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Based on record review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to initiate the triage process or medically screen patients prior to utilizing a reasonable registration process by collecting insurance information. See A 2408.

Based on observation and interview the facility failed to post EMTALA signs in areas likely to be noticed by all individuals that visit the emergency department (ED). Findings include:

On 11/19/2012 at approximately 11:05 a.m. it was revealed during a tour of the ED, that patients entering the facility via ambulance would not be able to see the EMTALA signs that were posted in the waiting room. All ambulance traffic enters through the ambulance bay, which does not pass the EMTALA signs in the waiting room.

On 11/19/12 at approximately 1105 during an interview with staff A and staff B it was asked by this surveyor "How do the patients that enter by ambulance see the EMTALA signs?" Staff A stated "That's a good question. I don't think that they do."

Based on observation, interview and record review the facility failed to follow a reasonable registration process by failing to initiate the triage process or medically screen patients prior to requesting insurance information for 20 out of 20 patients reviewed (#1-#20) resulting in the potential to delay care and miss a medical emergency. Findings include:

On 11/19/2012 at approximately 1120 during observation of the triage process it was observed that staff F was the first hospital employee a patient would encounter when the patient presented to the emergency department (ED). Then staff F would ask for an ID, insurance information and have the patient sign a consent to treat and responsibility for payment. The patient would then see a triage nurse after submitting/signing the above information.

On 11/19/2012 at approximately 1120 during an interview with staff F it was confirmed that every patient who walks into the emergency department will first be seen by the patient care associate (PCA) who requests the ID, insurance information and has them sign a consent.

On 11/19/2012 at approximately 1130 during an interview with staff G a triage nurse, this surveyor asked "Do you collect the insurance information once you have completed your triage assessment?" Staff G stated "No that is done by the PCA before they see me."

On 11/19/2012 at approximately 1140 during an interview with staff H, a patient access associate (PAA), this surveyor asked "When do you see the patient and what do you do with them?" Staff H replied "I see them when I get time, it just depends on what's going on. I confirm their address and their insurance information to make sure it is correct." This surveyor then asked "Do you see the patient's before or after the doctors?" Staff H replied "I see them when I have time, so it could be before or after the doctor. Unless they are self pay [no insurance] then I wait for the doctor." This surveyor then asked "How do you know when the doctor see's them?" Staff H replied "I talk to the nurses."

On 11/19/2012 at approximately 1330 during medical record review for patient's #1-#20 it was revealed that every patient had insurance information collected before being seen by a triage nurse and a doctor, resident or physician assistant.

On 11/19/2012 at approximately 1330 during an interview with staff G it was confirmed that the patient's insurance information was collected and documented in the medical records (#1-#20) before seeing a physician.

On 11/19/2012 at approximately 1430 during review of the policy titled Patient Access Registration Standards to include Borgess Medical Center, Woodbridge, Borgess ED, Borgess Lee and Borgess Pipp it was stated under Procedure: "Registrars [PCA] will obtain an informed consent on all patients prior to treatment along with copies of insurance and ID card."