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Based on a review of policy and procedures, medical records, and interviews with staff it was determined that the facility failed to provide one patient P (#1) out of 20 sampled patients with an appropriate transfer; specifically, the facility failed to provide medical treatment that was within its capacity to minimize the risks to the P#1's health by transferring P#1 to another facility because their insurance was out-of-network. Additionally, the facility delayed treatment to P#1; specifically, the facility failed to provide treatment to P#1 once the provider was notified that P#1's insurance was not in network with the facility.

Findings Included:

Cross refer to A-2408, as it relates to the facility's failure to provide treatment to P#1 following notification that P#1's insurance was out-of-network with the facility.

Cross refer to A-2409 as it relates to the facility's failure to provide P#1 with an appropriate transfer.

Based on a review of policy and procedures, facility documents, medical records, and interviews with staff it was determined that the facility delayed treatment to one patient (P) #1 out of 20 patients sampled. Specifically, P#1 was diagnosed with a hip fracture and when the provider was notified by facility staff that P#1's insurance was not in network, the provider stopped treatment measures and facilitated P#1's transfer to another facility.

Findings Included:

A review of the facility policy titled "EMTALA/COBRA Policy", no number, last approved 1/26/22, revealed that the purpose of this policy was to delineate the policies and procedures for the screening, stabilization, and transfer of individuals with an Emergency Medical Condition (EMC) presenting to the facility.

III. Statement of Policy

1. It is the Policy of the Medical Center to provide a Medical Screening Examination by a Qualified Medical Person to any individual who comes to the Medical Center's dedicated emergency department or the campus of the facility and seeks an examination or medical treatment to determine if the individual has an Emergency Medical Condition, whether or not eligible for insurance benefits and regardless of ability to pay; and if it is determined that the individual has an Emergency Medical Condition, to provide the individual with such further medical examination and treatment as required to stabilize the Emergency Medical Condition, within the capability of the Medical Center, or to arrange for transfer of the individual to another medical facility in accordance with the procedure set forth below. This policy shall further apply to all individuals in any ambulance owned and operated by the Medical Center, subject to the policies and procedures of the local Emergency Medical Services (EMS) authority, or any ambulance not owned and not operated by the Medical Center that is on Medical Center property, even if instructed not to come to the Medical Center.
2. It is further the Policy of the Medical Center that it shall not delay the provision of a Medical Screening Examination, stabilizing treatment, or appropriate transfer in order to inquire about the individual's method of payment of insurance status; or request, or allow a health plan to require prior authorization for services before the individual has received a Medical Screening Examination and stabilizing treatment; or condition the provision of emergency services and care upon an individual's race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing medical condition, physical or mental disability, insurance status, economic status or ability to pay for medical services, except to the extent that a circumstance such as age, sex, pre-existing medical condition, or physical or mental disability is medically significant to the provision of appropriate medical care to the individual.
5. Individuals Who Have an Emergency Medical Condition. When it is determined that the individual has an Emergency Medical Condition, the Medical Center shall: 1) within the capability of the Medical Center stabilize the individual to the point where the individual is either "Stable for Discharge" or "Stable for Transfer,";

A review of the facility's EMTALA training 2024 titled "EMTALA Duties & Challenges", revealed that the facility would provide an MSE for every person who came to the facility's dedicated ED or the campus of the hospital and requested an examination or treatment for a medical condition or had such a request made on his or her behalf.
There were three basic EMTALA Requirements:
4. Appropriate Medical Screening
5. Stabilization of an EMC
6. Transfer to Another Facility

If the MSE revealed the existence of an EMC, EMTALA required the patient to be stabilized and or transferred.
A patient was considered to be stabilized when:
2. Sufficient medical treatment of the EMC was provided as may be necessary to ensure, within reasonable medical probability, that no material deterioration of the condition was likely to result from or occur during the discharge/transfer of the individual from the facility.
The facility may transfer or discharge a patient with an EMC when:
1. The patient was fully informed of the facility's EMTALA obligation and risk of transfer.
2. The request was obtained in writing.
3. The request must not be coerced- even implicitly.

Delay of the transfer caused by questioning an individual's ability to pay for care was strictly prohibited.

A review of P#1's medical record (MR) revealed that P#1 was a 58-year-old female who was brought to facility #1's ED by Emergency Medical Services (EMS) on 4/2/24 at 8:17 p.m. with left-sided hip pain associated with a ground-level fall. P#1 had a past medical history of diabetes mellitus (DM) (a metabolic disease, involving inappropriately elevated blood glucose levels).

A review of a "Provider Note" dated, 4/3/24 at 12:13 a.m., revealed that upon exam P#1 had pain with internal and external rotation of the left hip. Further review revealed that an order for an x-ray (used to generate images of tissues and structures inside the body) of the left hip was ordered.

Continued review revealed that the X-ray result was inconclusive for a fracture and a computerized tomography scan (CT) (imaging that uses X-ray techniques to create detailed images of the body) was ordered. Further review revealed that the CT result showed P#1 had a nondisplaced intertrochanteric fracture (hip fracture or broken hip. Hips that break between the bone bumps at the top of the thigh bone are said to have broken in the intertrochanteric area of the femur or hip) with adjacent soft tissue swelling. It is additionally noted that P#1's insurance was out of network (OON) so staff were working on finding a facility with orthopedics where they could transfer P#1.

Continued review of "Provider Note", medical decision-making, dated 4/3/24, revealed that Medical Doctor Resident (MDR) JJ noted, "I considered need for additional hospitalization/observation and further care including: Patient will need orthopedic consult as her left hip CT showed nondisplaced intertrochanteric fracture with adjacent soft tissue swelling. Patient insurance was out of network so working on finding a facility with orthopedics that we can transfer her to. If not, we will consult our orthopedic group for inpatient medicine. The patient has uncontrolled type 2 DM."

A review of "Case Management Clinical Note", dated 4/2/24 at 3:20 a.m., revealed that social worker (SW) WW was contacted by an ED provider to seek assistance with facilitating P#1's transfer. It was noted that P#1 was OON with her insurance but planned to stay at facility #1 and that OON benefits would be provided unless P#1 decided otherwise.

Continued review revealed that SW WW instructed staff that P#1 would need to sign an OON form (confirming that she understood that she would be responsible for the bill and hospital payments) to stay or begin the in-network process where the MD would call where she would want to go to secure an accepting MD at one of the facilities she could choose from.

A review of "Flowsheets", dated 4/3/24 at 1:08 a.m., revealed that the risks and benefits of transfer were discussed with P#1. The reason for the transfer was noted as "specialized treatment or services."

A review of "ED Timeline", dated 4/3/24 at 3:11 a.m., revealed that EMS arrived, received report, and transported P#1 to facility #2.

A review of P#1's MR from facility #2 revealed that P#1 was transferred from facility #1 and arrived at facility #2 on 4/3/24 at 4:01 a.m. P#1 was diagnosed with a nondisplaced intertrochanteric fracture of the left femur. Further review revealed that upon arrival at the ED, an orthopedic surgeon was consulted, and P#1 was prepped for the operating room (OR).

A telephone interview was conducted on 5/21/24 at 4:10 p.m. with Orthopedic Surgeon (OS) DD. OS DD stated that he has been an on-call Orthopedic Surgeon with facility #1 for two years. He explained that facility #1's orthopedics group specializes in hip fracture surgeries and non-complicated pelvic injuries. He added that major pelvic injuries, complicated hip fractures, and acetabular surgeries would be transferred to facility #1's flagship campus. OS DD stated that hip fractures are considered a higher acuity level that typically requires surgical intervention within 24-48 hours. He added that the only instance a patient with a hip fracture would be transferred out of facility #1 would be due to potential complications in which case the patient would be transferred to the flagship campus. OS DD said that he never looks at or considers what insurance a patient has and that he would be shocked if facility #1 transferred a patient with a hip fracture to another facility due to insurance. The only way he could see that happening was if a patient had a low acuity injury, but high acuity patients need to be treated right away.

