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Based on interview and document review, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, as evidenced by the deficient practice cited at 42 CFR489.24 (d) (4-5).

Based on observation, the hospital failed to post EMTALA signs in a location that was easily noticeable by persons entering the emergency department and persons waiting for examination and treatment. Findings include:

Observations on 05/04/12 at 10:55 a.m. revealed that the pediatric portion of the hospital had posted the EMTALA signage in a corridor leading to the examination and treatment area of the childrens' ED, which was at a 90-degree angle from the emergency department waiting room and approximately fourteen feet from the Security check-in point for patients entering the emergency department. The corridor where the EMTALA signage was posted was in the opposite direction from where patients were directed to wait for examination and treatment, and was not visible from the emergency department waiting room. The EMTALA signage was visible only to those individuals who walked towards the examination and treatment area, which was around the corner from the emergency department waiting room.

Based on documentation, the hospital failed to maintain a central log in the emergency department (ED) that accurately tracked the care and disposition of each patient in 6 of 39 patients reviewed (Patients #6, #7, #8, #9, #11, and #12). Findings include:

The medical record of Patient #6 indicated that she presented to the ED on 03/30/11 at 11:11 a.m. for evaluation of right lower quadrant pain. An imaging study at 2:47 p.m. indicated that a CT was performed and was negative for appendicitis. The ED notes at 4:51 p.m. indicated that Patient #6 reported to non-nursing staff that "this is taking too long" and then eloped. The nurse found Patient #6's gown on the bed, as well as the patient's IV, which the patient had removed prior to eloping. The ED log for 03/30/11 did not include any information about Patient #6 or that Patient #6 had ever presented to the ED. Patient #6's name was absent from the ED log on 03/30/11.

The ED log on 03/29/11 indicated that Patient #7 arrived at the ED at 5:15 p.m. The ED log did not indicate a reason or diagnosis for Patient #7's arrival, nor did it indicate Patient #7's disposition. Patient #7's medical record face sheet indicated that Patient #7's expected time of arrival on 03/29/11 was 5:15 p.m., at which time he was roomed. The face sheet reflected that the patient was subsequently discharged at 5:17 p.m., but the discharge disposition section of the face sheet indicated that Patient #7 "never arrived." Information on the patient's medical record face sheet and ED log was contradictory and incomplete.

The medical record of Patient #11 indicated that the patient presented to the ED on 03/28/11 at 5:28 p.m. for evaluation of shortness of breath and cold symptoms. The ED record indicated that Patient #11 left without being seen at 8:55 p.m. The ED log for Patient #11 was incomplete and did not include the date or time of Patient #11's arrival to the ED, nor did it include Patient #11's disposition or diagnosis on 03/28/11.

The medical record of Patient #9 indicated that she arrived to the ED on 03/31/11 at 4:12 p.m. for evaluation of increasing pain with any movement to the left lower quadrant and buttock, after having fallen three days earlier. The ED record indicated that Patient #9 left without being seen at 6:48 p.m., because she was unwilling to wait any longer to be seen by a physician. The ED log for Patient #9 was incomplete and did not indicate the date or time that Patient #9 presented to the ED, nor did it indicate Patient #9's diagnosis on 03/31/12.

The medical record of Patient #8 indicated that he presented to the ED on 04/16/12 at 5:30 p.m. for evaluation of right hip pain. The ED record indicated that Patient #8 was roomed at 6:07 p.m. and at 8:19 p.m., Patient #8's call light was on and he was asking when he would be evaluated by a physician. The ED notes indicated that Patient #8 was advised that ED patients were seen in order of their acuity and that he would be seen by a physician as soon as it was possible. The ED notes at 8:26 p.m. indicated that that Patient #8 signed out AMA (against medical advice) because he wasn't willing to wait any longer to be seen by a physician. The ED log for Patient #8 was incomplete and did not include a diagnosis for Patient #8 on 04/16/12.

