HospitalInspections.org

Based on document review, audio recording review and interview, it was determined that:
A. 1 (patient #1) of 21 MRs reviewed of patients who requested transfer to the hospital to stabilize an emergency condition, the facility failed to ensure compliance with 489.24 in that the recipient facility delayed an appropriate transfer in order to verify the insurance eligibility of the patient, and
B. 4 (patient #s 2, 3, 4 & 5) of 21 MRs reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to document an assessment of the patient's condition on arrival to ensure the individual was appropriately prioritized until a MSE (medical screening exam) by a physician or other QMP (qualified medical provider) was completed.

Findings include:

1. See findings cited at 489.24(1) A2406, 489.24(d)(4) A2408, and 489.24(f) A2411.

Based on document review, audio recording review and interview, the receiving facility with specialized services and the capacity to provide care delayed the treatment of an accepted transfer patient with an unstabilized medical condition in route from a referring facility in order to verify the insurance eligibility for 1 of 21 medical records (MR) reviewed (patient #1).

Findings include:

1. The policy/procedure Emergency Medical Treatment And Patient Transfer - EMTALA (revised 7-14) indicated the following: "(III)(A)(3) Inquiry for Insurance Status. Hospitals will follow reasonable registration procedures; however, a medical screening exam, stabilizing treatment, or appropriate transfer will not be delayed in order to obtain patient financial information... "

2. The MR for patient #1 from facility #1 indicated the patient presented to the ED (emergency department) on 6-30-16 at 0947 hours with complaints of chest pain with hypotension (low blood pressure) and was seen by the ED physician MD1. The MR indicated patient #1 requested a transfer to the regional facility #2. Physicians MD2 and MD3 were contacted and accepted the patient in transfer, and the patient left the ED by ambulance for transport to the facility. An addendum by physician MD1 indicated the patient's insurance did not provide coverage for facility #2 and the patient was accepted in transfer and diverted to the ED of facility #3.

3. The 6-30-16 EMS (emergency medical service) ambulance transport record for patient #1 obtained on 7-11-16 from the Compliance and Privacy Director for facility #1, staff A12, indicated the ambulance was notified by the county EMS dispatch to return to [facility #1]. The record indicated the ambulance pulled off the highway and telephoned the dispatcher and the ER and the ambulance was on hold for 6 minutes until alternative transfer arrangements were established and the ambulance was diverted to the ED of facility #3.

4. The MR entry for patient #1 by ED physician MD4 at facility #3 indicated the following: "...The patient was in route to [facility #2] where he/she was to be a direct admit to the ICU. [facility #2] reportedly redirected the ambulance because the patient no longer has [facility #2] based insurance, but now has [facility #3] insurance. The physician (MD1) from [facility #1] called me and told me the ambulance had been instructed to return to [facility #1]. [MD1] felt it would be best if the patient was diverted here instead so I accepted the patient."

5. Audio recordings obtained on 7-11-16 from the Compliance and Privacy Director for facility #1, staff A12, included a conversation held on 6-30-16 at 1110 hours between the facility #2 transfer center staff A38 and a dispatcher A17 with a county EMS (emergency medical service) associated with the ambulance transporting patient #1. The audio recording was replayed on 7-11-16 at approximately 1310 hours, in the company of the Compliance and Privacy Director, staff A12, and indicated the following: "...[staff A38]... you need to stop that truck - they need to take that patient back to [facility #1]... it, uh... it (sic) cannot come here, for insurance reasons... "

6. On 7-11-16 at 1310 hours, the Compliance and Privacy Director, staff A12, confirmed the transfer center staff A38 of facility #2 directed the dispatcher to divert the ambulance for insurance reasons.

Based on document review, audio recording review and interview, the regional facility with specialized services and the capacity to provide care refused to accept the appropriate transfer from a rural referring facility of a patient with an unstabilized medical condition in need of the specialized services not available at the rural facility for 1 of 21 medical records (MR) reviewed (patient #1).

Findings include:

1. The policy/procedure Emergency Medical Treatment And Patient Transfer - EMTALA (revised 7-14) indicated the following: "(III)(A)(3) Inquiry for Insurance Status. Hospitals will follow reasonable registration procedures; however, a medical screening exam, stabilizing treatment, or appropriate transfer will not be delayed in order to obtain patient financial information... (5) Nondiscrimination. The hospital shall not refuse to accept an appropriate transfer of an individual with an emergency medical condition if the individual requires a specialized service ... available at the hospital, if the hospital has the capacity to treat the individual, and the transferring facility does not have the specialized services needed."

2. The MR for patient #1 from facility #1 indicated the patient presented to the ED (emergency department) on 6-30-16 at 0947 hours with complaints of chest pain with hypotension (low blood pressure) and was seen by the ED physician MD1. The MR indicated patient #1 requested a transfer to the regional facility #2 based on a 2015 admission there with treatment by physician MD2 for the same condition (heart failure and cardiomyopathy). The MR indicated that physician MD2 and MD3 were contacted and accepted the patient in transfer and an ICU (intensive care unit) room was assigned. The MR indicated the patient left the ED by ambulance for transport to facility #2 and an addendum by physician MD1 indicated the patient's insurance did not provide coverage for facility #2 and the patient was accepted in transfer and diverted to the ED of facility #3.

3. The MR entry for patient #1 by ED physician MD4 at facility #3 indicated the following: "...The patient was in route to [facility #2] where he/she was to be a direct admit to the ICU. [facility #2] reportedly redirected the ambulance because the patient no longer has [facility #2] based insurance, but now has [facility #3] insurance. The physician (MD1) from [facility #1] called me and told me the ambulance had been instructed to return to [facility #1]. [MD1] felt it would be best if the patient was diverted here instead so I accepted the patient."

4. Audio recordings obtained on 7-12-16 from the Executive Director of Quality for facility #2, staff A30, included a conversation held on 6-30-16 at 1110 hours between the facility #2 transfer center staff A38 and a dispatcher A17 with a county EMS (emergency medical service) associated with the ambulance transporting patient #1. The audio recording was replayed on 7-12-16 at approximately 1306 hours, in the company of the risk manager for facility #2, staff A33, and indicated the following: "...[staff A38]... you need to stop that truck - they need to take that patient back to [facility #1]... it, uh... it (sic) cannot come here, for insurance reasons..."

5. On 7-12-16 at 1310 hours, the risk manager, staff A33, confirmed the transfer center staff A38 directed the dispatcher to divert the ambulance for insurance reasons.