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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2408: (4) Delay in treatment. Based on interviews, document review and observations, the facility failed to ensure an appropriate medical screening examination (MSE) was completed without a delay in order to inquire about the individual's method of payment or insurance status of patients who presented to the Dedicated Emergency Department (DED) seeking a MSE for their Emergency Medical Condition (EMC). Specifically, the facility inquired about patients' insurance status before a MSE (Patient #3, Patient #24 and Patient #25).

Based on interviews, document review and observations, the facility failed to ensure an appropriate medical screening examination (MSE) was completed without a delay in order to inquire about the individual's method of payment or insurance status of patients who presented to the Dedicated Emergency Department (DED) seeking a MSE for their Emergency Medical Condition (EMC). Specifically, the facility inquired about patients' insurance status before a MSE (Patient #3, Patient #24 and Patient #25).

Findings include:

Facility policy:

The EMTALA policy read, the purpose of this policy is to set forth policies and procedures for use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). If an individual comes to the Emergency Department: The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists; and the Hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below. The Hospital will not base the provision of emergency services and care upon an individual's race, ethnicity, religion, national origin, citizenship, culture, language age, sex, preexisting medical condition, physical or mental disability, insurance status, sexual orientation, gender identity or expression, economic status or ability to pay for medical services, except to the extent that a circumstance is relevant to the provision of appropriate medical care.

Procedure: Triage: As soon as practical after arrival, individuals who come to the Emergency Department should be triaged in order to determine the order in which they will receive a medical screening examination. Triage is not a medical screening examination, as it does not determine the presence or absence of an emergency medical condition, but rather, simply determines the order in which individuals will receive a medical screening examination.

Registration: The Hospital may not delay the provision of an appropriate medical screening examination or any necessary stabilizing medical examination and treatment in order to inquire about the individual's method of payment or insurance status.

1. The facility failed to ensure registration staff did not delay patient care while inquiring about a patient's insurance status or method of payment prior to an MSE being done by a QMP.

A. Interviews

a. On 5/4/21 at 8:50 a.m., a tour of the DED was conducted. During the tour, an interview was conducted with Registrar #2. Registrar #2 described the process for patients who presented to the DED who were over 20 weeks pregnant and explained they were registered differently than other patients. Registrar #2 stated women who were over 20 weeks pregnant were registered and asked: demographic information to include name, date of birth along with consent for treatment and insurance information. Once the information was obtained, the patient was taken to the Labor and Delivery (L&D) area where the patient was triaged and an MSE was performed. He stated even if the mother felt the need to push, this process of registration was completed since it only took two to three minutes to complete. Registrar #2 stated all other patients were seen in the ED and registration staff only asked for their name and DOB.

An interview with Registered Nurse (RN) #5 from the DED was in contrast to Registrar #2's interview which stated if a patient felt the need to push, she should be taken immediately back for an evaluation and assessment due to birth being imminent.

b. On 05/05/21 at 11:13 a.m., an interview with the Director of Patient Access (Director #3) was conducted. Director #3 stated any patient who presented to the DED were only initially asked their name and DOB. After a physician had seen the patient, the registration staff then asked for insurance information and completed the registration process to include all demographic information, patient privacy and consents for treatment. Director #3 stated this process was to ensure patient care/treatments were not to be delayed to inquire about patient insurance or payment for care.

Director #3 then stated this process was different if a patient came to the DED and was greater than 20 weeks pregnant. Director #3 stated pregnant patients were completely registered to include being asked for insurance information because "those patients were not ER patients".

This was in contrast to the EMTALA log which identified patients over 20 weeks to be ER patients.

Director #3 was unable to explain why patients who presented to the DED were registered differently and why registration staff identified patients who were over 20 weeks pregnant were not ER patients. Director #3 confirmed all registration staff followed the above process.

c. On 5/5/21 at 1:26 p.m., an interview with the Director of Quality (Director #4) was conducted. Director #4 stated all patients who presented to the DED were Emergency Department (ED) patients to include those who were over 20 weeks pregnant. Director #4 stated even though the pregnant patients were seen in the L&D area, they were still ED patients. Director #4 confirmed those patients who were over 20 weeks pregnant did show up on the EMTALA log.

Director #4 stated anyone who presented to the DED was to be asked their name and DOB only, prior to being seen by a QMP. Director #4 stated this was to ensure no delay in care occurred or patients were not discouraged from seeking care for a MEC.

B. Observations:

a. On 5/5/21 at 1:26 p.m., a second tour of the DED was conducted with the Director of Emergency Services (Director #1). Patient interviews were conducted with Patient #24 and Patient #25.
i. Patient #24, who occupied a bed in the DED, stated she was asked to confirm her insurance information while being registered into the DED. Patient #24 stated the registration process was done prior to her being triaged by the RN or being seen by the physician.

ii. Director #1 stated Patient #24 should have been brought back to the ER into a bed, registration was then to ask the patient her name and DOB only, the patient was then to be triaged by the registered nurse and then seen by a QMP. Director #1 then stated registration was to come in after the provider had assessed the patient to complete the registration.

Director #1 confirmed the process was not followed with Patient #24.

Director #1 stated if patients were asked for insurance and payment information prior to being seen by a QMP this could delay patient care and discourage patients from seeking treatment.

iii. An interview with Patient #25 confirmed the same findings. Patient #25 stated he was asked to confirm his work, which included his insurance information, while being registered into the DED. Patient #25 stated this occurred prior to triage and being seen by a physician.

iv. Director #1 who was present for Patient #25's interview confirmed the patient was asked for insurance information prior to being seen by a QMP to determine if an EMC existed.

Director #1 stated this was an EMTALA violation as patients were not to be delayed treatment to confirm insurance information. Director #1 stated patients could be discouraged from telling staff what was truly going on, it could delay an assessment by a QMP and delay overall care if a patient was asked for insurance and payment information prior to being seen by a QMP.

Director #1 stated she had identified issues with registration and was worried about EMTALA violations with registration not following the process appropriately. Director #1 stated she had spoken to Director #3 several times but nothing had changed.

b. Both Patient #24 and Patient #25's interviews were in contrast to Director #3's interview in which he stated any patient who presented to the DED were only initially asked their name and DOB. After a physician had seen the patient, the registration staff then asked for insurance information and completed the registration process to include all demographic information, patient privacy and consents for treatment.

C. Document review

Review of the EMTALA log revealed Patient #3.

Review of Patient #3's history and physical dated 3/28/21 at 5:04 a.m. read, the patient was 38 weeks pregnant and presented to the DED in active labor with contractions one minute apart. The H&P revealed Patient #3 delivered in the hallway on the way to L&D. The report read, Patient #3 was being registered when her membranes ruptured and she soon after delivered the baby.

The facility was unable to provide any evidence the incident was reviewed to determine if treatment was delayed while the patient was registered to include verification of insurance information.

This was in contrast to facility policy and interviews in which patients who were in active labor should be taken immediately for an examination by a QMP as birth is imminent.