who had sustained a ruptured globe (eyeball). The Transferring Hospital did not have the equipment to appropriately treat and care for the emergency. The Transferring Hospital ED physician was asked, "How old is he (Patient #1), do you think he's on Medicare" by the Nearby Alternate Hospital Transfer Center RN. The Nearby Alternate Hospital Transfer Center RN spoke with the wife of Patient #1 regarding the type of insurance Patient #1 had and stated, "We simply want to protect you all. We are trying to protect you. We would never turn you down even if you don't have insurance."

The wife of Patient #1 reported the type of insurance coverage to the nearby Alternate Hospital Transfer Center RN. The Nearby Alternate Hospital Transfer Center RN told the Transferring Hospital ED physician the type of coverage was out of Network for the Nearby Alternate Hospital and the family would get a huge bill and advised the physician to try to find another hospital (identified as Level 1 Trauma Center Hospital in this report). The Transferring Hospital ED physician had initially contacted the Ophthalmology resident physician on call for the Level 1 Trauma Center Hospital regarding Patient #1 and was initially not accepted. After the Nearby Alternate Hospital suggested the Transferring Hospital ED physician contact another hospital the Transferring Hospital ED physician contacted the ED physician directly at the Level 1 Trauma Center Hospital, who accepted Patient #1.

During the investigation it was discovered that the Nearby Alternate Hospital Transfer Center Registered Nurse on 11/29-30/09 (Patient #2) and 12/13/09 (Patient #3) again asked about the type of insurance coverage potential patients had prior to accepting, treating and stabilizing the patients in need of care. It was also discovered that one patient potentially endured a delay in treatment and was transferred unnecessarily on 8/31/09 (Patient #4).

During the investigation the following additional concerns were identified:
During the 20 randomly picked clinical record reviews at the Transferring Hospital the clinical record of Patient #17 was reviewed. The review of the clinical record revealed the following:

? The Transferring Hospital ED physician documented at 6:05 P.M. he spoke with the physician on call for Patient #17 ' s local neurosurgeon whose office is at the Nearby Alternate Hospital.
? The note by the ED physician from the transferring hospital documented the on-call neurosurgeon of Patient #17 stated Patient #17 could not be treated at the Nearby Alternate Hospital because of (Name of Insurance).

On 11/29-30/09 the Nearby Alternate Hospital Transfer Center RN was contacted by the Nearby Alternate Hospital ED physician regarding a Patient #2 who was being treated for cancer of the tongue and needed to be seen at the Level 1 Trauma Center Hospital. The Nearby Alternate Hospital Transfer Center RN stated she was going to put the Nearby Alternate Hospital ED physician on the phone with the ED physician at the Level 1 Trauma Center Hospital but prior to doing this she asked the Nearby Alternate Hospital ED physician, "Excuse me Dr.(Name of ED physician) she (Patient #2) doesn't have Tricare (type of insurance coverage) does she, where we would have to start with them first?" The Nearby Alternate Hospital ED physician stated, "No".

Patient #2 left the Nearby Alternate Hospital ED AMA (Against Medical Advice) prior to being transferred to the Level 1 Trauma Center Hospital. The Level 1 Trauma Center Hospital had accepted Patient #2 prior to Patient #2 leaving AMA.

On 8/31/09 at 1:07 A.M. Patient #3 presented to the Nearby Alternate Hospital ED following a MVA (Motor Vehicle Accident). The x-rays obtained on 8/31/09 indicated Patient #3 had an 1. acetabular fracture on the right and 2. dislocation of the femoral head due to the fracture. The Nearby Alternate Hospital ED physician recommended admitting Patient #3 and called the orthopedic surgeon on call (Orthopedic Surgeon (OS)). The Orthopedic Surgeon (OS) reviewed the x-rays of Patient #3 online and refused to admit Patient #3 to Nearby Alternate Hospital.

The OS was interviewed by telephone on 1/26/10 and provided a written statement of events dated September 1, 2009. The OS stated, "I was uncomfortable in caring for the complexity of the trauma and recommend the patient (Patient #3) be transferred to (Name of Level 1 Trauma Center Hospital). He (Patient #3) needed an orthopedist who specializes in trauma." OS stated, "I never came in to see him (Patient #3) because I didn't think it was necessary after reviewing his films." The OS stated, "The General Surgeon on Call for that evening (for Nearby Alternate Hospital) was willing to admit the patient (Patient #3) but wanted a Orthopedic Surgeon who was going to handle the case to back him up. The General Surgeon saw the patient (Patient #3) in the ED."

OS stated, "I spoke with (Name of Physician at Level 1 Trauma Center Hospital, who treats orthopedic trauma patients) who agreed to take the patient (Patient #3) but then said the Nearby Alternate Hospital had hired a trauma orthopaedist specialist (OTS) and he would call him." "Dr. (Name of Physician at Level 1 Trauma Center Hospital who treats orthopedic trauma patients) called back saying the trauma orthopaedist specialist (OTS) at (Name of Nearby Alternate Hospital) would take the case." "I received a call from (Name of general surgeon on call for Nearby Alternate Hospital) who said trauma orthopaedist specialist (OTS) was not on call and he would see the patient tomorrow (9/1/09)." "I was not comfortable with that and did not feel the patient could wait so I recommended the patient be transferred to another hospital."

