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Based on document review and staff interview, the hospital Emergency Department (ED) administrative staff failed to ensure hospital staff followed hospital policies, and did not provide 1 of 30 patients, selected for review from 1/1/11 to 7/5/11 with an appropriate Medical Screening Examination. The hospital administration identified an average of 157 patients with Iowa Cares insurance per month come to the ED seeking care.

Failure to follow hospital policies and procedures resulted in ED staff failing to provide an appropriate medical screening exam that resulted in a patient with a possible emergency medical condition not receiving appropriate care, potentially leading to disability, loss of limb, or death.

Findings include:
1. Review of Patient #1's medical record revealed ED Physician A accepted the transfer of Patient #1 to the hospital ED, because the ED physician at the sending hospital could not successfully perform a lumbar puncture on Patient #1.

On 6/16/11 at 11:54 PM, Registered Nurse (RN) B documented in the ED Nurse's Notes that Patient #1 arrived at St. Luke's Hospital.

On 6/17/11 at 7:00 AM, ED Resident Physician C documented in the Doctor's Progress Notes Patient #1 was transferred to St. Luke's Hospital for a fluoroscopic guided lumbar puncture.

ED Resident Physician C also documented in the Doctor's Progress Notes, "[Patient] with Iowa Cares [insurance] needing hospitalization. Transfer for further work-up and admission."

At 1:55 AM, RN B documented they transferred Patient #1 to Receiving Hospital A.

Review of Patient #1's medical record revealed hospital staff did not perform a lumbar puncture on Patient #1, despite Patient #1's transfer to St. Luke's Hospital to receive a lumbar puncture under fluoroscopy.

2. Review of the policy "EMERGENCY EXAMINATION AND TRANSFER POLICY - EMTALA", effective 9/09, revealed in part, "The medical screening examination provided for a patient shall be within the capabilities of the [St. Luke's Hospital] department to which the patient is presenting, including ancillary services routinely available to that department..." On page 10 of the policy, under the section "TRANSFERS FROM ANOTHER MEDICAL FACILITY TO SLH" revealed in part, "The physician and or St. Luke's Hospital shall not consider the patient's financial circumstances or insurance or means of payment in the decision to respond to, treat or transfer the patient."

3. During an interview on 7/8/11 at 9:00 AM, ED Resident C stated they spoke with ED Physician D, and decided to not perform a lumbar puncture on Patient #1, since they decided to transfer Patient #1 because of Patient #1's insurance.

4. During an interview on 7/7/11 at 9:05 AM, ED Physician D stated the hospital had the capacity to perform a lumbar puncture on Patient #1, including the use of fluoroscopy. However, they decided to delay performing a lumbar puncture on Patient #1 because Patient #1's insurance, Iowa Cares, required Patient #1 to seek care at Receiving Hospital A. ED Physician D decided to delay Patient #1 receiving a lumbar puncture, until after transfer to Receiving Hospital A due to financial considerations.

Based on document review and staff interview, the hospital's Emergency Department (ED) administrative staff failed to ensure ED staff provided an adequate Medical Screening Exam (MSE) for 1 of 30 ED patients selected for review from 1/1/11 to 7/5/11. The ED administrative staff identified an average of 153 patients per month who presented to the ED with Iowa Cares insurance.

Failure to provide an appropriate medical screening exam resulted in a patient not receiving appropriate care, potentially leading to disability, loss of limb, or death.

Findings include:

1. Review of Patient #1's medical record revealed ED Physician A accepted the transfer of Patient #1 to the hospital ED, because the ED physician at the sending hospital could not successfully perform a lumbar puncture on Patient #1. On 6/16/11 at 11:54 PM, Registered Nurse (RN) B documented in the ED Nurse's Notes that Patient #1 arrived at St. Luke's Hospital. On 6/17/11 at 7:00 AM, ED Resident Physician C documented in the Doctor's Progress Notes Patient #1 was transferred to St. Luke's Hospital for a fluoroscopic guided lumbar puncture. ED Resident Physician C also documented in the Doctor's Progress Notes, "[Patient] with Iowa Cares [insurance] needing hospitalization. Transfer for further work-up and admission." At 1:55 AM, RN B documented they transferred Patient #1 to Receiving Hospital A.

Review of the medical record revealed Patient # 1 presented to the ED with an altered mental status. Documentation indicated Patient # 1 was "very slow to answer simple questions" and not at his baseline and that the ED was concerned about the possibility of an infection vs. an "elevated ammonia" level. The medical record lacked evidence Patient # 1 received an examination which would have included a lumbar puncture, laboratory tests and radiological imaging. The ED did not determine the etiology of Patient # 1's altered mental status prior to transfer.

2. Review of the policy "EMERGENCY EXAMINATION AND TRANSFER POLICY - EMTALA", effective 9/09, revealed in part, "The medical screening examination provided for a patient shall be within the capabilities of the [St. Luke's Hospital] department to which the patient is presenting, including ancillary services routinely available to that department..."

