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Based on review of medical records, policies/procedures, and staff interviews, it was determined that the hospital failed to comply with the provider agreement as defined in ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

Cross reference: Fed-C-2402: The facility failed to post notification of patient rights, under EMTALA, in all places that individuals seeking emergency medical treatment might note when entering the facility. The facility's EMTALA posting did not clearly state patient rights under section 1867 of the Act and the participation of the facility in the Medicaid program under a State plan approved under Title XIX.

Cross reference: Fed-C-2405: A patient came to the facility's ED seeking emergency medical care and was not documented on the facility's central log.

Cross reference: Fed-C-2406: The facility failed to provide a medical screening examination to a patient who presented to the Emergency Department seeking emergency medical care.

Cross reference: Fed-C-2409: The facility did not ensure that patients were informed of the risks and benefits of being transferred from the Emergency Department (ED) to other facilities for medical care.

Based on observation, document review, and interview, the facility failed to have posted, at all places likely to be seen by individuals entering the facility seeking emergency medical treatment, a posting clearly describing patients' rights under section 1867 of the Act and the participation of the facility in the Medicaid program under a State plan approved under Title XIX.

This failure created the potential for individuals seeking emergency medical treatment to be unaware of their rights under the Emergency Medical Treatment and Active Labor Act (EMTALA).

Findings:

1. The facility failed to post notification of patient rights, under EMTALA, in all places that individuals seeking emergency medical treatment might note when entering the facility.

a) On 05/14/13 at 8:15 a.m., postings were observed at the facility's main entrance. No posting was noted which described patients' rights under EMTALA.

b) On 05/14/13 at 2:33 p.m., observation of the facility's Emergency Department (ED) was conducted with the facility's Director of Quality and Risk and the facility's ED Nursing Director. A posting was noted in the ED waiting area that staff stated described patient rights under EMTALA. The Directors confirmed a second entrance to the ED, through the door used to transport patients who arrived by ambulance. This area was observed and was found to have no EMTALA posting.

c) On 05/15/13 at 3:00 p.m., an interview was conducted with the facility's Director of Quality and Risk and the facility's ED Nursing Director. Both Directors confirmed the only EMTALA posting was inside the ED waiting area. Both Directors confirmed that patients do enter the ED through the ambulance bay, and these patients would not see the EMTALA posting found in the ED waiting area. The Directors confirmed it would be possible for individuals to also enter the main entrance to the facility, not the ED entrance, seeking emergency medical treatment during the hours that this door was unlocked and that in this instance, the Directors could not confirm that individuals would necessarily see the EMTALA posting found in the ED waiting room. The Directors confirmed 3 entrances into the facility, housing the ED, and that only one entrance contained an EMTALA posting.

2. The facility's EMTALA posting did not clearly state patient rights under section 1867 of the Act and the participation of the facility in the Medicaid program under a State plan approved under Title XIX.

a) On 05/15/13 at 3:00 p.m., an interview was conducted with the facility's Director of Quality and Risk and the facility's ED Nursing Director to review the wording of the facility's EMTALA posting. The posting stated, "If you have an emergency you have the right to receive, within the capabilities of this (facility's) staff and facilities: an appropriate medical screening examination; necessary stabilizing treatment (including treatment of an unborn child); an appropriate transfer to another facility, even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid." The regulation requirements were reviewed with the Directors, as the facility's posting was unclear with regard to the rights of individuals with emergency medical conditions and women in labor who come to the ED seeking emergency medical care. The posting did not clearly state that the facility participated in the Medicaid program under a State plan approved under Title XIX. The Directors confirmed that the EMTALA posting could be made more clear.

Based on interview and document review, the facility failed to ensure that all patients who came to the Emergency Department (ED) seeking emergency medical care were documented on the ED central log.

This failure created the potential for patients seeking emergency medical treatment and not documented on the facility's central log, to leave the facility's ED remaining in need of treatment or care, and to be unable to be tracked by the facility in order to ensure the safety and well being of these patients.

