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Based on medical record review, review of transcripts of recorded conversations between physicians, interviews, policy reviews, review of hospital census records, and review of on call schedules, the facility failed to comply with the responsibilities of Medicare Hospitals in emergency cases for one patient (#2) of twenty six patients reviewed.

The findings included:

Review of Medical Records from Hospital #1 revealed Patient #2 presented to the Emergency Department (ED) at Hospital #1 on July 9, 2011, at 10:23 p.m., for complaint of drug overdose and suicide attempt. Review of the Emergency Patient Record revealed the patient had "drank a water bottle of antifreeze yesterday". Review of the ED physician's (MD #1) Emergency Room Report, dated July 9, 2011, revealed the patient's family was informed of the " ...potential lethality ..." of the patient's condition. Review fo the ED Physician's notes also revealed, "Clinical Impression ...Intentional overdose with ethylene glycol, with resulting metabolic acidosis and acute renal insufficiency" and "Disposition ...Transferred to ...Medical Center. Condition: Critical but stable."

Further review of the Medical Record at Hospital #1 revealed no documentation of Patient #2 requesting transfer to another facility. Review of the EMTALA Memorandum of Transfer form revealed no documentation of the patient requesting transfer to another facility. The reason for transfer documented on the EMTALA Memorandum of Transfer form was, "out of Network Amerigroup". The medical benefits documented on the Transfer form were, "In Network Facility".

Review of Medical Records from Hospital #2 revealed Patient #2 was admitted to the Medical Intensive Care Unit (MICU) at Hospital #2, on July 10, 2011, at 3:21 a.m. with diagnoses of Ethylene Glycol Poisoning, Metabolic Acidosis, Acute Kidney Injury, Depressive Disorder, Suicide Attempt, and Bipolar Disorder. Review of a Progress note dated July 11, 2011, revealed the patient was medically stable and was committed to a psychiatric facility on July 11, 2011, at 4:00 p.m.

Review of the transcript of a conversation recorded on July 10, 2011, at 1:33 a.m., between MD #1 and the Access Center staff at Hospital #2 discussing the transfer of Patient #2 to Hospital #2, revealed MD #1 stated, "...has an emergency medical condition, and her insurance is out of our network. Otherwise I'd admit...here."

Further review of the July 10, 2011, transcripts, on page 10, revealed at 2:01 a.m. Access Center staff asked MD #1, "You want to transfer...for higher level care...", and MD #1 answer to the Access Center staff was, "No, because...out of our insurance network...otherwise we could care for here, but may well need dialysis." Access Center staff then asked, "Do you guys do that?" and MD #1 stated, "Yep, this is purely insurance".

Further review of the July 10, 2011, transcripts revealed, on page 12, a recorded conversation between MD #1 and MD #2 (Physician on-call at Hospital #2), in which MD #1 stated, "...I would admit...here, but...is out of our insurance network, so I've got to transfer."

Interview with MD #1, by telephone, on July 19, 2011, at 2:00 p.m. revealed MD #1 remembered transferring Patient #2 on July 10, 2011. MD #1 stated, "the patient was potentially dangerously ill and needed admission to an ICU". MD #1 also stated Patient #2 could have been treated at Hospital #1, but was transferred to Hospital #2 because, "...was out of our network. This patient had Amerigroup Tenncare which is out of our network which means we have to transfer these people". MD #1 also stated he notified the patient regarding...out of network status and explained Hospital #1 did not accept the patient's insurance. MD #1 stated Patient #2 was depressed and uninterested in care, and did not respond when the transfer was discussed. MD #1 stated the patient had, "no response or preference in any manner regarding...care or transfer". MD #1 stated the patient's grandparents were present when the transfer was discussed. MD #1 stated the patient was stable enough for transfer but needed admission to an Intensive Care Unit (ICU).

Interview with Patient #2's grandmother (PGM), by telephone, on July 21, 2010, at 9:45 a.m., revealed PGM was present in the ED at Hospital #1 on July 9, 2011, and remembered the conversation regarding transfer from Hospital #1 to Hospital #2. PGM stated the patient and family were told, "Summit did not take...insurance and we would have to be transferred to..." PGM stated the patient did not request a transfer and the family present did not request a transfer. PGM stated they were "simply told...did not take...insurance and...would have to be transferred."