A telephone interview was conducted on 5/22/24 at 7:45 a.m. with a Doctor of Osteopathic Medicine (DO) II, DO II stated that he is a nightshift ED physician for facility #1. He said that he assumed care of P#1 on 5/2/24 when he came on shift. DO II recalled P#1 presented at the ED for hip pain and was ultimately diagnosed with a hip fracture. He said P#1 was offered the choice to be admitted to facility #1 for treatment or to be transferred to a facility that was within her insurance network. He recalled P#1 and P#1's family expressing with great desire to be transferred to facility #2 for treatment because facility #2 was in-network with P#1's insurance. DO II said that he did not speak directly with P#1 or P#1's family but that the nurses would relay information to him. He explained that registration is responsible for telling patients if their insurance is in-network or out-of-network. DO II considers hip fractures to be emergent injuries that require emergent admission. DO II explained that there are times when registration will add "OON" next to a patient's name on the patient tracker. He said it is a nonofficial way to communicate and has zero bearing on patient disposition.

During an interview on 5/22/24 at 9:30 a.m. with Patient Access Representative Manager (PARM) PP in a conference room, PARM PP stated that she has worked in patient access for 15 years and began working for facility #1 in 2016. PARM PP said that once the provider has performed the MSE it will be notated on the patient tracker board. A patient access representative (PAR) will run the patient's insurance through a program called, "real-time eligibility" (RTE) to determine the patient's benefits. A PAR will go over the insurance benefits with the patient and collect a copay or deposit for self-pay customers if applicable. If the patient is OON, they will have them sign a "Beneficiary Notification Letter" and discuss the "Surprise Billing Letter" with them. The PAR will add "OON" next to the patient's name on the patient tracker board to alert case management (CM). PARM PP said that "OON" is not added to alert all of the ED staff, but it is there to let case management know because that patient is going to be an inpatient admission. She added if it is a Keiser patient, they will add "Keiser" next to the patient's name on the patient tracker board, so it is known the patient is OON. She explained that management encourages admission versus transfer when it is after hours, and case management is unavailable.

During an interview on 5/22/24 at 9:55 a.m. with Emergency Department Medical Director (EDMD) OO in a conference room, EDMD OO stated that he has been the EDMD at facility #1 for five years. EDMD OO said that when someone presents to the ED with a hip fracture they would be checked in, undergo a work-up, and have blood work done for pre-op because hip fractures usually require surgical treatment. He added that he would have someone from internal medicine or orthopedics do a consultation with the patient to formulate a treatment plan for the patient. EDMD OO said he does not usually know if a patient is OON or not. He added that registration will sometimes send "e-chats" to let the team know that a patient is OON. When this surveyor asked why it would be necessary or pertinent for registration to let providers know in an "e-chat" if a patient is OON? EDMD OO said the information is not pertinent to the doctors and he does not know why registration tells them. He speculated that maybe it is so doctors will know case management is going to be involved. He added that it is his expectation of ED staff to initiate care regardless of payment.

During an interview on 5/22/24 at 10:30 a.m. with Case Management Manager (CMM) QQ, in a conference room, CMM QQ stated that she has been a CMM for facility #1 since 2019. CMM QQ said that CM will collaborate with the providers when a patient is OON. She said that there is a CM column on the ED patient tracker board where registration will add "OON" so case management can identify which patients are OON. CMM QQ said she is unsure whether that information is visible to all ED staff or if it is visible only to members of the CM team. She added that CM will approach a patient about being OON once they are stabilized. CMM QQ said that registration will review the "Surprise Billing Letter" with OON patients, but she is not sure what specific verbiage registration uses.

A telephone interview was conducted on 5/22/24 at 11:05 a.m. with Resident Medical Doctor (RMD) JJ, MDR JJ said that he joined facility #1's resident program in July 2023. MDR JJ stated that P#1 was brought in by EMS for hip pain associated with a ground-level fall. He stated that he ordered a CT scan and the results revealed that P#1 had a nondisplaced intertrochanteric left hip fracture. MDR JJ said that upon getting the CT results his next step was going to be to ask for an orthopedic consultation. He explained that before he was able to contact the on-call orthopedic provider, a staff member notified him that P#1 was OON and needed to be sent somewhere for treatment that was within P#1's insurance network. MDR JJ could not recall who gave him those instructions, but he thought it was someone from registration. He added that hip fractures are considered emergent and that he was unable to follow up with P#1's transfer and outcome as his shift had ended and DO II assumed P#1's care.

Cross Refer to 2409.