Findings:

1. A patient came to the facility's ED seeking emergency medical care and was not documented on the facility's central log.

a) On 05/14/13 at 9:53 a.m., an interview was conducted with the facility's Emergency Department Nursing Director. The Director stated the central log for patients who entered the ED seeking emergency medical treatment was electronic and was contained in a spreadsheet format. S/he stated that transfers out of the ED, patients who left the ED against medical advice (AMA), and patients who left without being seen (LWBS), were captured on the log as well as patients who were seen in the ED and discharged or were seen in the ED and admitted to the hospital. A list of all transfers, AMA, and LWBS patients were requested for the past 12 month period, April, 2012 through April, 2013. The Director stated these categories of patients were tracked by the facility for quality purposes.

b) On 05/07/13 at 10:15 a.m., in a phone interview with the facility's Director of Quality and Risk, the Director confirmed that the patient involved in the complaint investigation was not documented on the facility's central log. Review of the central log for the date 04/28/13 was conducted and did not contain record of this patient who entered the facility's ED seeking emergency medical care.

Cross reference: Tag -C- 2406: The facility failed to provide a medical screening examination to a patient who presented to the Emergency Department seeking emergency medical care.

Based on interview and document review, the facility failed to provide a medical screening examination to a patient who entered the the Emergency Department seeking emergency medical treatment.

This failure created the potential for negative outcome(s) to the patient as s/he did not receive a medical screening examination and treatment and instead, went to another facility to receive emergency medical screening and treatment.

Findings:

1. The facility failed to provide a medical screening examination to a patient who presented to the Emergency Department seeking emergency medical care.

a) On 05/14/13 at 8:35 a.m., an interview was conducted with the facility's Director of Quality and Risk and the facility's Emergency Department (ED) Director of Nursing. A recent complaint was reviewed that the facility's Director of Quality and Risk reported to the Department concerning a violation of Emergency Medical Treatment and Active Labor Act ( EMTALA). The complaint described that an individual entered the facility's ED on 04/28/13 with a complaint of nausea and vomiting that had been on-going for 2 days. This individual was traveling with friends and had health insurance issued outside of the United States as s/he was not a resident of the United States. In the compliant, this insurance was referred to as "travel insurance." The complaint stated the individual seeking treatment was informed by the employee registering ED patients that his/her insurance would not be honored and that s/he would not be seen in the ED unless $850.00 was paid prior to being seen. The individual seeking emergency medical treatment did not receive a medical screening exam (MSE) and was denied screening and any necessary treatment as s/he was asked to pay "up front" prior to receiving a medical screening and any needed emergency care. The individual left the facility and was seen at another facility's ED, approximately 60 miles away, where s/he received a medical screening exam and treatment. The facility Directors interviewed confirmed the incident and that an individual seeking emergency medical care was denied a medical screening exam due to his/her insurance status. The ED Director of Nursing stated the facility employee who was registering ED patients on 04/28/13 had received EMTALA training upon hire, annually, and again on 01/09/13, as a Registered Nurse (RN) overheard the employee make a statement to an individual waiting in the ED waiting room on 12/27/12, Sample Patient #18, that sounded like it could have been an EMTALA infraction. In this instance, an RN intervened and, per the facility, an EMTALA violation was avoided.

b) On 05/14/13 at 9:53 a.m., review of the personnel file for the registration employee referenced above was conducted. The file contained documentation of EMTALA training as stated by the ED Director of Nursing, including initial training, annual training, and additional EMTALA training presented to this employee on 01/09/13.

c) On 05/15/13, the medical record review for Sample Patient #18 was conducted. No evidence could be found in the record that an EMTALA violation had occurred. The patient received a medical screening examination, emergency care, and was discharged with orders for follow up care.

d) On 05/14/13 at 2:02 p.m., the facility's EMTALA training documents/power point was reviewed along with the facility's EMTALA policy. The EMTALA training document stated, "(Facility) may not delay the MSE or necessary stabilizing treatment to inquire about an individual's insurance or method of payment." The facility's policy titled, "EMTALA," dated 01/01/08, contained the following statement: "7. Financial Information/Managed Care. a. A medical screening examination or necessary stabilizing treatment will not be delayed to inquire about the individual's method of payment or insurance status, inform the patient of payment obligations, or to obtain pre-authorization for services from an individual's health plan. Reasonable registration processes may be implemented and may include requesting information about insurance as long as these procedures do not delay screening or treatment. The Hospital shall not discourage an individual from remaining for further evaluation...c. Patients care will not be delayed or denied for the purpose of collecting co-payments."