Interview with the Emergency Department Director, in the ED Employees Lounge, on July 20, 2011, at 11:00 a.m. confirmed there was no documentation of Patient #2 requesting to be transferred in the medical records for the July 9, 2011, ED visit. The ED Director confirmed it was the facility's policy to document the patient's request for transfer on the EMTALA Memorandum of Transfer form, and confirmed that Patient #2's request was not documented.

Interview with the Director of Case Management (DCM), on July 19, 2011, at 1:45 p.m. revealed Hospital #1 is not part of the Tenncare Amerigroup network which meant they do not recieve payment from this insurance network. The DCM stated patient's with Amerigroup insurance, are called "out of network". The DCM stated there were no written policies for handling out of network patients, but the facility followed instruction given by the insurance company. The DCM stated out of network patients recieve a Medical Screening Exam, and stabilizing treatment. The DCM stated stable out of network patients, that need additional treatment or hospitalization, are educated on the fact Hospital #1 does not accept their insurance, and the patient is given the choice of transfer to another hospital, or admission to Hospital #1.

Review of the facility's policy titled, "EMTALA-Transfer Policy" last review date May 2010, revealed, "The transfer of an individual shall not be predicated upon...economic status." The policy also states, "The request must be in writing and indicate the reasons for the request..."

Review of the Midnight Daily Census report for July 9, 2011, revealed Hospital #1 had six (6) Medical Intensive Care Unit Beds available on July 9, 2011.

Review of the Daily Call Schedule for July 9, 2011, revealed Hospital #1 had physician's on call for Internal Medicine, Urology, and Psychiatry specialties.

C/O # TN28385.

Based on medical record review, review of transcripts of recorded conversations between physicians, interviews, policy reviews, review of hospital census records, and review of on call schedules, the facility failed to assure that patient (#2) of twenty six patients was appropriately stabilized prior to transfer.

The findings included:

Review of Medical Records from Hospital #1 revealed Patient #2 presented to the Emergency Department (ED) at Hospital #1 on July 9, 2011, at 10:23 p.m., for complaint of drug overdose and suicide attempt. Review of the Emergency Patient Record revealed the patient had "drank a water bottle of antifreeze yesterday". Review of the ED physician's (MD #1) Emergency Room Report, dated July 9, 2011, revealed the patient's family was informed of the " ...potential lethality ..." of the patient's condition. Review of the ED Physician's notes also revealed, "Clinical Impression ...Intentional overdose with ethylene glycol, with resulting metabolic acidosis and acute renal insufficiency" and "Disposition ...Transferred to ...Medical Center. Condition: Critical but stable."

Further review of the Medical Record at Hospital #1 revealed no documentation of Patient #2 requesting transfer to another facility. Review of the EMTALA Memorandum of Transfer form revealed no documentation of the patient requesting transfer to another facility. The reason for transfer documented on the EMTALA Memorandum of Transfer form was, "out of Network Amerigroup". The medical benefits documented on the Transfer form were, "In Network Facility".

Review of Medical Records from Hospital #2 revealed Patient #2 was admitted to the Medical Intensive Care Unit (MICU) at Hospital #2, on July 10, 2011, at 3:21 a.m. with diagnoses of Ethylene Glycol Poisoning, Metabolic Acidosis, Acute Kidney Injury, Depressive Disorder, Suicide Attempt, and Bipolar Disorder. Review of a Progress note dated July 11, 2011, revealed the patient was medically stable and was committed to a psychiatric facility on July 11, 2011, at 4:00 p.m.

Review of the transcript of a conversation recorded on July 10, 2011, at 1:33 a.m., between MD #1 and the Access Center staff at Hospital #2 discussing the transfer of Patient #2 to Hospital #2, revealed MD #1 stated, "...has an emergency medical condition, and her insurance is out of our network. Otherwise I'd admit...here."

Further review of the July 10, 2011, transcripts, on page 10, revealed at 2:01 a.m. Access Center staff asked MD #1, "You want to transfer...for higher level care...", and MD #1 answer to the Access Center staff was, "No, because...out of our insurance network...otherwise we could care for here, but may well need dialysis." Access Center staff then asked, "Do you guys do that?" and MD #1 stated, "Yep, this is purely insurance".

Further review of the July 10, 2011, transcripts revealed, on page 12, a recorded conversation between MD #1 and MD #2 (Physician on-call at Hospital #2), in which MD #1 stated, "...I would admit...here, but...is out of our insurance network, so I've got to transfer."