Based on a review of policy and procedures, facility documents, medical records, and interviews with staff it was determined that the facility inappropriately transferred P (#1) to Facility #2, when the sending hospital had the capability and capacity to provide stabilizing treatment for P#1's Emergency Medical Condition (EMC), for one of 20 sampled patients. P#1 presented to the Emergency Department (ED) on 4/2/24 and was diagnosed with a hip fracture. Orthopedic services, including an on-call Orthopedic Surgeon, were available to ED staff on 4/2/24. When the provider was notified that P#1's insurance was out-of-network the facility transferred P#1 to another facility for treatment.

Findings Included:

A review of the facility policy titled "EMTALA/COBRA Policy", no number, last approved 1/26/22, revealed that the purpose of this policy was to delineate the policies and procedures for the screening, stabilization, and transfer of individuals with an Emergency Medical Condition (EMC) presenting to the facility.

III. Statement of Policy
1. It is the Policy of the Medical Center to provide a Medical Screening Examination by a Qualified Medical Person to any individual who comes to the Medical Center's dedicated emergency department or the campus of the facility and seeks an examination or medical treatment to determine if the individual has an Emergency Medical Condition, whether or not eligible for insurance benefits and regardless of ability to pay; and if it is determined that the individual has an Emergency Medical Condition, to provide the individual with such further medical examination and treatment as required to stabilize the Emergency Medical Condition, within the capability of the Medical Center, or to arrange for transfer of the individual to another medical facility in accordance with the procedure set forth below. This policy shall further apply to all individuals in any ambulance owned and operated by the Medical Center, subject to the policies and procedures of the local Emergency Medical Services (EMS) authority, or any ambulance not owned and not operated by the Medical Center that is on Medical Center property, even if instructed not to come to the Medical Center.

5. Individuals Who Have an Emergency Medical Condition. When it is determined that the individual has an Emergency Medical Condition, the Medical Center shall: 1) within the capability of the Medical Center stabilize the individual to the point where the individual is either "Stable for Discharge" or "Stable for Transfer,"; or 2) provide for an appropriate transfer of the non-stabilized individual to another medical facility in accordance with these procedures. If an individual has an Emergency Medical Condition that has not been stabilized, the individual may be transferred only if the transfer is carried out in accordance with the procedures set forth below. The individual may be transferred:
a) On Patient Request. The individual may be transferred if the individual or the legally responsible person acting on the individual's behalf is first fully informed of the risks of the transfer, the alternatives (if any) to the transfer, and of the Medical Center's obligations to provide further examination and treatment sufficient to stabilize the individual's Emergency Medical Condition, and to provide for an appropriate transfer. The transfer may then occur if the individual or legally responsible person: (i) makes a written request for transfer to another medical facility, stating the reasons for the request; and (ii) acknowledges his request and understanding of the risks and benefits of the transfer, by signing the Patient Transfer to Other Facility Form.

7. On-Call Physicians. The Medical Center shall maintain an on-call list of physicians, including specialists and sub-specialists who are available for duty to screen, examine, and treat patients with potential Emergency Medical Conditions. On-call physicians shall respond to the Medical Center calls for emergency coverage within a reasonable time after receiving communication indicating that their attendance is required. If an on-call specialist or sub-specialist is not available, the emergency department physician or his or her designee shall attempt to obtain the services of another appropriate specialist or sub-specialist from the Medical Center's medical staff as defined by the medical staff bylaws. If the necessary on-call services remain unavailable despite these efforts, such that the patient requires a transfer in order to obtain the necessary services at another medical facility, the emergency department physician or his or her designee shall note the name and address of the on-call physician who refused or failed to appear, in the C-3 Form.

A review of the facility's EMTALA training 2024 titled "EMTALA Duties & Challenges", revealed that the facility would provide an MSE for every person who came to the facility's dedicated ED or the campus of the hospital and requested an examination or treatment for a medical condition or had such a request made on his or her behalf. There were three basic EMTALA Requirements:
1. Appropriate Medical Screening
2. Stabilization of an EMC
3. Transfer to Another Facility

If the MSE revealed the existence of an EMC, EMTALA required the patient to be stabilized and or transferred.
A patient was considered to be stabilized when:
1. Sufficient medical treatment of the EMC was provided as may be necessary to ensure, within reasonable medical probability, that no material deterioration of the condition was likely to result from or occur during the discharge/transfer of the individual from the facility.
The facility may transfer or discharge a patient with an EMC when:
1. The patient was fully informed of the facility's EMTALA obligation and risk of transfer.
2. The request was obtained in writing.
3. The request must not be coerced- even implicitly.
Conversations with patients regarding the need for potential transfer should occur after the MSE had been conducted- even if the transfer may be needed for additional testing. Transfer certification (EMTALA form) was to be completed and records were made available to the receiving facility.

Transfer of the patient required written certification that the expected medical benefits of the transfer outweighed the risk. The transfer must be medically indicated and should not be for the convenience of the on-call schedule.

Delay of the transfer caused by questioning an individual's ability to pay for care was strictly prohibited.

A review of P#1's medical record (MR) revealed that P#1 was a 58-year-old female who was brought to facility #1's ED by Emergency Medical Services (EMS) on 4/2/24 at 8:17 p.m. with left-sided hip pain associated with a ground-level fall. P#1 had a past medical history of diabetes mellitus (DM) (a metabolic disease, involving inappropriately elevated blood glucose levels).

A review of a "Provider Note" dated, 4/3/24 at 12:13 a.m., revealed that upon exam P#1 had pain with internal and external rotation of the left hip. Further review revealed that an order for an x-ray (used to generate images of tissues and structures inside the body) of the left hip was ordered.

Continued review revealed that the X-ray result was inconclusive for a fracture and a computerized tomography scan (CT) (imaging that uses X-ray techniques to create detailed images of the body) was ordered. Further review revealed that the CT result showed P#1 had a nondisplaced intertrochanteric fracture (hip fracture or broken hip. Hips that break between the bone bumps at the top of the thigh bone are said to have broken in the intertrochanteric area of the femur or hip) with adjacent soft tissue swelling. It is additionally noted that P#1's insurance was out of network (OON) so staff were working on finding a facility with orthopedics where they could transfer P#1.

Continued review of "Provider Note", medical decision-making, dated 4/3/24, revealed that Medical Doctor Resident (MDR) JJ noted, "I considered need for additional hospitalization/observation and further care including: Patient will need orthopedic consult as her left hip CT showed nondisplaced intertrochanteric fracture with adjacent soft tissue swelling. Patient insurance was out of network so working on finding a facility with orthopedics that we can transfer her to. If not, we will consult our orthopedic group for inpatient medicine. The patient has uncontrolled type 2 DM."

A review of "Case Management Clinical Note", dated 4/2/24 at 3:20 a.m., revealed that social worker (SW) WW was contacted by an ED provider to seek assistance with facilitating P#1's transfer. It was noted that P#1 was OON with her insurance but planned to stay at facility #1 and that OON benefits would be provided unless P#1 decided otherwise.

Continued review revealed that SW WW instructed staff that P#1 would need to sign an OON form (confirming that she understood that she would be responsible for the bill and hospital payments) to stay or begin the in-network process where the MD would call where she would want to go to secure an accepting MD at one of the facilities she could choose from.

A review of "Flowsheets", dated 4/3/24 at 1:08 a.m., revealed that the risks and benefits of transfer were discussed with P#1. The reason for transfer was noted as "specialized treatment or services."

A review of "ED Timeline", dated 5/3/24 at 3:11 a.m., revealed that EMS arrived, received report, and transported P#1 to facility #2.

A review of P#1's MR from facility #2 revealed that P#1 was transferred from facility #1 and arrived at facility #2 on 4/3/24 at 4:01 a.m. P#1 was diagnosed with a nondisplaced intertrochanteric fracture of the left femur. Further review revealed that upon arrival at the ED, an orthopedic surgeon was consulted, and P#1 was prepped for the operating room (OR).

During an interview on 5/21/24 at 3:30 p.m. in a conference room with Registered Nurse (RN) NN, RN NN stated that she has been an ED Nurse for the facility since 2/23. RN NN was unable to recall caring for P#1 during her admission because the ED treats quite a few patients with hip fractures. She said that her primary focus is caring for the patients and not what insurance patients have. She said that out-of-network (OON) patients are identified with "OON" next to the patient's name on the ED patient tracker board. RN NN is unsure who is responsible for placing the identifier and she does not know whether or not the facility transfers OON patients regularly. She added that her role in preparing patients for transfer as an RN is to prepare the transfer form, ask the patient if they have any questions, and provide the patient with an ETA. RN NN said that occasionally she will ask her Charge Nurse why a patient is being transferred but she doesn't make it standard practice to ask because the decision doesn't involve her.