3. During an interview on 7/6/11 at 4:00 PM ED nurse G stated when Patient # 1 arrived in the ED he looked sick. He was weak, drowsy, fatigued, we had a hard time getting him out of his clothes. We had to use two nurses to sit him up. We put him on the monitor and then the ED Resident C went into the room and evaluated him. ED nurse G stated that if a patient has Iowa Cares, the registration staff highlights the Iowa Cares insurance in yellow and the charge nurse gets a yellow sheet of paper which is placed on a clipboard and given to the doctor.

4. During an interview on 7/8/11 at 9:00 AM, ED Resident C stated they spoke with ED Physician D, and decided to not perform a lumbar puncture on Patient #1, since they decided to transfer Patient #1 because of Patient #1's insurance.

Based on document review and staff interview, the hospital's Emergency Department (ED) administrative staff failed to ensure ED staff did not base Medical Screening Examination decisions on a patient's ability to pay for 1 of 30 ED patients selected for review from 1/1/11 to 7/5/11. The ED administrative staff identified an average of 153 patients per month who presented to the ED with Iowa Cares insurance.

Failure to base MSE decisions on a patient's ability to pay could result in a patient with an emergency medical condition not receiving appropriate care, potentially leading to disability, loss of limb, or death.

Findings include:

1. Review of Patient #1's medical record revealed ED Physician A accepted the transfer of Patient #1 to the hospital ED, because the ED physician at the sending hospital could not successfully perform a lumbar puncture on Patient #1.

On 6/16/11 at 11:54 PM, Registered Nurse (RN) B documented in the ED Nurse's Notes that Patient #1 arrived at St. Luke's Hospital.

On 6/17/11 at 7:00 AM, ED Resident Physician C documented in the Doctor's Progress Notes Patient #1 was transferred to St. Luke's Hospital for a fluoroscopic guided lumbar puncture.

ED Resident Physician C also documented in the Doctor's Progress Notes, "[Patient] with Iowa Cares [insurance] needing hospitalization. Transfer for further work-up and admission."

ED Resident Physician C documented on the Authorization for Transfer form "Specific benefit of transfer: Hospital Admission. Iowa Care... Transfer requested by: ... Physician".

At 1:55 AM, RN B documented they transferred Patient #1 to Receiving Hospital A.

2. Review of the policy "EMERGENCY EXAMINATION AND TRANSFER POLICY - EMTALA", effective 9/09, revealed in part, "Provision of the medical screening examination and further examination and treatment may not be delayed in order to inquire about the individual's method of payment or insurance status." On page 10 of the policy under the section "TRANSFERS FROM ANOTHER MEDICAL FACILITY TO SLH" revealed in part, "The physician and or St. Luke's Hospital shall not consider the patient's financial circumstances or insurance or means of payment in the decision to respond to, treat or transfer the patient."


3. During an interview on 7/7/11 at 7:10 AM, Registration Specialist E stated they retrieved Patient #1's demographic information, that included Patient #1's insurance information, and generated a face sheet for Patient #1's hospitalization at St. Luke's. After noticing Patient #1 had Iowa Cares insurance, Registration Specialist E made an extra copy of the face sheet, highlighted Patient #1's name and insurance, and gave the face sheet and yellow Iowa Cares patient sheet to the charge nurse. The highlighted face sheet and yellow Iowa Cares patient sheet alerted the staff of Patient #1's insurance status if hospitalization was necessary.

4. During an interview on 7/6/11 at 9:05 AM, Financial Counselor F stated they give the ED nurse a yellow sheet of paper with the patient's sticker on it (if the patient has Iowa Cares). There is also a wood clipboard we give the charge nurse, to put the doctor's paperwork on, so the doctor knows the patient has Iowa Cares.

5. Review of the document "Iowa Care Insurance Program Process ER", not dated, revealed if a patient with Iowa Cares insurance needed inpatient admission, a financial counselor was to speak with the patient, and inform the patient if they "want to continue receiving healthcare at St. Luke's will need deposit of $500 today and patient will be responsible for remainder of bill OR can be seen at [Receiving Hospital A's name]."

6. During an interview on 7/8/11 at 9:00 AM, ED Resident Physician C stated after they determined Patient #1 needed admission for inpatient care, they informed Patient #1 Iowa Cares insurance only paid for care at Receiving Hospital A. Patient #1 requested to stay at St. Luke's, since they had family in the area. ED Resident Physician C spoke with hospital staff, and was informed Patient #1 would need a $500 deposit, if they wanted to stay at St. Luke's. After ED Resident Physician C informed Patient #1 about the deposit, Patient #1 stated they could not afford the deposit, and reluctantly agreed to the transfer to Receiving Hospital A.