On 1/26/10 the Orthopedic Trauma Specialist (OTS) was interviewed via telephone and stated he had dictated a concern which was given to the medical director. The OTS stated, "Most orthopedics could manage the dislocation as an emergency and then a Orthopedic Trauma Specialist could come in 2-4 days later and do the definitive surgery from the posterior wall fracture standpoint." The OTS stated, "I received a call from the Orthopedic Trauma Specialist at (Name of Level 1 Trauma Center Hospital) asking why they wanted to transfer patient (Patient #3) and why he was not being managed at our hospital (Nearby Alternate Hospital)." "I called (Name of Doctor OS) and he stated he was not comfortable stabilizing the hip." "I told (Name of Doctor OS) I would help if he would handle the initial injury." "I was not on call on 8/31/09 and I did not agree to accept the patient (Patient #3)."

A review of Patient #3's clinical record revealed the following occurred on 8/31/09:
? 1:07 A.M. arrived at Nearby Alternate Hospital ED
? 2:35 A.M. x-rays obtained and preliminary results
? 4:42 A.M. OS reviews record on line and determines he can not treat Patient #3
? 5:46 A.M. Level 1 Trauma Center Hospital initially accepts Patient #3
? 6:14 A.M. Level 1 Trauma Center Hospital refuses Patient #3 until discusses case with Orthopedic Trauma Specialist
? 1:55 P.M. Helicopter arrives to transport Patient #3 to a fourth hospital
There were no additional notes in Patient #3's clinical record that addressed the transfer of Patient #3 to another facility

A review of OS's "Order of events written on September 1, 2009 revealed the following:
? 6:45 A.M. Level 1 Trauma Center Hospital ED physician want OS to discuss case with Orthopedic Trauma Specialist
? 7:10 A.M. Orthopedic Trauma Specialist from Level 1 Trauma Center Hospital wanted to discuss case with Orthopedic Trauma Specialist from Nearby Alternate Hospital
? 7:45 A.M. OS discussed case with Level 1 Trauma Center Hospital Orthopedic Trauma Specialist and relayed Nearby Alternate Hospital would keep Patient #3 and Orthopedic Trauma Specialist at Nearby Alternate Hospital would consult on case with the General Surgeon on call for 8/31/09
? 9:30 A.M. Orthopedic Trauma Specialist at Nearby Alternate Hospital declines to come to Nearby Alternate Hospital because not on call; recommends transferring to Level 1 Trauma Center Hospital
? 11:30 A.M. General Surgeon reported Level 1 Trauma Center Hospital Orthopedic Trauma Specialist refuses to accept Patient #3
? Discussed Patient #3 with a fourth hospital who agreed to accept Patient #3

The Nearby Alternate Hospital ED Medical Director reviewed the information from Patient #3's clinical record and stated, "I remember this case because they called me to consult."

The ED Medical Director for Nearby Alternate Hospital was interviewed on 1/22/10 and stated, "The nurses in the (Nearby Alternate Hospital)Transfer Center are scripted on what to say. All of their calls are recorded." When asked if they collect insurance information in their demographics of patients they are attempting to transfer in or out he stated, "No one asks insurance questions."

On 1/22/10 the Director of Customer Relations (DCR) Management (Transfer Center Director) was interviewed regarding how the service works. The DCR stated, "We (Nearby Alternate Hospital) opened the Transfer Center in 2006." "We have facilitated over 8,000 requests which includes ED transfers and direct admits, consults, direct admits to a hospital and transfusions/infusions." "We are staffed by RNs 24 hours per day, 7 days per week." "We try to collect what we can such as name, address, telephone number, next of kin, date of birth, chief complaint, physician name and insurance information if they have it." "If it is an emergent situation we don't ask about insurance."

The DCR continued to explain, "We never refuse to admit a patient." "As a courtesy we will inform the physician or patient when we are an out of network provider and will facilitate the transfer to an in network hospital." "Once we answer a call we help facilitate what is warranted regardless where the call came from or where the patient is going to."

The DCR provided a copy of the Patient Transfer Center Intake Form for review. A description of the form is as follows:
The first block/space on the top left of the form is labeled Patient Name. The top right block/space is labeled Gender, Pregnant, DOB (Date of Birth), age, SSN (Social Security Number) and Weight. The second block/space on the left of the from in labeled Insurance:_____ In Network/Out of Network Courtesy Notification *NEVER APPLIES FOR EMERGENT TRANSFER.

At the bottom of the form is the following statement: WHEN MD STATES IT IS SAFE TO TRANSFER IN NETWORK RELAY OUT OF NETWORK COURTESY NOTIFICATION if the patient's insurance is out of network relay courtesy insurance statement. "(Name of Hospital) will accept you, however, we are not in your insurance network and going out of network will result in you paying higher out of pocket expenses." When patient/family prefers to be transferred in network, offer to assist with facilitation of the transfer to facility that is in the insurance network. Communicated to:______by:______ Facility Refereed (sig) if Patient chooses an in network facility:_______