A telephone interview was conducted on 5/21/24 at 4:10 p.m. with Orthopedic Surgeon (OS) DD. OS DD stated that he has been an on-call Orthopedic Surgeon with facility #1 for two years. He explained that facility #1's orthopedics group specializes in hip fracture surgeries and non-complicated pelvic injuries. He added that major pelvic injuries, complicated hip fractures, and acetabular surgeries would be transferred to facility #1's flagship campus. OS DD stated that hip fractures are considered a higher acuity level that typically requires surgical intervention within 24-48 hours. He added that the only instance a patient with a hip fracture would be transferred out of facility #1 would be due to potential complications in which case the patient would be transferred to the flagship campus. OS DD said that he never looks at or considers what insurance a patient has and that he would be shocked if facility #1 transferred a patient with a hip fracture to another facility due to insurance. The only way he could see that happening was if a patient had a low acuity injury, but high acuity patients need to be treated right away.

A telephone interview was conducted on 5/22/24 at 7:45 a.m. with a Doctor of Osteopathic Medicine (DO) II, DO II stated that he is a nightshift ED physician for facility #1. He said that he assumed care of P#1 on 5/2/24 when he came on shift. DO II recalled P#1 presented at the ED for hip pain and was ultimately diagnosed with a hip fracture. He said P#1 was offered the choice to be admitted to facility #1 for treatment or to be transferred to a facility that was within her insurance network. He recalled P#1 and P#1's family expressing with great desire to be transferred to facility #2 for treatment because facility #2 was in-network with P#1's insurance. DO II said that he did not speak directly with P#1 or P#1's family but that the nurses would relay information to him. He explained that registration is responsible for telling patients if their insurance is in-network or out-of-network. DO II considers hip fractures to be emergent injuries that require emergent admission. DO II explained that there are times when registration will add "OON" next to a patient's name on the patient tracker. He said it is a nonofficial way to communicate and has zero bearing on patient disposition.

During an interview on 5/22/24 at 9:30 a.m. with Patient Access Representative Manager (PARM) PP in a conference room, PARM PP stated that she has worked in patient access for 15 years and began working for facility #1 in 2016. PARM PP said that once the provider has performed the MSE it will be notated on the patient tracker board. A patient access representative (PAR) will run the patient's insurance through a program called, "real-time eligibility" (RTE) to determine the patient's benefits. A PAR will go over the insurance benefits with the patient and collect a copay or deposit for self-pay customers if applicable. If the patient is OON, they will have them sign a "Beneficiary Notification Letter" and discuss the "Surprise Billing Letter" with them. The PAR will add "OON" next to the patient's name on the patient tracker board to alert case management (CM). PARM PP said that "OON" is not added to alert all of the ED staff, but it is there to let case management know because that patient is going to be an inpatient admission. She added if it is a Keiser patient, they will add "Keiser" next to the patient's name on the patient tracker board, so it is known the patient is OON. She explained that management encourages admission versus transfer when it is after hours, and case management is unavailable.

During an interview on 5/22/24 at 9:55 a.m. with Emergency Department Medical Director (EDMD) OO in a conference room, EDMD OO stated that he has been the EDMD at facility #1 for five years. EDMD OO said that when someone presents to the ED with a hip fracture they would be checked in, undergo a work-up, and have blood work done for pre-op because hip fractures usually require surgical treatment. He added that he would have someone from internal medicine or orthopedics do a consultation with the patient to formulate a treatment plan for the patient. EDMD OO said he does not usually know if a patient is OON or not. He added that registration will sometimes send "e-chats" to let the team know that a patient is OON. When this surveyor asked why it would be necessary or pertinent for registration to let providers know in an "e-chat" if a patient is OON? EDMD OO said the information is not pertinent to the doctors and he does not know why registration tells them. He speculated that maybe it is so doctors will know case management is going to be involved. He added that it is his expectation of ED staff to initiate care regardless of payment.

