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Based on review of hospital policies and procedures, observations on tour, documents, a sample size of 43 medical records, and interviews, it was determined that the administrator failed to ensure that a patient presenting to the hospital and/or freestanding emergency departments (ED) is not delayed treatment or discouraged from seeking medical attention by requiring health insurance information prior to a medical screening exam for four (4) of four (4) patients; which poses a high potential health risk for the patient that their needs will not be met, if care is delayed and emergent needs are not assessed/addressed until health insurance information or financial status is obtained from the patient prior to their receiving a medical screening exam (MSE). (Patient's # 16, 10, 11, and 25)

Findings include:

The facility policy and procedure titled " Immediate Transfer from the Emergency Room " revealed the following: " ...Hospital provides a medical screening examination to every patient who comes to the hospital requesting emergency examination or treatment and provides the patient with necessary stabilizing treatment that is within the capabilities of the hospital. These services are provided to each patient, without regard to the patient ' s financial status. Furthermore, no patient treatment is delayed to inquire about the insurance or financial status.... "

Main Hospital

The main hospital emergency department has 8 emergency department examination rooms and 4 "fast track" rooms for a total of 12 treatment areas within the emergency department.

The surveyors toured the emergency department, located within the hospital beginning with the waiting and registration areas on 01/06/2016 at around 0900. There were two patients waiting in the emergency department and one patient who had just been triaged and was taken to the examination area. The registration clerk responded to a question of "What information do you obtain at the time of the patient's check in here at the registration desk?" The registration clerk responded that they obtain the patient's identification and that is all of the information that they obtain until the patient is taken to the examination area and the physician has seen the patient.

Following the registration and waiting area tour, the surveyors toured the treatment area of the emergency department. The surveyors observed medical records in a rack and the racks were identified by examination room or location and then sub-divided by action required to provide services; such as physician to see, RN (registered nurse) action required; etc.

The Director of the Emergency Department stated the registration clerk does not obtain registration information on a patient until the physician has seen the patient and this is identified by where the chart of the patient is located. When the chart is in the physician's section and turned facing the physician this means the physician has not seen the patient. When the chart is turned away from the physician then this would mean the physician has completed an initial assessment and the registration process could occur and would not delay the continued care of the patient or interfere with the medical screening examination.

The registration clerk who was assigned to the treatment area confirmed during an interview that she was trained not to complete the registration process or obtain insurance information without the physician having initiated the screening examination.

The Patient Access Manager #17 confirmed in an interview conducted on 01/06/2016, that the staff is instructed to ask for the patients' identification and insurance card when the patient signs in to be seen. She confirmed that the staff has a script they use at all of the emergency departments. She also confirmed that the patient access staff at the five emergency departments are trained during orientation to use this script.
The script was provided to the surveyors on 01/06/2016, by the Patient Access Manager. The script revealed the following: "...For safety and identity purposes, may I have your ID and insurance card, please...."

Patient # 16

Patient #16's medical record revealed the patient arrived at 20:15 on 12/25/2015. The consent for treatment was signed at 20:15. Attached to this documentation were the insurance card and the identification of the patient. The admission documentation included the financial responsibility and the statement that professional fees were billed separately. The patient was triaged at 2110, one hour after signing the admission documentation. The medical provider documented having seen the patient at 23:50, 3 hours and 35 minutes after arrival to the emergency department.

Patient # 10

Patient # 10's medical record revealed the patient arrived to the hospital emergency department at 2145 on 01/01/2016. The medical record provided to the surveyor on 01/06/2016 revealed the admission paperwork of a face sheet containing insurance information. The patient was triaged at 2150 on 01/01/2016. There was documentation that the patient left without treatment at 2206.

Patient # 11

Patient # 11's medical record revealed the patient arrived to the hospital emergency department at 2340 on 01/02/2016. The admission papers provided to the surveyor on 01/06/2016 revealed the admission paperwork was signed by the patient at 2338 on 01/02/2016. The admission paperwork also contained copies of the insurance card. The documentation revealed that the patient was triaged at 2342 on 01/02/2016. There was documentation that the patient left without treatment at 0616 on 01/03/2016. There was no documentation that a medical screening exam was completed.

Glendale Freestanding Emergency Department

The surveyor toured the Glendale freestanding emergency department, beginning with the waiting and registration areas on 01/05/2016 and 01/06/2016. The registration clerk was observed asking for the patient 's identification and insurance card when the patients signed in requesting to be seen.

Patient #25's medical record revealed the patient arrived to the Glendale freestanding emergency department at 1350 on 01/04/2016. The medical record provided to the surveyor on 01/06/2016 revealed the admission paperwork of a face sheet containing insurance information. The triage form revealed that only vitals were obtained; the patients pain level was 6/10 (six ranking in a scale of one to ten with ten being the worst); and both the primary assessment and secondary assessment was not completed. There was no documentation that a medical screening exam was completed. There was documentation that the patient left without treatment, time unspecified.

