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Based on observation, interviews and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2408: §489.24(d)(4),(5)(4) Delay in Examination or Treatment.(i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual's method of payment or insurance status.(ii) A participating hospital may not seek, or direct an individual to seek, authorization from the individual's insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section.(iii) An emergency physician or non-physician practitioner is not precluded from contacting the individual's physician at any time to seek advice regarding the individual's medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section.(iv) Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. Based on document reviews and interviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment in two of two pregnant patients who sought emergency care. (Patient #10, and #11)

Based on document reviews and interviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment in two of two pregnant patients who sought emergency care. (Patient #10, and #11)

Findings include:

Facility Policy:

The Emergency Medical Treatment and Labor Act (EMTALA) policy read, neither the medical screening exam nor any required stabilizing treatment for an emergent medical condition shall be delayed to inquire about the individual's insurance status. Under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. Registration could occur so long as it does not delay or otherwise adversely affect the medical screening exam and/or treatment to stabilize an emergent medical condition.

1. The facility failed to ensure the registration process did not delay examination and treatment for pregnant patients who sought emergency care.

a. On 12/18/24 at 10:02 a.m., the financial responsibility form, referred to in the EMTALA policy, was requested. The Agreement for Assignment of Insurance Benefits consent was provided. Review of the Agreement for Assignment of Insurance Benefits consent revealed section one allowed the facility to bill and receive payment from patients' insurance companies. Section two was a statement of financial responsibility in which patients promised to pay for any service not covered by their insurance company.

b. Medical record review revealed Patient #10, who was 34 weeks and 2 days pregnant, arrived at the facility on 12/3/24 at 7:45 a.m. with a chief complaint of cramping and vaginal leaking. Patient #10 signed the Agreement for Assignment of Insurance Benefits consent (financial responsibility form) at 7:53 a.m. Nursing documentation revealed Patient #10's vital signs were obtained at 7:59 a.m., and a triage assessment was completed at 8:00 a.m. Provider documentation at 9:11 a.m. revealed Patient #10 had preterm premature rupture of membranes (PPROM) (the breaking of the amniotic sac surrounding a baby before 37 weeks of pregnancy significantly increasing the risk of preterm birth and potential complications for both mother and baby).

c. Medical record review revealed Patient #11, who was 30 weeks and 5 days pregnant, arrived at the facility on 7/31/24 at 8:14 p.m. with a chief complaint of abdominal pain. Patient #11 signed the Agreement for Assignment of Insurance Benefits consent at 8:22 p.m. Nursing documentation revealed Patient #11's triage assessment was completed at 8:42 p.m, an ultrasound was performed at 9:04 pm. Provider documentation at 9:53 p.m. revealed Patient #11 was stable and discharged.

These medical record reviews were in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment.

d. Review of the Admission, Discharge, and Transfer of Emergency Department (ED) Patients policy revealed financial information for ED patients was requested after the medical screening exam had begun. Registration associates could request information from patients to begin the registration process, provided care was not delayed due to inquiry about the patient's insurance status.

e. On 12/17/24 at 9:45 a.m., an interview was conducted with patient access registration (PAR) #1. PAR #1 stated they registered patients in the ED and at the OB unit. PAR #1 stated when patients presented to the OB unit, the staff called Registration to go to the patient. PAR #1 stated they were not to ask patients to sign financial consents before being screened because the patient might want to leave, refuse treatment and could give birth outside of the hospital setting. PAR #1 stated they relied on the nurses to let them know if a patient was in distress and consents were signed at a later time.

f. On 12/18/24 at 7:28 a.m., an interview was conducted with PAR #2. PAR #2 stated when a patient presented to the ED, registration had to wait at least 30 minutes until they entered the patient's room. PAR #2 also stated that the ED patient had to be seen by a medical provider before the registration process, including financial consents were signed. PAR #2 stated when a patient presented to the OB unit the nurse called registration and registration immediately went to the unit. PAR #2 stated this was the process they were trained to follow and was unsure why there was a difference between the ED and OB unit.

This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment.

g. On 12/18/24 at 8:33 a.m., an interview was conducted with PAR #3. PAR #3 stated registration was notified when a patient presented to the OB unit and an account account was created with the patient's name and date of birth. PAR #3 stated registration then went to the OB unit, checked with the nurse to make sure the patient was not in active labor and could sign the consents. PAR #3 stated financial consents were included with other consents that were presented to the patients. PAR #3 stated they did not have a clinical background and did not want to delay care for patients who were in labor. PAR #3 stated laboring patients needed to be examined and receive the treatment they required.

This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment.

h. On 12/18/24 at 9:13 a.m., an interview was conducted with OB registered nurse (RN) #4. RN #4 stated a medical screening was an evaluation which determined if a medical condition needed to be addressed and had been EMTALA training. RN #4 stated nurses and providers determined if pregnant patients had an emergent medical condition. RN #4 stated there were emergent medical conditions that could occur in patients who were greater than 20 weeks pregnant, such as vaginal bleeding, placenta previa (a condition where the placenta implants low in the uterus, partially or completely covering the cervix (the opening of the uterus), decreased fetal movement and decreased fetal heart rate. RN #4 stated pregnant patients needed to be assessed to determine the interventions needed. RN #4 further stated they had seen registration ask patients to sign the consent forms before the patient was put on the fetal heart rate monitor or vital signs obtained.

This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment.

i. On 12/18/24 at 10:15 a.m., an interview was conducted with OB provider (Provider) #5. Provider #5 stated labor, seizures, severe preeclampsia (blood pressure condition occurring during pregnancy), abruption (when the placenta pulls away from the uterus), fetal demise and fetal low heart rate were examples of emergent medical conditions patients greater than 20 weeks could experience. Provider #5 stated it was important not to delay the medical screening exam for these patients because staff could not determine these emergent medical conditions had occurred and the patients were physically examined. Provider #3 stated patients could be very ill and a monitor was needed to determine the fetal heart rate or if an emergent medical condition needed to be immediately addressed.

This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment.