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Based on interviews, medical record review, the emergency department (ED) meeting minutes, and documentation in a letter of complaint from Hospital # 2, the facility's (Hospital # 1's) emergency department (ED) Medical Director failed to inform Hospital #1's Chief Executive Officer (CEO) that Alabama Medicaid patients, discharged from the ED and referred to one of the on-call orthopedic clinic specialists, complained to ED after discharge and complained that the orthopedic clinic refused to accept Alabama Medicaid insurance. Clinic staff contacted patients and told Alabama Medicaid patients that the clinic did not accept this insurance and the patient (or family members) would be expected to pay out of pocket for follow-up care.
As a result, Alabama Medicaid patients (or their insurance carrier) incur additional health care costs due to the patients having to pay out of pocket for care covered by their insurance, or costs incurred as a result of being directed by ED staff to (a) to go to their primary care physician and ask for a referral to an Alabama orthopedic doctor or group (there are no local orthopedic doctors), (b) to go to an Alabama orthopedic specialist they (patient) may have seen in the past, or (c) to go to another acute care hospital (nearest located approximately 30 miles from this facility) and see another ED doctor who could refer the patient to an orthopedic specialist in Alabama. There is no documentation in the ED medical records indicating the patients had called back with a complaint, or that the discharge instructions were changed or altered.
ED staff interviewed during the survey confirmed that patients insured with Alabama Medicaid have called back to the ED complaining that the orthopedic clinic refused to accept their insurance. Documentation in the June 2011 ED meeting minutes revealed ED staff had identified concerns with orthopedic follow-up care but there is no documentation indicating that the ED Medical Director or the Chief Operating Officer (COO) communicated these patient issues to the Hospital #1's CEO (prior to the second day of the survey).
This deficient practice effected twenty (20) of thirty-eight (38) sampled ED patients (Patient Identifier (PI) #'s 1, 3, 4, 6, 7, 8, 10, 12, 14, 16, 17, 19, 20, 21, 22, 24, 25, 28, 31, 50) and has the potential to effect any Alabama Medicaid patient presenting to this ED with an orthopedic complaint or injury and who would need follow-up orthopedic care.

Findings Include:

On 8/25/2011, the state agency (SA) received a complaint alleging that twenty-one (21) ED patients, who presented to Hospital #1's emergency department (ED) between 3/1/2011 through 6/15/2011 with orthopedic complaints or injuries, were discharged without follow-up discharge instructions appropriate and or necessary to prevent relapse or worsening of the patients presenting conditions: The complaint includes Patient Identifier numbers (PI #): 1, 3, 4, 6, 7, 8, 10, 12, 14, 16, 17, 19, 20, 21, 22, 24, 25, 28, 31, and 50.

During the on-site survey (conducted 8/30-9/1/2011), documentation in the above patient's ED medical records revealed that each patient was seen and treated in Hospital #1's ED. Each patient was discharged in "stable" condition and given written discharge instructions to follow-up with one of the on-call orthopedic physicians. The follow-up / discharge instructions (signed by the patient or the patient's legal representative) included contact information for the on-call orthopedic clinic that is located in Georgia (less than 10 miles from this Alabama Hospital /Hospital # 1). Each on-call orthopedic physician is (according to the ED Medical Director) affiliated with this orthopedic clinic and can admit to Hospital #1. There is no documentation in the above patient's ED medical records indicating that the patients had contacted the ED and or complained after discharge, or that the patient's follow-up / discharge instructions had changed after the patient left the ED.

On 8/30/11 at 4:22 PM and 8/31/11 at 1:55 PM, Hospital #1's ED Medical Director / Employee Identifier number (EI#) 4 was interviewed. When asked if all ED orthopedic patients are referred to any orthopedic group or clinic, besides the orthopedic clinic in Georgia, EI# 4 responded, "No..." EI # 4 states that he talks with the on-call orthopedic doctor before patient's are discharged and referred to the orthopedic clinic (in Georgia).
According to EI # 4, he and other ED staff had discussed ED patient complaints about the Georgia orthopedic clinic refusing to take some patient insurances. EI #4 stated that he (EI# 1 the ED Medical Director) does not "...not get involved" because the insurance issues are sporadic and are usually handled by the ED nurses who talk to the patients.

