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Based on patient and staff interview and review of medical records and hospital policies, it was determined the hospital failed to comply with the provisions at CFR 489.24(d4,d5). The hospital failed to ensure an appropriate medical screening examination was not delayed for 1 of 22 ER patients (Patient #4) whose records were reviewed, in order to inquire about the individual's method of payment. The findings include:

1. Refer to A2408 as it relates to a delay in treatment provided to a patient.

Based on patient and staff interview and review of medical records and CAH policies, it was determined the CAH failed to ensure an appropriate medical screening examination was not delayed for 1 of 22 ER patients (Patient #4) whose records were reviewed, in order to inquire about the individual's method of payment. This resulted in one patient leaving the ER without treatment and had the potential to delay the treatment of all patients who came to the hospital's ER. The findings include:

Hospital policies prohibited staff from inquiring about payment until a medical screening examination had been conducted.

The policy "Medical Screening Examinations," revised 4/01/09, stated "Boundary Community Hospital (BHC) will provide a medical screening examination to any individual who presents to the hospital, by him or herself or with another person, requesting treatment and, if necessary, stabilizing treatment...and appropriate transfer to another facility." The policy stated "After the Medical Screening Examination and stabilization, the patient will be registered by registration clerk or the registered nurse. At this time inquiries about method of payment, insurance status, and financial information can be obtained."

The policy "Emergency Medical Screening, Treatment and Transfer," revised 11/23/09, stated "In providing a medical screening examination, BHC shall not discriminate against any individual because of diagnosis, financial status, race, color, national origin, or handicap."

The CAH failed to comply with these policies regarding requesting financial information before medical screening examinations and discriminating against patients due to financial status. Examples include:

a. Patient #4 was interviewed on 11/30/10 beginning at 11:00 AM. She stated she had injured her leg 2 weeks before presenting to the ER and she had seen a practitioner at a local clinic. She stated her knee was still swollen and bruised, including fresh bruising, when she went to the emergency room for treatment. She stated she spoke to a relative who was a physician and he advised her to go to the ER to have it examined. She stated when she arrived at the ER, the physician refused to treat her because she did not have insurance. She stated she felt humiliated. She said she then went to a second hospital and was treated.

b. Patient #4's medical record documented a 26 year old female who presented to the ER on 10/03/10 at 3:42 PM. A nursing note in the "Emergency Department Charting" form, not dated or timed, stated Patient #4 complained of right knee pain since September. The note stated Patient #4 had been examined by a PCP after the fall. The note stated Patient #4 was told to have the knee x-rayed if the pain worsened. The note stated Patient #4 could not stand on her knee at all now. The nursing note on the other side of the form, also not timed, stated "To ER via wc. Brace on leg. MD here to examine pt. Advised pt. that this is not an emergency & he will see her but she needs to pay her bills. After some discussion, she called her friend for ride and left [without] being seen via wc." The nursing note stated she left at 4:00 PM.

The "EMERGENCY PHYSICIAN RECORD," dated 10/03/10 at 4:05 PM, stated "Patient already has knee immobilizer and stated she's out of pain meds and was told to get x-rays. ED very busy& informed pt. this is not an emergency at this time, so she should see her PCP. I did offer to evaluate it, but because she is self pay & does not pay her many ED visit bills, seeing her PCP is more appropriate. Patient decided to leave without being seen. No charge."

Patient #4 went to another hospital approximately 33 miles away. The "EMERGENCY NURSING RECORD" from the second hospital stated Patient #4 arrived at 8:10 PM on 10/03/10. The nursing record stated Patient #4 appeared in mild distress and had pain and swelling in her right knee and ankle. The nursing record stated "splints/braces" were applied at 12:05 AM on 10/04/10.

The "EMERGENCY PHYSICIAN RECORD" from the second hospital, dated 10/03/10 at 11:45 PM, stated pain and swelling of the right lower extremity had worsened over the past 2 weeks. The physician ordered an x-ray of the right knee and ankle and an ultrasound of the right lower extremity. The x-rays showed soft tissue swelling and joint effusion but no fracture. The ultrasound showed no deep venous thrombosis [clot]. The physician listed Patient #4's diagnoses as internal derangement of the right knee and right ankle ligamentous injury. The physician documented Patient #4 was given morphine and phenergan for pain and was observed for 1 hour. Patient #4 was discharged home from the second hospital at 12:14 AM on 10/04/10.

c. The physician on duty in the ER on 10/03/10, when Patient #4 presented, was interviewed on 11/30/10 beginning at 10:26 AM. He stated Patient #4 had injured her knee approximately 3 weeks before presenting to the ER. He stated she had then seen a medical provider at a local clinic. He stated the provider at the local clinic had told Patient #4 that if the pain persisted she should get her knee x-rayed. He stated Patient #4 was at the hospital for an x-ray. He stated he did not examine Patient #4. Instead, he stated he told Patient #4 she owed the hospital thousands of dollars and she should pay her bills. He said he then offered to evaluate her but she became angry and "stormed out" of the ER.

d. The RN on duty in the ER on 10/03/10, when Patient #4 presented, was interviewed on 11/30/10 beginning at 10:55 AM. She stated Patient #4 came to the ER and complained that her leg was getting worse and she wanted to get it x-rayed. The RN confirmed the physician asked Patient #4 how she was going to pay for services before he had examined her. She stated Patient #4 would not have refused an examination by the physician if he had not confronted the patient about her finances.

Hospital staff delayed treatment of Patient #4 in order to inquire about her method of payment.