HospitalInspections.org

This STANDARD is not met as evidenced by:

Based on interview, record review, review of the facility's policy, and review of facility "Medical Staff Rules and Regulations", it was determined the facility failed to have an effective system in place to ensure one (1) of twenty-four (24) sampled patients (Patient #1), who presented to the Emergency Department (ED) received an appropriate Medical Screening Exam (MSE) to determine whether or not an emergency medical condition existed.

The findings include:

Review of the facility's Medical Staff Rules and Regulations, last revised February 2012, revealed qualified medical personnel would perform a MSE for all persons that present to the ED.

Review of the facility's policy titled, "Medical Screening Exam", start date 03/01/13, last review date 12/01/16, revealed the purpose was to establish and define the rights of all patients to the access of a MSE regardless of ability to pay for services.

Review of the facility's policy titled, "Credit and Collection", approval date 11/18/16, revealed
payment is not to be collected from patients until after a MSE and treatment has been provided (related to the ED).

Review of the medical record revealed Patient #1 arrived at the ED, on 10/05/16 at 6:59 PM, with a complaint of chest pain. Record review revealed Patient #1 was triaged and an electrocardiogram (EKG) was completed by Registered Nurse (RN) #1 at 7:15 PM. Review of the EKG results revealed no abnormalities. Patient #1 was assigned to the Rapid Medical Exam (RME) Room #5 at 7:18 PM. Further review of the medical record revealed registration was completed at 7:36 PM by ED Registration Clerk #1.

Interview with RN #1, on 12/01/16 at 2:54 PM, revealed Patient #1 was triaged, then assigned a room because of his/her complaint of chest pain. Further interview with RN #1 revealed the EKG was normal. She stated the registration process was completed once the patient was seen by a provider and assigned a room.

Interview with ED Registration Clerk #1, on 12/01/16 at 1:25 PM, revealed, after completing the registration process, she informed Patient #1 he/she had a co-pay and asked how he/she wanted to pay. Further interview with Registration Clerk #1 revealed Patient #1 replied, "I can't believe a hospital is asking for money." She stated she informed Patient #1 a copay did not have to be paid at that time; however, Patient #1 left the ED without receiving a MSE.

Interview with the Advanced Practice Registered Nurse (APRN), on 12/01/16 at 3:30 PM, revealed as she entered Patient #1's room to perform a MSE, the patient was leaving the exam room. Further interview with the APRN revealed Patient #1 stated, "I can't believe a hospital is asking for money." The APRN revealed she informed the patient that a co-pay did not have to be collected at the present time; however, Patient #1 declined a MSE and left the ED.

Interview with the Chief Nursing Officer (CNO), on 12/01/16 at 2:10 PM, revealed registration staff were supposed to collect co-pays after triage initially.

Further interview revealed the following changes have occurred with the registration process, effective 11/01/16: when someone presents to the ED for care/treatment, there will be a quick registration process. This process consists of obtaining his or her name, date of birth, phone number, and the complaint to minimize delay in treatment. The CNO revealed the patient will then be triaged and have a MSE. After that, the registration process may be completed and the patient will be informed of the copay. Further interview revealed patients will be seen regardless of the ability to pay. Additionally, anyone who leaves the ED without being seen or against medical advice, the ED Nurse Manager will do a follow up with the patient to ensure services are still available at the facility and attempt to reconnect with the patient.

Prior to the investigation by Office of Inspector General (OIG), the facility self-reported the incident after conducting an internal investigation. Based on the facility's investigation, the allegation was substantiated and was corrected.

**The facility implemented the following actions to correct the deficient practice:

1. Obtain for review a copy of Lourdes medical staff by-laws detailing the Medical Screening Exam (MSE).

2. Obtain for review a copy of Patient Access Policy "Credit and Collections".

3. Retrain ER Registration staff to ensure MSE is completed before completing the registration process.

4. Ensure ED Registration staff and ED staff complete the EMTALA training online via I-Learn no later than 11/01/16.

5. Patient Access management provided face-to-face training on Credit and Collections policy specifically addressing ED patients to complete the registration process after a MSE is complete.