On 8/31/2011(at 10:20 AM, 10:45 AM, 10:50 AM and 11:00 AM), four randomly selected sampled ED patients (PI# 1, 6, 7, 22) were interviewed by telephone. Each patient interviewed was evaluated in Hospital #1's ED and presented with orthopedic complaints or injuries. Each patient was referred by the ED physician to one of the on call orthopedic physicians at the orthopedic clinic in Georgia. All four patients, or their representative, confirmed that they talked with someone at the orthopedic clinic and were told that this Georgia orthopedic clinic does not accept Alabama Medicaid insurance. The patients or patient representatives said staff at the orthopedic clinic (designated on their ED discharge instructions from Hospital # 1) said the patients (or their representatives would be expected to pay out of pocket if they came to the clinic (as ordered by the ED doctor) for their follow-up care. These patients (or their representative) were told to go to another doctor or another hospital in Alabama and ask to be referred to another orthopedic doctor in Alabama.

On 9/1/2011, EI # 5 / Hospital #1's Chief Operating Officer (COO) provided a copy of a letter of complaint sent to Hospital #1 from Hospital #2 (another acute care hospital in Alabama). Hospital # 2's letter reported they they received " ...numerous reports that patients presenting to...[Hospital #1's] Emergency Department with an emergency medical condition are not being seen by on-call physicians, not properly stabilized and/or improperly transferred..." This letter describes three patient's visit to Hospital #1's ED who report being referred to the orthopedic clinic located in Georgia. Hospital# 2 reports that these patients, after contacting orthopedic clinic in Georgia, were informed that the doctors at this clinic did not accept Alabama Medicaid, as a result, the patients presented to Hospital # 2's emergency room with conditions that had already been assessed at Hospital # 1. On 8/31/2011 at 4:55 PM, EI # 5 / Hospital # 1's COO stated she and other members of Hospital # 1's Quality Assurance / Risk Management, Administration, and Legal staff had reviewed the complaint from Hospital # 2 and found the complaint unsubstantiated and no need to implement corrective actions. When asked if anyone talked with ED patients or their representatives, the COO responded, "No."

Documentation in Hospital #1's Emergency Department Meeting minutes (dated 6/14/2011) include: "...Orthopedic referrals were discussed. After a fairly long discussion it was decided that ...would attempt to establish relationships with outside orthopedic services for patients who could not arrange to follow up at the ... clinic [orthopedic in Georgia]. It was agreed that in similar cases referral back to the primary care doctor was appropriate..."

On 9/1/2011 at 2:15 PM, EI# 2 / Hospital #1's Chief Executive Officer (CEO) stated that he first learned about Hospital #2's letter of complaint on 8/31/2011 (the second day of the survey). EI #2 confirmed the complaint from Hospital #2 concerned Alabama Medicaid patient's and the ED on call orthopedic physician refusing to accept Alabama Medicaid insurance. EI #2 /CEO states that Hospital #1 staff had investigated Hospital #2's allegations and determined the complaint had no merit. When asked, what if any issues, were identified relative to follow up ED care for Alabama Medical patients, EI #2 /CEO stated that he was not aware of any complaints or problems, but they (Hospital #1) are working to develop a referral processes to deal follow-up with orthopedic care.

This citation written as a result of the investigation of complaint AL00025024.