e) On 05/15/13 at 3:00 p.m., an interview was conducted with the facility's Business Office Manager who confirmed that after the above referenced EMTALA violation was discovered by the facility, both registration staff and business office staff received repeat EMTALA training. The training was held on 05/08/13 for registration staff and on 05/09/13 for business office staff. Documents showing employee sign in for training was reviewed for these dates. The Business Office Manager stated the facility currently had 4 employees whose job was to register patients, both in the ED and in the hospital. S/he stated any one of the 4 could work registration in the ED, but that typically the staff members worked either the ED side of registration or the hospital side of registration. The Manager stated registration staff who typically work on the hospital side would cover for registration in the ED to cover staff illness or vacations. When asked to review the written process registration staff was instructed to use when registering patients in the ED, s/he stated there was no written policy or process for registering patients in the ED. When asked how the facility could state with certainty that EMTALA violations would not occur again without a clear process for any registration employee who should work ED registration, s/he stated the facility was in the process of putting the ED registration process in writing for staff. Otherwise, the requirements of ED registration staff was verbal only. Both the Business Office Manager and the facility's Director of Quality and Risk confirmed that in order to ensure that EMTALA violations would not continue when registering patients, the facility needed a written process and training for the registration staff in addition to EMTALA training and an EMTALA policy.

Based on interview and document review, the facility failed to provide documentation, in 14 of 14 patient medical records reviewed, that risks and benefits of these patients transferred from the facility's Emergency Department to other facilities was provided to patients and that risks and benefits were individualized in patient medical records for all transferred patients.

This failure created the potential for patients being transferred out of the facility to have inadequate understanding or no understanding of the risks and benefits of transfer.

Findings:

1. The facility did not ensure that patients were informed of the risks and benefits of being transferred from the Emergency Department (ED) to other facilities for medical care.

a) On 05/14/13 and 05/15/13, 20 patient medical records were reviewed. Fourteen of the medical records indicated that patients seen in the ED for medical issues were transferred to other facilities for continued care after being stabilized in the ED. In 14 of 14 patient medical records (Sample Patients #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #16, #17, and #20), there was no documentation that physicians completing the required certification for transfer had informed patients of their individual risk(s) and benefit(s) of being transferred. Review of the document titled, "(Facility name) Physician Certification for Transfer of Patient to Another Medical Facility," contained the following pre-populated statements for each of the 14 records reviewed:

Risks: Risks of all transfers include the possibility the patient's condition may worsen en route; patient may be injured by a vehicular accident or equipment failure; and if the patient is in labor, she may progress to delivery while en route. Summary of additional risks: _________

Benefits: Further care by a specialist, and hospitalization at a higher level of care. Summary of additional benefits: _________________

In the the 14 medical records referred to, patients' medical diagnosis were documented as severe nose bleed, pneumonia, pre-term labor, sepsis, trauma from motor vehicle accident, dog bite to face, brain tumor, and hypoxia.

b) On 05/15/13 at 1:36 p.m., an interview was conducted with the facility's ED Nursing Director who confirmed the generic risks and benefits contained on the physician certification document. The Director confirmed that on the certification document, there were blanks titled "Summary of additional benefits" and "Summary of additional risks" that were not completed by physicians. The Director confirmed that in addition to the generic risks and benefits of transfers to other facilities, each individual patient reviewed had risks and benefits individual to their medical conditions as each of the 14 medical records reviewed had documented an individual diagnosis, stabilizing treatment, and patients were transferred to different facilities that could best meet their individual medical needs. The Director confirmed that risks and benefits to patients who were transferred out from the ED were not documented on the physician certification document and therefore s/he could not confirm that patients had been informed of the risks and benefits of transfer. In addition the individual risks and benefits to transferred patients were not found in other sections of the medical records.