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Based on review of records, the ED (Emergency Department ) logs, and interview, it was determined that the facility failed to maintain a log that accurately reflected the disposition of patients who present to the ED, but who left prior to triage or registration.

Findings include:

Review of the ED logs on 11/25/13 found no reference regarding patients who present to the walk in triage area and who leave prior to registration.

During the ED tour on 11/25/13, nursing staff provided ED (Emergency Department ) documents ( "Triage Sign In" form) that the patients are given prior to triage. This pre-triage form is completed by patients, in which they write name and chief complaint. These forms are time stamped by the patient and left under the triage window. This activity was observed during the ED tour on 11/25/13 at approximately 11:00 AM

At interview with the triage nurse, the ED Nursing Manager, and the ED Medical Director on 11/25/13 at approximately 11 AM, it was stated that these forms are not kept for any period of time, and are not attached in or become part of the patient's ED record.

At interview with the triage nurse on 11/27/13 at approximately 3 PM, the nurse showed approximately 12 of these "forms" to the survey team, which had been filled out by the patients and stated that these would be placed in the shredder in the triage room at the end of the shift. She pointed to the paper shredder in the ED triage area. The nurse stated that she routinely shreds all of these pre-triage documents at the end of the shift.

During review of the ED log on 11/25/13 at approximately 12 PM, there was no documentation for any category assigned for patients who walk out prior to triage, but who leave after they have completed these forms. There was a category noted for "walk outs " on the ED log, but this designation referred only to patients who were registered.

It was also determined that patients who arrive by ambulance and who walk out prior to triage or before registration are not included in the ED Log as having walked out and no medical record of the encounter is made. During follow-up interview with the ED Medical Director and the ED Nurse Manager on 11/25/13 at approximately 2 PM, it was also stated that patients whose ACR (ambulance call report, which is a pre - hospital care report ) is signed by the triage nurse, but who walk out upon arrival and who are not triaged or registered, are not included in the ED log as "walk outs" . It was stated that these ambulance call reports (ACR's) for patients who walk out before triage are subsequently filed in the Medical Records Department.

At interview with the Medical Records Manager on 11/ 27/13 at 2 PM, it was stated that attempts are then made to reconcile the ambulance call reports for patients who walk out before triage with an existing prior medical record. However, it was also stated that attempts to reconcile these ACR's with existing medical records are usually not successful. These would be filed in a separate box as unattached medical records.

Based on review of records, documents, and policy, and staff interviews, it was determined that the hospital emergency department failed to ensure that patient stabilization is achieved prior to any inquiry made regarding the patient's method of payment or insurance status. This was identified in 1 of 33 emergency medical records reviewed. (Medical Record #1)


Findings include:


Review of investigative documents, including a written physician statement produced in reference to a grievance received for the patient in MR#1 on 11/25/13, found the physician consultant solicited a patient and a family member for payment for care at the time treatment was provided to the patient in the emergency room on 9/16/13.

Review of MR #1 on 11/25/13 at approximately 3 PM determined this 61 year old female walked in to the emergency room on 9/16/13 at 19:52 (7:52 PM) for complaint of laceration and bleeding to the back of the right leg while exiting a taxi.

The emergency department (ED) attending physician evaluated the patient at 21:42 (9:42 PM) and noted the patient had a 5 centimeter (cm) laceration on the back of the right calf into the muscle fascia (connective tissue). The physician noted "cannot pull edges over it, distal neuro and vasc intact, no limitation of foot extension". Under section of the note labeled "medical decision making" the differential diagnosis noted "deep laceration" and the care plan noted "complex laceration plan consult plastic surgeon".

At 22:22 hours (10:22 PM) the attending physician noted in the medical record "wound closed by our plastic surgeon, will put on keflex per his request and discharge for follow up in Kansas City". (The patient resided in Kansas City and keflex is an antibiotic medication used to prevent infection).


A grievance letter dated 10/16/13 was submitted to the hospital by the patient's spouse and was reviewed by the surveyor on 11/25/13 at 4 PM. The spouse described that a plastic surgeon on call to the emergency room had requested the patient pay for the consultation on 9/16/13, prior to provision of treatment to stabilize the bleeding wound. It was noted in this document that the physician stated the reasoning that the insurance companies are more responsive to patients than physicians and that by paying for care in advance, reimbursement would be expedited. The hospital received the correspondence on 10/23/13 and responded in writing to the spouse that the complaint would be investigated.

A written e-mail dated 11/6/2013 from the plastic surgeon to the Chief Medical Officer was reviewed on 11/25/13 at 4 PM, in which it was noted that as he worked on the patient by suture and staple closure of the wound, he discussed with the spouse that he is an out of network provider and that it was his custom to collect the fee by credit card. He noted that he told the spouse he would also provide a coded insurance form to submit for insurance reimbursement. He also noted the spouse agreed to this. The approximate fee of $3000 was discussed and the spouse did not disagree and signed a paper copy. The physician took the information to his office where the credit card was charged the next day.

In addition, review on 11/26/13 of grievance documentation included a copy of a form titled " Health Insurance Claim form" which noted a total charge $3000 and amount paid $3000 for services rendered on 9/16/13. The form was signed by the physician on 9/17/13.


The facility failed to follow EMTALA regulations which prohibit delay in required medical treatment in order to inquire about method of payment or insurance status.
Review of the hospital's procedure, no. A4-110, titled "Emergency Medical Treatment & Active Labor Act ( EMTALA)" on 11/25/13 found under section II for Medical screening examinations, that "A medical screening exam cannot be delayed in an attempt to secure verification or authorization from a third party payor". The hospital staff also did not follow this policy and procedure.

At interview with the Chief Medical Officer and Vice President of Risk Management on 11/26/13 at approximately 2 PM, it was stated that the plastic surgeon physician of record had acknowledged that he discussed payment with the patient and the family prior to providing care. Following provision of treatment, a copy of the credit card was obtained, and the plastic surgeon billed for care upon return to his private office.

Further, review of the ED medical record on 11/25/13 also determined there was no documentation of any interventions written by the consultant plastic surgeon in the emergency room. It was stated by the Risk Manager at interview on 11/26/13 that it is expected that the consultant physician document on a separate sheet the record of interventions for the consultation but that the document of the plastic surgeon's consultation in this record could not be located.