During an interview on 5/22/24 at 10:30 a.m. with Case Management Manager (CMM) QQ, in a conference room, CMM QQ stated that she has been a CMM for facility #1 since 2019. CMM QQ said that CM will collaborate with the providers when a patient is OON. She said that there is a CM column on the ED patient tracker board where registration will add "OON" so case management can identify which patients are OON. CMM QQ said she is unsure whether that information is visible to all ED staff or if it is visible only to members of the CM team. She added that CM will approach a patient about being OON once they are stabilized. CMM QQ said that registration will review the "Surprise Billing Letter" with OON patients, but she is not sure what specific verbiage registration uses.

During an interview on 5/22/24 at 5:00 p.m. with RN HH in a conference room, RN HH stated that she has been an ED nurse for facility #1 for two years. She said that facility #1 does not typically transfer patients with a hip fracture to another facility but sometimes it happens. She said that facility #1 will keep OON patients and provide treatment if the receiving hospital refuses the transfer, which occasionally occurs. RN HH said that when a patient is out-of-network with their insurance and going to be admitted someone will add "OON" next to the patient's name on the patient tracker board. RN HH said that registration will collaborate with the doctors on deciding whether ONN patients will be transferred to another facility. She said that patients with hip fractures are considered to be of a high acuity level. She added that if a patient were dyslexic, she would make sure she verbally explained the consent information to the patient. RN HH said her understanding of EMATALA is that if a patient needs emergent care and treatment, treatment should not be delayed due to insurance. She further said that she receives EMTALA training annually.

A telephone interview was conducted on 5/23/24 at 9:50 a.m. with the ED Flow Coordinator (FC) LL for Facility #2. FC LL stated that she remembered taking the patient report from an RN at facility #1 because she was told P#1 was being transferred to their facility for an orthopedic service. FC LL recalled a provider in facility #2's ED inquiring about why facility #1 was transferring a patient for orthopedics when facility #1 had orthopedic services. She further recalled that the nurse explained to her that P#1's insurance was OON with their facility and the patient wanted to be transferred to a facility that is within her insurance network. FC LL said that ED staff at facility #2 began looking up EMTALA regulations because they didn't feel like the transfer was entirely appropriate and were trying to discern appropriateness based off EMTALA regulations.

During a telephone interview on 5/23/24 at 12:55 p.m. with OS RR, OS RR stated that he works as an on-call OS for facility #2 and could recall everything about P#1's case because of the circumstances surrounding her transfer. OS RR said that he received a call from facility #2's ED to let him know he had a patient with a fractured hip coming in as a transfer from facility #1. He said he was immediately concerned because he knew that facility #1 had the capability of providing orthopedic services to P#1 so he wondered why they were transferring a patient over. He recalled P#1 explaining to him that facility #2 had told her that her insurance was not in-network with them and that she would be stuck with the bill if she did not transfer to a facility for treatment that was within her insurance network. OS RR said that P#1 seemed very confused about the insurance and transfer issue when he spoke with her. He added that she seemed as if she was coerced into the transfer. He further added that P#1's fracture was straightforward and could have been treated by any OS on-call and there was no reason why it couldn't have been done at facility #1. OS RR recalled telling P#1 that what facility #1 did was an EMTALA because she did not elect to break her hip, it was an emergent admission, and as long as facility #1 had the capabilities to treat her injury, they were obligated to treat her regardless of whether her insurance was in-network or OON. OS RR said that he reported the situation to facility #2's Chief Medical Officer (CMO). He followed up with the CMO who explained that he listened to facility #2's phone recording and felt there was not much he could do because the RN from facility #1 made it sound like P#1 requested the transfer.

During a telephone interview on 5/24/24 at 10:30 a.m. with EDMD VV, EDMD VV stated that he has worked for facility #2 for 20 years. He said he did not physically see P#1 when she arrived at the ED, but he had been notified about the details regarding P#1's transfer. EDMD VV said over the last few years facility #1 has transferred quite a few patients to them due to the patient being OON. He said facility #1 will say the patient requested it. He added that facility #2 will not deny the transfers because they are obligated to accept the transfers and treat the patients.

Cross Refer to 2408.