Interview with MD #1, by telephone, on July 19, 2011, at 2:00 p.m. revealed MD #1 remembered transferring Patient #2 on July 10, 2011. MD #1 stated, "the patient was potentially dangerously ill and needed admission to an ICU". MD #1 also stated Patient #2 could have been treated at Hospital #1, but was transferred to Hospital #2 because, "...was out of our network. This patient had Amerigroup Tenncare which is out of our network which means we have to transfer these people". MD #1 also stated he notified the patient regarding...out of network status and explained Hospital #1 did not accept the patient's insurance. MD #1 stated Patient #2 was depressed and uninterested in care, and did not respond when the transfer was discussed. MD #1 stated the patient had, "no response or preference in any manner regarding...care or transfer". MD #1 stated the patient's grandparents were present when the transfer was discussed. MD #1 stated the patient was stable enough for transfer but needed admission to an Intensive Care Unit (ICU).

Interview with Patient #2's grandmother (PGM), by telephone, on July 21, 2010, at 9:45 a.m., revealed PGM was present in the ED at Hospital #1 on July 9, 2011, and remembered the conversation regarding transfer from Hospital #1 to Hospital #2. PGM stated the patient and family were told, "Summit did not take...insurance and we would have to be transferred to..." PGM stated the patient did not request a transfer and the family present did not request a transfer. PGM stated they were "simply told...did not take...insurance and...would have to be transferred."

Interview with the Emergency Department Director, in the ED Employees Lounge, on July 20, 2011, at 11:00 a.m. confirmed there was no documentation of Patient #2 requesting to be transferred in the medical records for the July 9, 2011, ED visit. The ED Director confirmed it was the facility's policy to document the patient's request for transfer on the EMTALA Memorandum of Transfer form, and confirmed that Patient #2's request was not documented.

Interview with the Director of Case Management (DCM), on July 19, 2011, at 1:45 p.m. revealed Hospital #1 is not part of the Tenncare Amerigroup network which meant they do not recieve payment from this insurance network. The DCM stated patient's with Amerigroup insurance, are called "out of network". The DCM stated there were no written policies for handling out of network patients, but the facility followed instruction given by the insurance company. The DCM stated out of network patients recieve a Medical Screening Exam, and stabilizing treatment. The DCM stated stable out of network patients, that need additional treatment or hospitalization, are educated on the fact Hospital #1 does not accept their insurance, and the patient is given the choice of transfer to another hospital, or admission to Hospital #1.

Review of the facility's policy titled, "EMTALA-Transfer Policy" last review date May 2010, revealed, "The transfer of an individual shall not be predicated upon...economic status." The policy also states, "The request must be in writing and indicate the reasons for the request..."

Review of the Midnight Daily Census report for July 9, 2011, revealed Hospital #1 had six (6) Medical Intensive Care Unit Beds available on July 9, 2011.

Review of the Daily Call Schedule for July 9, 2011, revealed Hospital #1 had physician's on call for Internal Medicine, Urology, and Psychiatry specialties.

C/O # TN28385.

Based on medical record review, review of transcripts of recorded conversations between physicians, interviews, policy reviews, review of hospital census records, and review of on call schedules, the facility failed to appropriately transfer one patient (#2) of twenty six patients reviewed.

The findings included:

Review of Medical Records from Hospital #1 revealed Patient #2 presented to the Emergency Department (ED) at Hospital #1 on July 9, 2011, at 10:23 p.m., for complaint of drug overdose and suicide attempt. Review of the Emergency Patient Record revealed the patient had "drank a water bottle of antifreeze yesterday". Review of the ED physician's (MD #1) Emergency Room Report, dated July 9, 2011, revealed the patient's family was informed of the " ...potential lethality ..." of the patient's condition. Review fo the ED Physician's notes also revealed, "Clinical Impression ...Intentional overdose with ethylene glycol, with resulting metabolic acidosis and acute renal insufficiency" and "Disposition ...Transferred to ...Medical Center. Condition: Critical but stable."

Further review of the Medical Record at Hospital #1 revealed no documentation of Patient #2 requesting transfer to another facility. Review of the EMTALA Memorandum of Transfer form revealed no documentation of the patient requesting transfer to another facility. The reason for transfer documented on the EMTALA Memorandum of Transfer form was, "out of Network Amerigroup". The medical benefits documented on the Transfer form were, "In Network Facility".