The Glendale Freestanding Emergency Department Administrator #5 confirmed in an interview conducted on 01/06/2016 that the staff ask the patients for their identification and insurance card when the patient signs in to be seen. She confirmed that the staff has a script they use at all of the emergency departments.

Chandler at Ray and McQueen Freestanding ED

The surveyor toured the Chandler at Ray and McQueen Freestanding ED, beginning with the waiting and registration areas on 01/05/2016. The registration clerk was observed asking for the patient's identification and insurance card when the patients signed in requesting to be seen.

Chandler 2977 E Germann Freestanding ED

The surveyor toured the Chandler 2977 E. Germann freestanding emergency department, beginning with the waiting and registration areas on 01/06/2016. The registration clerk was observed asking for the patient's identification and insurance card when the patients signed in requesting to be seen.

GIlbert Freestanding ED

The surveyor toured the Gilbert freestanding emergency department, beginning with the waiting and registration areas on 01/05/2016. The registration clerk was observed asking for the patient's identification and insurance card when the patients signed in requesting to be seen.

The Director of the Emergency Department (employee #4) confirmed in an interview conducted on 01/06/2016 that the insurance information was obtained after the medical screening exam (MSE). The Director of the Emergency Department was not aware that the patient access technicians were asking patients for insurance cards when the patients sign in requesting emergency treatment.

The CNO confirmed in an interview conducted on 01/06/2016 that the insurance information was obtained after the medical screening exam (MSE). The CNO was not aware that the patient access technicians asking patients for insurance cards when the patients sign in requesting emergency treatment. The CNO was not aware of the script that the patient access technicians were following at all emergency departments.

Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to conduct an appropriate transfer for 1 of 1 minor patient (Pt # 27) who presented to the freestanding ED for treatment of scorpion stings and was transferred to a local acute hospital ED, posing a risk to health and safety due to delay in required ED treatment, as evidenced by:

1. failure to document a certification that the medical benefits outweighed the increased risks of transfer to the patient, signed by a physician;

2. failure to obtain and document verbal agreement of the receiving hospital/medical facility and physician to accept the transfer; and

3. failure to obtain written consent for transfer.

Findings include:

Review of hospital policy/procedure titled MSE and Transfer Procedures for Patients Seeking Emergency Treatment revealed: "...Procedure...1. A patient considered appropriate for transfer will have met all of the following requirements:...b. A physician at the receiving hospital has agreed to accept the transfer of the patient and to provide appropriate medical treatment; c. The receiving hospital has available space and qualified personnel for the treatment of the patient, and has agreed to accept the transfer of the patient and to provide appropriate treatment...Transfer of stable patients: a. If a patient has been stabilized...the hospital may transfer the patient, if written informed consent is obtained from the patient, after the patient has been provided complete information pertaining to the transfer decision, including without limitation, the risks and benefits of the transfer...."

Review of Pt # 27's medical record revealed:


Pt # 27 is a minor who presented to the freestanding ED due to scorpion "stings" on his right third finger and left medial foot. The medical record for Pt # 27 revealed that he was treated in the ED. "...Patient presents with scorpion envenomation. The patient was in severe respiratory distress and was moved immediately back to the resuscitation room for critical management...was given one vile scorpion (sic) [antivenom] and had the start of resolution of his symptoms. He was actively suctioned during this due to heavy secretions. His symptoms slowly resolved over the course of 1 hour...The patient will be discharged to follow up closely with his primary care provider...." He was given morphine and SoluMedrol IV and transfer was attempted to a local Acute Children's Medical Center. EMS arrived for transport and the medical record contained documentation that EMS personnel were at the patient's bedside. EMS refused transport to the Children's Medical Center since another Acute Medical Center was "...closest and they cannot bypass...."
A physician documented: "...D/W (Discussed with) (Name of Children's Acute Medical Center) and accepted by (name of physician). Emergency transport to ER. Pt stable but serious...Unchanged...EMS (Emergency Medical Service) Refuses to transport child to children's hospital as they state (Name of Acute Medical Center) is closest and they cannot bypass. Report was called to (Name of Children's Acute Medical Center)...."

An RN documented: "...paramedics at bedside...."

Review of the form titled Patient Transfer Form revealed that it contained the name of Receiving Facility (Name of Children's Acute Medical Center). The form contained the name of the accepting physician at the Children's Acute Medical Center. The patient's family member signed consent for the patient to be transferred to the Children's Acute Medical Center.

The patient's medical record did not contain documentation of acceptance by a physician at the receiving Acute Medical Center hospital. It did not contain documentation that the receiving hospital had available space and qualified personnel to treat the patient and accept the transfer of the patient. It did not contain written consent by a parent of the minor patient for transfer to the receiving hospital.

Physician # 5 confirmed, during interview conducted on 1/5/16, that EMS transported the patient to (Name of Acute Medical Center) due to availability of scorpion anti-venom at that facility and EMS refused to transport the patient to the facility that had accepted the patient.