Based on observations, interviews, medical record review, and emergency department (ED) meeting minutes, and documentation in a letter of complaint from Hospital #2, staff in Hospital #1's ED failed to assure that the discharge instructions / plans, provided to Alabama Medicaid recipients treated in the ED with orthopedic complaints or injuries, are coordinated with other hospital departments in a manner that assures each patient receives follow-up orthopedic care as specified by the ED physician, with the designated orthopedic specialist, in the time frame specified in the ED discharge orders, and that is necessary to protect the health and safety of orthopedic patients.
Interviews with ED Medical Director and ED administrative staff (during the survey) revealed that all ED orthopedic patients are referred to on-call orthopedic specialists whose main office is in Georgia. Hospital # 1's ED Medical Director stated that ED patients who do not have a preferred orthopedic physician, or preferred primary care doctor, are referred to the designated on call orthopedic doctor (who works with the orthopedic clinic in Georgia) for follow-up care.
The ED staff interviewed during the survey said some patients call back (after discharge) and complained that the designated orthopedic clinic does not accept Alabama Medicaid insurance and if they (patients) go to the clinic (as directed by Hospital #1's ED) they will be expected to pay out of pocket for their follow-up care. ED staff stated that when patients call back with this complaint, the patients are instructed to (a) to go to their primary care physician and ask for a referral to an Alabama orthopedic doctor or group (there are no local orthopedic doctors), (b) to go to an Alabama orthopedic specialist they (patient) may have seen in the past, or (c) to go to another acute care hospital (nearest located approximately 30 miles from this facility) and see another ED doctor who could refer the patient to an orthopedic specialist in Alabama. However, these patient complaints and or changes in the ED discharge instructions are not documented in the medical record or communicated to departments outside the ED (such as social services or discharge planning).
Documentation in Hospital # 1's 6/14/2011 ED meeting minutes, and ED staff interviews, confirm that ED patient concerns are know to ED staff and ongoing at the time of the survey. These complaints are verbally addressed but not documented after discharge. Staff do not document when an ED patient calls back with a complaint in the ED medical record or communicate the patient's concerns to department outside the ED. As a result, Alabama Medicaid who present to the ED at Hospital # 1 do not receive the follow-up orthopedic care ordered by the ED physician after discharge.
This deficient practice effected twenty (20) of thirty-eight (38) sampled ED patients (Patient Identifier (PI) #'s 1, 3, 4, 6, 7, 8, 10, 12, 14, 16, 17, 19, 20, 21, 22, 24, 25, 28, 31, 50) and has the potential to effect any Alabama Medicaid patient presenting to this ED with an orthopedic complaint or injury and who would need follow-up orthopedic care.

Findings Include:

On 8/25/2011, the state agency (SA) received a complaint alleging that the following twenty-one (21) ED patients, who presented to Hospital #1's emergency department (ED) between 3/1/2011 through 6/15/2011 with orthopedic complaints or injuries, were discharged without the follow-up discharge instructions appropriate and or necessary to prevent relapse or worsening of the patients presenting conditions: Patient Identifier numbers (PI #): 1, 3, 4, 6, 7, 8, 10, 12, 14, 16, 17, 19, 20, 21, 22, 24, 25, 28, 31, and 50.

During the on-site unannounced survey (conducted 8/30-9/1/2011), documentation in these ED medical records revealed each of patient was seen, treated, and discharged in stable condition from Hospital #1's ED with written discharge instructions to follow-up with an ED on-call orthopedic physicians. The discharge instructions (signed by the patient or the patient's legal representative) and included contact information for the on-call orthopedic clinic that is located in Georgia (less than 10 miles from Hospital #1 in Alabama). Each of the on-call orthopedic physicians can admit to Hospital # 1 and are affiliated with the Georgia orthopedic clinic. There is no documentation in the ED medical records reviewed that indicates the sampled patients contacted Hospital #1's ED staff to complain that they could not go to the specified orthopedic clinic for follow-up due to the clinic not accepting Alabama Medicaid, or that the ED patients discharge instructions changed after the patients left Hospital #1's emergency department.

On 8/30/11 at 4:22 PM and 8/31/11 at 1:55 PM, Employee Identifier number (EI#) 4, Hospital #1's ED Medical Director, was interviewed. When asked if all ED orthopedic patients are referred to any orthopedic clinic, other than the orthopedic clinic in Georgia, EI# 4 responded, "No..." According to EI # 4, he and other ED Staff at Hospital #1 had discussed patients complaints about the Georgia orthopedic clinic refusing to take some of the ED patient's insurance, but he (EI #4) stated that he does "...not get involved.." because the ED nurses that talk to the patients usually handles the patient's complaints. EI# 4 states that he talks to the on-call orthopedic doctor while the patients are in Hospital #1's ED and before the patient's are discharged and referred to the orthopedic clinic in Georgia.

On 8/31/2011(at 10:20 AM, 10:45 AM, 10:50 AM and 11:00 AM), four randomly selected sampled patients were interviewed by telephone (PI# 1, 6, 7, 22). Each patient presented to Hospital #1's ED with an orthopedic complaints or injury and each was referred to one of the on-call orthopedic physicians. All four patients, or their representative, confirmed that after contacting the orthopedic clinic, they (patients or representatives) were told that the Georgia based orthopedic clinic does not accept Alabama Medicaid insurance, and they (ED patients/representatives) would be expected to pay out of pocket if they came to the clinic for their follow-up care. The patients (or their representative) called back to Hospital #1's ED and were directed by Hospital #1's ED staff to go to another doctor, or another hospital in Alabama so they could be referred to an orthopedic doctor in Alabama.

