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On the days of the EMTALA Investigation based on observations, interviews and record reviews, the hospital failed to provide appropriate medical screening examinations to determine if a medical condition existed and provide medical screening exams available to patients regardless of payment source.


The findings are:


Cross Reference to A 2406: The hospital failed to provide a medical screening examination to determine the existence of an emergency medical condition for 2 of 34 (patient #33 and patient #34) patient records reviewed.

Cross Reference to A 2408: The hospital failed to ensure that the patient care was not delayed by way of inquiring about an individual's ability to pay prior to receiving an Emergency Medical Screening for 1 of 1 (Patient #34) patients interviewed and whose record was reviewed for care and services.

On the days of the EMTALA investigation based on observations, interviews, review of medical record reviews, ER daily patient Location list, and hospital policies and procedures, the hospital failed to provide a medical screening examination to determine the existence of an emergency medical condition for two (2) of thirty - four (34) patient records reviewed. (Patient #33 and #34)


The findings include:

On 7/17/2013 at 1100, review of hospital policy and procedure, titled, EMERGENCY DEPARTMENT REGISTRATION, effective date October 1, 2012, reads, "....Registering an Emergency Department Patient at Desk (Walk-in), ...Greet patient at window, Have patient sign registration slip...Sign patient name, time of arrival, and complaint on triage clipboard...inform triage nurse of patient's arrival...after triage, call patient into the registration area...ask patient for insurance cards, driver's license and other identification as needed...verify insurance information...sign into eMedic...enter insurance information...print results...If self-pay, advise patient of their financial responsibility...collect any payment the patient may be able to pay...have patient sign a promissory note...advise patient of charity program..." The facility failed to have an effective EMTALA (Emergency Medical treatment and Labor Act) policy in place that clearly addresses anti-dumping provisions related to requesting payment and/or collecting money prior to a medical screening examination being performed to determine whether or not an emergency medical condition exists.

On 07/18/2013 at 3:25 p.m., observations revealed Patient #34 in the patient waiting room area who reported that he/she had been triaged and was waiting to see the doctor. On 7/18/2013 at 3:30 p.m., Patient
#34 reported that he/she had come to the emergency department with low back pain and difficulty walking. Patient #34 stated, "I do not have any insurance so they asked me to pay $285.00." Patient #34 reported that the hospital did not refuse to see him/her but asked that he/she wait in the patient waiting room until the physician could see him/her. On 07/19, 2013 at 12:00 p.m. (noon), review of Patient #34's emergency department chart revealed Patient #34 arrived to the hospital's emergency department on 07/18/2013 at 2:37 p.m.. Patient #34 was triaged on 07/18/2013 at 2:46 p.m.. Documentation in the section of the emergency department nursing triage form revealed, "Pain is described as sharp. Pain intensity at this time is rated as ten on a scale of zero to ten with ten being the worst pain ever felt, Pain in lower back with acute onset." Triage (assessment by the triage nurse to determine a patient's medical priority of need) level was documented as a category four(4).

Review of the hospital's policy, titled, Assessment/Reassessment, with an effective date of 3/01/2001 and an amended date of 09/2008, reads, "2. C. Category IV - Patients in this category generally need evaluation and treatment but time is not a critical factor. 4. D. Category IV, within two hours. Patients will be reassessed every 2 hours until Emergency Room is available."

There was no further documentation of a re-assessment of Patient #34's pain level, vital signs, or any pain control administered. On 07/18/2013 at 8:05 p.m., staff documented, "Left Without Being Seen" which was approximately five (5) and one half hours after the patient's triage assessment. Patient #34 was assigned a "self pay" financial level. Review of the hospital form, "ER Patient Daily Location List" revealed twelve patients had presented to the hospital's emergency department between 2:37 p.m. and 8:05 p.m. on 7/18/2013. On 07/19/2013 at 12:10 p.m. (noon), the finding was verified with the Emergency Department Director. This deficient practice resulted in Patient #34 leaving the emergency room without being seen after being asked to pay $285.00 prior to the hospital staff providing the patient with a medical screening examination as required regardless of ability to pay.

On 07/18/2013 at 4:00 p.m., the Director of Financial Services reported that the process for registering a patient in the emergency department is, "...We do a quick name, chief complaint and date of birth of the patient. Generate a quick form for the nurse to be able to access the patient record for triage in the electronic medical record (EMR). The registration clerk goes to the door and lets the nurse know a patient is here for triage. The patient is generally called into the triage area within 5 minutes, except for chest pain, bleeding, shortness of breath, asthma, or allergic reactions. They are called back immediately prior to quick form... Expectations are regarding copays-we like to get copays when registration is complete-after triage if no emergency, the patients are asked to pay prior to seeing the physician for an Emergency Medical Screening..." This interview verifies that the hospital failed to ensure that regardless of the patient ' s presenting symptoms the hospital is required to provide a medical screening examination to determine if an emergency medical condition exist, prior to requesting money and or collecting money from a patient.



31395

On 07/18/19 at 3:40 p.m., review of Patient #33's emergency department chart showed the patient presented to the hospital's emergency department on 7/18/2013 at 3:48 p.m. with a chief complaint of "Lower extremity pain both lower ext (extremities). started about a week ago.". Patient #33 was triaged at 3:48 p.m. and assigned a triage level of three (3).

Per the hospital's policy "Assessment/Reassessment" a Category III are "Patients that require prompt care, but will not generally cause loss of life or limb, permanent, or severe impairment if left untreated for several hours....Patient's treatment is identified based on Triage criteria and assessed as follows:...Category III within 2 hours. Patients will be reassessed every 2 hours until Emergency Department room is available...." .

Review of the Patient #33's triage pain assessment revealed the patient's pain level was a "10" with "10" as the worst pain ever. After the triage notes, there was no further documentation in the patient's chart until 7:05 p.m. when the nurse documented, "Left without being seen". Patient #33 was assigned a "self pay" financial level. