HospitalInspections.org

Based on observations, staff interviews, clinical record and document reviews, and review of the hospital's policies and procedures, Hospital 1's noncompliance with the requirements under EMTALA occurred when:

1. ED Staff did not enter Patient 100 into the ED Log [2405];

2. Hospital 1's Bylaws and Rules and Regulations did not contain information that determined personnel who were qualified to perform a Medical Screening Exam [2406]; and

3. Hospital 1 informed Patient 100 (prior to his medical screening exam) that his medical insurance was not contracted with the hospital. Patient 100 verbalized to staff that he did not want to get a bill, and subsequently left the ED without receiving medical care [2408]

Based on interview, review of the Emergency Department (ED) Central Log for all patients (patient name, arrival time, chief complaint, diagnosis, etc.), and review of the Hospital 1's policy and procedures, Hospital 1: 1) Failed to maintain an accurate Central log for 1 of 22 Sampled Patients (Patient 100) when Patient 100 presented to the ED on 3/28/2021 with a hand injury following a fall, but registration staff did not enter his name and other pertinent information into the Central Log; and 2) Failed to ensure all patients who presented to the ED seeking care were entered into the Central Log when 3 of 3 Patient Access/Registration staff, who worked in the ED, stated they did not enter all individuals into the Log.

These failure resulted in the potential inability of Hospital 1 to track the care provided to Patient 100 when he came to the ED for an emergency medical condition and potentially prevented Hospital 1 from tracking the care of other patients who presented to the ED seeking care.

(Central log - record reflecting the names and disposition of individuals presenting to the dedicated Emergency Department seeking or in need of examination or treatment for an emergency medical condition.)

Findings:

During an interview on 5/4/2021 at 9:45 a.m., Manager F stated Patient 100 had not been added to the ED Central Log and Hospital 1 did not have information regarding Patient 100 after he left the ED (on 3/28/2021). In a follow-up interview at 11:45 a.m., Manager F stated Patient 100's name and some demographic information had been entered into the Central Log three days after he came to Hospital 1's ED.

During a tour of the ED and interview on 5/4/2021 at 10:35 a.m., Staff L stated she worked in the ED as a Patient Access/Registration staff member (she registered patients on arrival). Staff L was asked about the patient registration process in the ED. Staff L stated she did a "Quick Registration" when patients initially presented to the department that included asking them why they were at the ED (chief complaint) and obtaining identification (drivers licence). Staff L stated a patient's name should go in (to the computer) as soon as they arrive. When asked what she would do if a patient entered the ED seeking care but decided to leave without being seen (by a physician/provider), Staff L stated she would not enter their name (in the log). When it was pointed out to Staff L that the facility would not be aware the patient had come to the hospital seeking care if their name was not logged, Staff L stated some patients say, "Pretend I wasn't here." She further stated some patients don't want to be tracked.

During a telephone interview on 5/4/2021 at 2:26 p.m., Patient 100 was asked about his experience at Hospital 1's ED on 3/28/2021. Patient 100 stated he did not speak good English and his brother was with him (for transportation and interpretation). Patient 100 stated he had broken his hand in an accident but Hospital 1 did not take his insurance. Patient 100 stated the woman at the window (in the ED) told him the hospital did not accept his insurance. When asked what he did when he found out Hospital 1 did not take his insurance, Patient 100 stated he left and his brother drove him to to Hospital 2. He stated Hospital 2 took X-rays and he later had surgery on 4/20/2021. Patient 100 stated his arm was, "good now" and he only needed the, "wires removed."

Review of an electronic document from Hospital 1, identified as a "Visit List" (undated), indicated Patient 100's admission date at Hospital 1's Emergency Department was 3/28/2021 at 1:57 p.m. The document further indicated the reason for Patient 100's visit was, "left hand pain" and he was, "discharged" on 3/28/2021 at 2:05 p.m. (eight minutes after arrival to the ED).

Review of Hospital 1's Central Log, dated 3/28/2021 (the date Patient 100 went to the ED), revealed Patient 100's name was not located on the log that day.

Review of Hospital 1's Central Log, dated 04/05/2021, indicated Patient 100's name and other information (chief complaint, checkout time, etc.), was located on the log on 4/5/2021 (eight days after he arrived at the ED).