The medical record of Patient #12 indicated that she presented to the ED on 07/08/11 at 2:54 p.m. for evaluation of depression. The ED record indicated that Patient #12 was roomed at 3:04 p.m. and then transferred to the behavioral emergency department at 3:24 p.m. The ED record indicated that Patient #12 left without being seen at 4:45 p.m. The ED log for Patient #12 was incomplete and did not include a diagnosis for Patient #12 on 07/08/11

Based on interview and document review, for two of three patients reviewed who presented to the hospital with an emergency medical condition (EMC) and who had not yet completed a medical screening examination (MSE) and stabilizing treatment (Patients #32 and #28), the hospital failed to utilize a reasonable registration process that does not unduly discourage individuals from remaining for further evaluation. In addition, for one of one patient (#1) who presented to the hospital for an evaluation of an EMC, the hospital failed to utilize a reasonable registration process when they requested the co-pay before the MSE had been completed. Findings include:

During ten of ten interviews of hospital registration staff conducted between 05/02 through 05/05/12, it was determined that the hospital's registration practice and policy was to request patient payment of either the current hospital charges or past hospital debts, after the MSE was initiated, but before the MSE was completed and, as applicable for patients with an EMC, before the patient's stabilizing treatment was completed. Registration staff were trained to ask for co-payments, co-insurance, and past due amounts when patients were still receiving examination and treatment required under EMTALA.

The observed practice in the ED, during the investigation from 05/02 - 05/05/12, established that registration staff had discontinued asking patients for co-insurance amounts and past due hospital bills, but registration staff continued to ask patients for insurance copayments.

Registration staff interviewed, between 05/02 - 05/05/12, all confirmed that they had been trained by the hospital to collect payments from patients, through a "scripting" process that did not allow the patient to opt out of immediate payment. (Registration staff were employed by the hospital but required to take direction from a hospital contractor (Accretive) in the manner in which they accomplished their work). Not only were registration staff required to ask patients for co-payments, co-insurances, and outstanding balances, but registration staff were also required to aggressively pursue setting up a payment plan for the patient, if the patient was unable to pay the full amount at the point of service. Registration staff were required to tell the patient that the hospital accepted cash, checks, and a variety of credit cards. All of the registration staff stated they were uncomfortable with the "scripting," but were required by Accretive staff to implement it. The registration staff were given weekly quotas regarding how much money they were each required to collect from patients.

Director of Patient Access & Finance/(H) was interviewed on 05/02/12 at 12:55 p.m. She stated that approximately two years ago, management contracted with a company to increase the hospital's revenue at the patient's point of service. (Registration staff were employed by the hospital but required to take direction from a hospital contractor (Accretive) in the manner in which they accomplished their work). Debt collection from patients was accomplished in three ways: collecting the patient's insurance co-payment at the time service was rendered, collecting the patient's co-insurance at the time service was rendered (the portion of the patient's charges that were estimated to be uncovered by the patient's insurance carrier), and collecting outstanding balances the patient had from former hospital services, at the time new service was being rendered. The contractor had designed computerized tools which provided financial information to the hospital's registration staff who registered patients for hospital services in the emergency departments. The hospital's registration staff were trained to utilize the tools to collect money from patients and check the patient's prior balance, at the point of service. Registration staff were trained by "scripting" their conversation with patients, to increase a better outcome with debt collection and cash flow. The training was assertive scripting and registration staff were coached and shadowed to increase success when patients owed the hospital money.

During observations conducted of patients in the emergency department on 5/02/12 from 10:20 a.m. to 11:30 a.m., Patient #1 was interviewed at 10:50 a.m. in his ED exam room. He was alert, oriented, and talkative. He stated he presented to the ED that morning with a sudden onset of bright red rectal bleeding. When he arrived at the ED, he was roomed immediately and was seen by a physician within minutes of being roomed. Shortly after the physician left his exam room, a hospital employee came into his room with a cart that had a computer on it. The employee asked him some questions such as his name and address, and verified his insurance information. "While a nurse inserted my IV," the employee asked him to pay his $75.00 insurance co-payment, which he paid with a credit card.

The registration process was started after the MSE was initiated but before the MSE was completed, the patient was asked to pay a $75.00 co-pay. According to documentation on the ED log, Patient #1 was admitted to the hospital for stabilization of his EMC.

Patient #32's medical record indicated that she arrived by ambulance to the emergency department (ED), from an urgent care, on 03/18/12 at 11:00 a.m. She had symptoms of chest discomfort, chills, sweats, and an elevated temperature of 101 degrees. The patient was roomed and triaged at 11:07 a.m.


A medical screening examination (MSE) was initiated by a physician at 11:31 a.m., at which time an intravenous infusion of sodium chloride was started.


Patient #32's diagnostic tests included blood drawn for laboratory studies. The record indicates that other tests and treatments were ordered.


The chest x-ray and EKG was obtained at 11:40 a.m. The chest x-ray confirmed a diagnosis of left-sided pneumonia.


Patient #32 received oral and intravenous antibiotics at 12:57 p.m. The patient received further treatment, education and instructions, and was discharged to home on a course of oral antibiotic therapy.


The hospital did not have an established system in place to identify the time the registration process began. There was no documentation in Patient #32's medical record identifying the time that Patient #32 was registered by hospital staff, however, according to Patient #32's interview, the registration process occurred between her blood draw and her chest x-ray.


Patient #32 was interviewed on 05/25/12 at 1:05 p.m. She stated she was taken by ambulance from an urgent care to the ED on 03/18/12. She had symptoms of chest pain and difficulty breathing. She thought she was having a heart attack. She had never had an emergency room encounter in her lifetime and when they transported her from the urgent care to the ED in an ambulance, she was anxious and "scared out of my mind." When she got to the ED, the staff roomed her immediately, assisted her into a hospital gown, and applied a cardiac monitor. The physician came in to examine her right away, indicating lab studies and a chest x-ray would be completed. After the lab drew the blood work, an employee came into her exam room. She had a rolling cart with a computer on it and asked her some general questions like her name and address, and then told her that she owed the hospital $672.00 for services she had received so far that day. She told the employee to leave her room and the employee complied. She was "angry, scared, and appalled" that a hospital employee would ask her for money when she thought she was having a heart attack. She felt this was "unethical." Shortly after the employee left the exam room, she was taken for a chest x-ray. The physician then updated her that she had pneumonia and intravenous antibiotics were administered. The physician advised her that she should be hospitalized overnight, but she opted to discharge because she had already been informed that she owed the hospital $672.00 and she wasn't sure she had the financial resources to pay the bill. Patient #32 stated that the hospital's debt collecting practices discouraged her from considering overnight hospitalization for further treatment and monitoring of her condition.

Twenty-four minutes after Patient #32 was roomed in the ED on 03/18/12 with symptoms of chest discomfort, sweats, and chills, hospital staff told Patient #32 she owed $672.00 for services the patient incurred so far that day and asked her to pay the bill. This payment was requested by hospital staff before the patient received a complete medical screening examination to determine any necessary stabilizing treatment the patient required. The patient was asked for money before cardiac issues were ruled out and before she received any stabilizing treatment to address her emergency medical condition related to her diagnosis of pneumonia.

Patient # 28's medical record was reviewed and indicated that an ambulance was called to her workplace on 02/03/12 because she had a sudden onset of sharp abdominal pain that worsened when taking deep breaths. The patient arrived by ambulance to the emergency department (ED) on 02/03/12 at 5:25 p.m. with an emergency medical condition.

The patient was triaged and roomed at 5:27 p.m. A medical screening examination (MSE) was initiated by a physician at 5:43 p.m. Laboratory studies were drawn at 5:45 p.m. Before the completion of the MSE and prior to the stabilizing treatment the registration took place at the patient's bedside and during this registration, the patient was asked to pay an outstanding debt. According to Patient #28's interview, the registration process began immediately after the lab staff drew her blood sample.

Patient #28 was interviewed on 05/29/12 at 10:10 a.m. She stated she was having significant abdominal pain with burning pain in her back, when she arrived in the ED on 02/03/12. She was taken to an exam room immediately upon arrival where she was greeted and assessed by a nurse, who started an intravenous infusion. Shortly afterward, a physician came into her room and examined her. The physician asked her many questions and assessed her pain. Laboratory personnel drew blood samples. After the lab staff left her exam room, an employee came to her bedside, registered her as an ED patient, and asked her to pay her bill from a previous visit, which was $527.00. She was "speechless" that someone would ask her for money, in the midst of "agonizing" pain that was so intense she could not "think clearly." She thought this practice was rude and uncaring, and it made her fearful that ED staff would not treat her acute condition if she didn't pay the money.