Emergency department nursing staff, EI #9 (interviewed 8/30/11 at 2:15 PM), EI# 3 (interviewed 8/31/11 at 3:05 PM) and EI #7 (interviewed 8/31/11 at 4:20 PM) confirmed that ED orthopedic patients (or family member) call back to the ED and complain or report that the Georgia based orthopedic clinic does not accept Alabama Medicaid, the nurses direct the patients / representatives (a) to call or see their primary care physician (PCP), (b) to go to another doctor and ask for referral to an orthopedic doctor in Alabama, or (c) to go to another acute care hospital and get a referral to an Alabama orthopedic doctor. Hospital #2 in Alabama is located approximately 30 miles from Hospital #1 and is affiliated with a different orthopedic group. Staff interviewed stated they give verbal instructions but do not document these as changes in the patient's medical record or as changes in the patient's original discharge instructions. Staff denied documenting or reporting these calls as patient complaints, or referring the calls to any department or staff outside the ED.

On 9/1/2011, EI #4 / Hospital #1's Chief Operating Officer (COO) was interviewed and provided a copy of a letter of complaint from acute care Hospital #2. This letter from Hospital #2 includes: "...received numerous reports that patients presenting to...[Hospital #1] Emergency Department with an emergency medical condition are not being seen by on-call physicians, not properly stabilized and/or improperly transferred..." The letter describes three ED patients discharged from Hospital #1's ED with referrals to the orthopedic clinic in Georgia. Hospital #2's letter noted these patients contacted the designated orthopedic clinic in Georgia but were told that the specified orthopedic doctor is with this clinic but the clinic does not accept Alabama Medicaid. As a result the patients presented to emergency room at Hospital #2.
EI # 5 / Hospital #1's COO (interviewed on 8/31/11 at 4:55 PM) stated she and members of the Quality Assurance / Risk Management staff, other administration staff, and a legal representative for Hospital #1 reviewed Hospital #2's letter and the ED patient records. They (Hospital # 1's staff and COO) determined that Hospital #2's complaint was not substantiated, and no corrective actions necessary. When asked if anyone talked with the patients or their representatives, the COO responded, "No."

EI #6 (interviewed on on 8/31/2011 at 10:05 AM) was identified as Hospital #1's designated staff member responsible for processing patient complaints. EI # 6 stated she had no complaints form Alabama Medicaid patients about being unable to go to the specified orthopedic clinic for their follow-up care. EI #6 stated she was not sure if she would get these complaints. When asked if any patient had complained about a doctor, or doctors, not accepting Medicaid, EI # 6 replied, yes. EI # 6 stated some patients have called to complain that thy have to pay for emergency services but she (EI #6) was not sure that Hospital #1 accepted Medicaid.

Documentation in Hospital #1's Emergency Department Meeting minutes (dated 6/14/2011) include: "...Orthopedic referrals were discussed. After a fairly long discussion it was decided that ...would attempt to establish relationships with outside orthopedic services for patients who could not arrange to follow up at the ... clinic [ED on-call orthopedic in Georgia]. It was agreed that in similar cases referral back to the primary care doctor was appropriate..."

On 9/1/2011 at 2:15 PM, EI# 2 / Hospital #1's Chief Executive Officer (CEO) stated he first learned about Hospital #2's letter of complaint on 8/31/2011 (the second day of the survey). EI #2 stated he read Hospital # 2's letter concerning Alabama Medicaid patient's presenting to Hospital # 2 because the on call orthopedic physician refused to accept Alabama Medicaid insurance. EI #2 /CEO stated that Hospital #1 staff (identified as part of the governing body) reported that this complaint was investigated and Hospital #2 allegations were found to have no merit, When asked, if Hospital # 1 staff had identified any issues relative to ED follow up care for Alabama Medicaid patients, EI #2 /CEO stated he was not aware of any complaints from Alabama Medicaid patients, but they (Hospital #1) is working to develop a referral processes to deal with follow-up orthopedic care.

This citation written as a result of the investigation of complaint AL00025024.

Surveyors:
Barbara Little, RN
Susan Reed, RN