During an interview on 5/5/2021 at 9:15 a.m., Administrator B (Admin B) was asked what individuals should be added to the ED Central Log. Admin B stated anybody who walks in (to the ED), seen or not (by a provider), should be added to the log. Admin B stated if the hospital does not know the person's name, they should enter, "John Doe" or "Jane Doe" as identifiers.

During an interview on 5/5/2021 at 11:07 a.m., Manager J was asked what should have happened regarding Patient 100's registration and the Central Log. Manager J stated Staff K should have registered Patient 100 into the system with a quick registration including his name, date of birth, chief complaint and address and phone number (if possible).

During a telephone interview on 5/5/2021 at 11:35 a.m., Staff K was asked about her experience with Patient 100 in the ED. Staff K stated she was the ED receptionist (on 3/28/2021) and Patient 100 came up to the window (located in the reception area of the ED) with a hand injury. Staff K stated Patient 100 was accompanied by a person who was acting as his translator. Staff K stated Patient 100 handed her his insurance card, she gave him a demographic form to fill out (name, date of birth, address, chief complaint), and she began to register him (in the computer). Staff K stated Patient 100's insurance was not contracted with Hospital 1 and she went to the nurses station because she was not sure what she should explain to him (about his insurance). Staff K stated the nurses and physician told her to, "give him his options" so he could make an intelligent decision. Staff K stated she went back to Patient 100 and told him, "We are willing to help you" but his insurance was not contracted with the hospital. Staff K stated Patient 100 kept saying, "I don't want a bill" and he, "chose to go to (Hospital 2)." When asked why she had deleted Patient 100 from the computer, Staff K stated he was a brand new patient, had not previously been in the system, and he was not seen (by a provider). When asked if Patient 100 should have remained in the system (and not been deleted), Staff K stated, "I don't know, I kept the paperwork (demographic form)."

During a interview on 5/5/2021 at 3:22 p.m., Staff M (who was a Patient Access/Registration staff member in the ED) was asked to describe the ED registration process. Staff M stated when a patient comes to the ED window, she asks for their name, chief complaint and identification, and then inputs them into the computer. Staff M stated if they were a new patient, she gave them a demographic form to complete. Staff M stated she was required to press the, "complete" button on the computer (after inputting their information) in order to register the patient. Staff M was asked what she would do if she had entered a patient's name and date of birth into the computer and the patient subsequently left the ED (and was not seen by a provider), Staff M stated she would not hit the "complete" button, "so it doesn't create a bill" (for the patient).

During a interview on 5/6/2021 at 1:30 p.m., Manager D was asked what should happen in the ED regarding documentation and registration of patients who present to the ED seeking care. Manager D stated the registration process should begin with the patient's name and demographic information being entered into the computer. Manager D stated patients asking for care (in the ED) should be entered into the system and if their names are not known, they should still be entered as "Jane Doe" or "John Doe."

Review of Patient 100's medical record form Hospital 2 indicated he arrived at the ED on 3/28/2021 at 2:49 p.m. (approximately forty-four minutes after leaving Hospital 1). The medical record indicated Patient 100's stated complaint was a, "fall from bicycle" with injury. Patient 100's head to toe assessment indicated his left wrist had, "swelling, tenderness, pain, (and) deformity." The ED provider documented, "Based on the patient's presentation to the ER today, the general diagnostic impression is left distal radius (arm bone) fracture and left ulnar (arm bone) styloid fracture, right wrist contusion (bruise), multiple abrasions (scraping of skin)."

Review of policy and procedure titled, "EMTALA - Central Log," subtitled, "B. Procedure" (revised 06/05/2019) indicated, "2. A log entry will be made for each individual who Comes to the Hospital seeding emergency care and treatment...An individual must be recorded in the Central Log even if he/she leaves the Hospital before Triage or receiving a Medical Screening Examination (MSE)...4. The log entry will contain...a. the name of the patient. b. The time of arrival. c. Patient medical number. d. The disposition of the patient, including: ...1. Left Without Being Seen - Before MSE..."

Based on staff interview and document review, the facility failed to specifically delineate who was qualified to conduct a Medical Screening Examination in their Bylaws or Rules and Regulations. This had the potential to create confusion as to who is able to conduct the examinations in the Emergency Department.

Findings:

During an interview on 5/5/21 at 9:15 a.m., Administrative Staff B stated neither the facility Bylaws, nor the Rules and Regulations delineated who was specifically qualified to conduct a Medical Screening Exam (MSE).

Review of the Medical Staff Bylaws, dated March 20, 2019, found no mention of EMTALA, nor which persons were qualified to conduct a MSE.

Review of the facility Rules and Regulations, approved by the Governing Board on September 2, 2015, found no mention of EMTALA, nor which persons were qualified to conduct a MSE.

Review of the Policy titled, "Model Policy: EMTALA--Medical Screening Examination (MSE) and Stabilization," last revised 6/5/19, indicated: "The Hospital and the Medical Staff will determine the categories of Qualified Medical Persons who may perform the Medical Screening Examinations. The Medical Staff bylaws or rules and regulations, as approved by the Hospital governing body, will designate the categories of Qualified Medical Persons in each Dedicated Emergency Department who are authorized to perform the Medical Screening Examination."

Based on patient/staff/physician interviews and review of facility policy and procedures, Hospital 1 failed to prevent a delay in the assessment and treatment of an emergency medical condition for 1 of 22 sampled patients (Patient 100) when Staff K, during the patient registration process, informed Patient 100 that his insurance was not contracted by the hospital. Patient 100 stated he did not want to get a bill and exited the Emergency Department, prior to receiving a Medical Screening Exam. This failure resulted in Patient 100 driving to another local hospital (Hospital 2), approximately 21 miles away. Patient 100 arrived at Hospital 2 approximately 45 minutes after leaving Hospital 1. Patient 100 was diagnosed with two fractures in his left arm (in his radius bone and ulnar bone) at Hospital 2 and he ultimately required surgical repair of the fractures.

Findings:

During a interview on 5/4/2021 at 1:51 p.m., Registered Nurse (RN) G stated she was working when Patient 100 came to the ED. RN G stated that Staff K was the Registration clerk at that time. RN G stated Staff K came back to the nurses station and told the nurses she had to tell Patient 100 we (Hospital 1) don't take his insurance. RN G stated she and RN's H and I told Staff K, "No, you can't do that." RN G stated Staff K told them she had to tell Patient 100 (about his insurance) because her boss had instructed to do so. RN G stated Physician E also told Staff K not to discuss insurance with Patient 100.

During a telephone interview on 5/4/2021 at 2:26 p.m., Patient 100 was asked about his experience at Hospital 1's ED on 3/28/2021. Patient 100 stated he did not speak good English and his brother was with him (for transportation and translation). Patient 100 stated he had broken his hand in an accident but Hospital 1 did not take his insurance. Patient 100 stated the woman at the window (in the ED) told him the hospital did not accept his insurance. When asked what he did when he learned Hospital 1 did not take his insurance, Patient 100 stated he left and his brother drove him to to Hospital 2. He stated Hospital 2 took X-rays and he had surgery on 4/20/2021. Patient 100 stated his arm was, "good now" and he only needed the, "wires removed."

Review of Patient 100's ED medical record from Hospital 1 (undated) indicated Patient 100's admission date at Hospital 1's Emergency Department was 3/28/2021 at 1:57 p.m. The record indicated the reason for Patient 100's visit was, "left hand pain" and he was, "discharged" on 3/28/2021 at 2:05 p.m. (eight minutes after arrival to the ED).

Review of Patient 100's medical record form Hospital 2 indicated he arrived at the ED on 3/28/2021 at 2:49 p.m. (approximately forty-four minutes after leaving Hospital 1). The medical record indicated Patient 100's stated complaint was a, "fall from bicycle" with injury. Patient 100's head to toe assessment indicated his left wrist had, "swelling, tenderness, pain, (and) deformity." The ED provider documented, "Based on the patient's presentation to the ER today, the general diagnostic impression is left distal radius (arm bone) fracture and left ulnar (arm bone) styloid fracture, right wrist contusion (bruise), multiple abrasions (scraping of skin)." His medical record further indicated he had surgery on his left arm on 4/20/2021.

During an interview on 5/5/2021 at 10:20 a.m., RN H stated she, RN G, RN I, and Physician E were at the nurses station when Patient 100 was in the ED. RN H stated Staff K was registering Patient 100 and she came to the back (where the nurse's station was located). RN H stated Staff K stated Hospital 1 did not take Patient 100's insurance and asked the nurses if she should tell him. RN H stated the nurses and Physician E were very clear when they told Staff K that the insurance issue was not a problem and to bring Patient 100 back (to be seen by the physician). RN H stated that Staff K told them her boss said she had to tell Patient 100 about his insurance. RN H stated she heard Staff K verbalize that Patient 100 was going to Hospital 2 (prior to his triage and MSE). RN H stated the nurses told Staff K to fill out a RADAR (internal incident report) because "you can't sent someone away due to finances."

During an interview on 5/5/2021 at 11:07 a.m., Manager J (Staff K's boss) was asked what should have happened regarding Patient 100 in the ED. Manager J stated Staff K should have registered Patient 100 into the system with a quick registration including his name, date of birth, chief complaint and address and phone number (if possible). Manager J stated Patient 100 should have been triaged by the nurse and seen by the physician, before insurance issues were addressed. Manager J stated Staff K should not have discussed insurance at the ED window or in the ED waiting room. Manager J stated there should be no discussion (of insurance) prior to the medical doctor seeing the patient.

During a telephone interview on 5/5/2021 at 11:35 a.m., Staff K was asked about her experience with Patient 100 in the ED. Staff K stated she was the ED receptionist and Patient 100 came up to the window (located in the reception area of the ED) with a hand injury. Staff K stated Patient 100 was accompanied by a person who was acting as his translator. Staff K stated Patient 100 handed her his insurance card, she gave him a demographic form (name, date of birth, address, chief complaint) to fill out, and she began to register him (in the computer). Staff K stated Patient 100's insurance was not contracted with Hospital 1 and she went to the nurses station because she was not sure what she should explain to the patient (about his insurance). Staff K stated the nurses and physician told her to, "give him his options" so he could make an intelligent decision. Staff K stated she went back to Patient 100 and told him, "We are willing to help you" but his insurance was not contracted with the hospital. Staff K stated Patient 100 kept saying, "I don't want a bill" and he, "chose to go to (Hospital 2)."

During a telephone interview on 5/5/2021 at 3:09 p.m., RN I stated she was at the nursing station with RN G and H while Staff K registered Patient 100. RN I stated Staff K came back and said we (Hospital 1) don't take his insurance. RN I stated she told her, "you can't tell him that." RN I stated Staff K stated she could tell him about his insurance because her boss said she should. RN I stated we (the nurses) told Staff K to fill out a RADAR report.

During a telephone interview on 5/6/2021 at 1:05 p.m., Physician E was asked about his experience with Patient 100. Physician E stated he never saw Patient 100. Physician E stated he was standing at the nurse's station and Staff K said there was a Spanish speaking male in the ED, but the hospital did not take his insurance. Physician E stated he told Staff K that they should not be asking for insurance (information) at the window. Physician E stated Staff K stated that she had been told by her supervisor that she needed to let the patient know (that his insurance was not accepted at the hospital). When asked what was the registration process at Hospital 1, Physician E stated the patient should be checked in, given medical treatment, and then the insurance could be addressed.

During a interview on 5/6/2021 at 1:30 p.m., Manager D was asked about the incident involving Patient 100 in the ED. Manager D stated some nurses informed him they overheard a clerk (Staff K) tell Patient 100 that Hospital 1 did not take his insurance. Manager D stated the nurses told Staff K that, "we don't discuss insurance," we take care of them (the patients). When asked what should have happened regarding Patient 100, Manager D stated his insurance should not have been discussed until after his Medical Screening Exam (MSE). He stated if Patient 100 handed his insurance card (to Registration staff), the staff member could tell the patient that,"we want to care for you first," then discuss insurance.

Review of facility policy and procedure titled, "EMTALA - Patient Registration," subtitled, "Key Elements" (revised 06/05/2019) indicated, "A. Policy: 1. The Hospital is committed to providing emergency medical care to all persons presenting to a Dedicated Emergency Department...for evaluation and/or treatment regardless of financial or insurance status...all patients presenting for evaluation or treatment to a Dedicated Emergency Department...seeking evaluation or treatment for a possible Emergency Medical Condition, will receive a Medical Screening Examination to determine if an Emergency Medical condition exists, without any delays due to information being obtained regarding insurance status ... 2. Note--California Hospitals must provide emergency services and care without first questioning the patient or any other person as to the patient's ability to pay."

Review of facility policy and procedure titled, "EMTALA - Medical Screening Examination (MSE) And Stabilization," subtitled, "Policy Summary/Intent" (revised 06/05/2019) indicated, "C. The Hospital will not delay the Medical Screening Examination in order to inquire about an individual's method of payment or insurance status. In California, Emergency Services and Care will be provided without first inquiring as to an individual's insurance or financial status."