Review of Medical Records from Hospital #2 revealed Patient #2 was admitted to the Medical Intensive Care Unit (MICU) at Hospital #2, on July 10, 2011, at 3:21 a.m. with diagnoses of Ethylene Glycol Poisoning, Metabolic Acidosis, Acute Kidney Injury, Depressive Disorder, Suicide Attempt, and Bipolar Disorder. Review of a Progress note dated July 11, 2011, revealed the patient was medically stable and was committed to a psychiatric facility on July 11, 2011, at 4:00 p.m.

Review of the transcript of a conversation recorded on July 10, 2011, at 1:33 a.m., between MD #1 and the Access Center staff at Hospital #2 discussing the transfer of Patient #2 to Hospital #2, revealed MD #1 stated, "...has an emergency medical condition, and her insurance is out of our network. Otherwise I'd admit...here."

Further review of the July 10, 2011, transcripts, on page 10, revealed at 2:01 a.m. Access Center staff asked MD #1, "You want to transfer...for higher level care...", and MD #1 answer to the Access Center staff was, "No, because...out of our insurance network...otherwise we could care for here, but may well need dialysis." Access Center staff then asked, "Do you guys do that?" and MD #1 stated, "Yep, this is purely insurance".

Further review of the July 10, 2011, transcripts revealed, on page 12, a recorded conversation between MD #1 and MD #2 (Physician on-call at Hospital #2), in which MD #1 stated, "...I would admit...here, but...is out of our insurance network, so I've got to transfer."

Interview with MD #1, by telephone, on July 19, 2011, at 2:00 p.m. revealed MD #1 remembered transferring Patient #2 on July 10, 2011. MD #1 stated, "the patient was potentially dangerously ill and needed admission to an ICU". MD #1 also stated Patient #2 could have been treated at Hospital #1, but was transferred to Hospital #2 because, "...was out of our network. This patient had Amerigroup Tenncare which is out of our network which means we have to transfer these people". MD #1 also stated he notified the patient regarding...out of network status and explained Hospital #1 did not accept the patient's insurance. MD #1 stated Patient #2 was depressed and uninterested in care, and did not respond when the transfer was discussed. MD #1 stated the patient had, "no response or preference in any manner regarding...care or transfer". MD #1 stated the patient's grandparents were present when the transfer was discussed. MD #1 stated the patient was stable enough for transfer but needed admission to an Intensive Care Unit (ICU).

Interview with Patient #2's grandmother (PGM), by telephone, on July 21, 2010, at 9:45 a.m., revealed PGM was present in the ED at Hospital #1 on July 9, 2011, and remembered the conversation regarding transfer from Hospital #1 to Hospital #2. PGM stated the patient and family were told, "Summit did not take...insurance and we would have to be transferred to..." PGM stated the patient did not request a transfer and the family present did not request a transfer. PGM stated they were "simply told...did not take...insurance and...would have to be transferred."

Interview with the Emergency Department Director, in the ED Employees Lounge, on July 20, 2011, at 11:00 a.m. confirmed there was no documentation of Patient #2 requesting to be transferred in the medical records for the July 9, 2011, ED visit. The ED Director confirmed it was the facility's policy to document the patient's request for transfer on the EMTALA Memorandum of Transfer form, and confirmed that Patient #2's request was not documented.

Interview with the Director of Case Management (DCM), on July 19, 2011, at 1:45 p.m. revealed Hospital #1 is not part of the Tenncare Amerigroup network which meant they do not recieve payment from this insurance network. The DCM stated patient's with Amerigroup insurance, are called "out of network". The DCM stated there were no written policies for handling out of network patients, but the facility followed instruction given by the insurance company. The DCM stated out of network patients recieve a Medical Screening Exam, and stabilizing treatment. The DCM stated stable out of network patients, that need additional treatment or hospitalization, are educated on the fact Hospital #1 does not accept their insurance, and the patient is given the choice of transfer to another hospital, or admission to Hospital #1.

Review of the facility's policy titled, "EMTALA-Transfer Policy" last review date May 2010, revealed, "The transfer of an individual shall not be predicated upon...economic status." The policy also states, "The request must be in writing and indicate the reasons for the request..."

Review of the Midnight Daily Census report for July 9, 2011, revealed Hospital #1 had six (6) Medical Intensive Care Unit Beds available on July 9, 2011.

Review of the Daily Call Schedule for July 9, 2011, revealed Hospital #1 had physician's on call for Internal Medicine, Urology, and Psychiatry specialties.

C/O # TN28385.