** The State Survey Agency validated the facility's plan of action was implemented by:

1. The Nurse Manager of the ED revealed she was the responsible person to review the facility's medical staff by-laws (date unknown), regarding the "Medical Screening Exam". The review, dated 12/01/16, revealed no revisions to the policy.

Interview with the Nurse Manager of the ED, on 12/01/16 at 2:15 PM, revealed there were no changes implemented to the "Medical Screening Exam" policy. Interview revealed the policy mandates a MSE is performed by a physician before the registration process is completed. Further interview revealed that has always been the facility's policy.

Interview with the CNO, on 12/01/16 at 2:10 PM, revealed when someone presented to the ED for care/treatment, there would be a quick registration process. The process consisted of obtaining his/her name, date of birth, phone number, and the complaint to minimize delay in treatment. The CNO revealed the patient would then be triaged and have a MSE. Further interview revealed the changes occurred with the registration process on 11/01/16.

2. Review of the Patient Access policy "Credit and Collections" dated 11/18/16, related to the ED revealed payment would not be collected from patients until after a MSE and treatment was provided.

Interview (post survey) with ED Registration Clerk #1, on 12/20/16 at 6:14 PM, revealed she attended in-service training in October 2016 conducted by the Patient Access Director/Manager, regarding the hospital's change in collection of copays at the time of registration.

Interview with the Patient Access Director, on 12/02/16 at 11:15 AM, revealed she was responsible to review the facility's policy, "Credit and Collections" dated 11/18/16. She revealed she was responsible to ensure registration staff in the out-patient areas were re-trained regarding collection of copays. Further interview revealed the facilty's policy related to ED registration was no collection of fees/copays from the patient until the patient has been seen by a provider and the MSE has been completed. Further interview revealed all registration and ED staff were mandated to have EMTALA training yearly.

3. Interview (post survey) with ED Registration Clerk #1, on 12/20/16 at 6:14 PM, revealed staff were mandated to complete the EMTALA web based training through I-LEARN and pass the posttest to ensure training was completed.

Interview (post survey) with RN #1, on 12/21/16 at 3:30 PM, revealed he was in-serviced regarding changes to the ED registration process by the ED Nurse Manager in October 2016. Further interview revealed changes to the registration process from a Triage Nurse's prospective were, "after a patient presenting to the ED was triaged, it was the Triage Nurse's responsibility to let the assigned Provider know the patient was ready for a MSE." Additional interview revealed the registration process would not be completed until the patient had a MSE. Copays were not collected prior to a patient being examined by a Physician, APRN, or PA. He revealed triage by an RN was not a MSE.

Interview (post survey) with the APRN, on 12/20/16 at 5:30 PM, revealed she was educated on changes in the ED registration process in October 2016 via an email she received from the ED Medical Director. She revealed education consisted of ensuring patients in the ED received a MSE prior to the registration process. The APRN revealed she also had to complete a mandatory EMTALA course through I-LEARN web training before November 2016, take a posttest after completing the training, and pass the competency with a score of 90% or greater. She revealed she e-signed an attestation acknowledgement upon completing the course, and emailed a copy of the posttest certificate to the ED Medical Director.

4. Interview with ED Registration Clerk #2, on 12/01/16 at 1:55 PM, revealed she completed mandatory EMTALA web training in October 2016. Interview revealed after completion of the EMTALA course, her supervisor, the Patient Access Director/Manager, viewed the staff's certificate of completion of the EMTALA training.

Post survey interview with the Patient Access Director, on 12/20/16 at 5:30 PM, revealed registration staff were re-trained 10/25/16 through 10/26/16 on the hospital's changes regarding the collection of copays during the registration process. Further interview revealed changes to the registration process started 11/01/16. Additional interview revealed registration staff were mandated and completed EMTALA training in the I-LEARN computer web based training with completion verified by her and the Patient Access Manager.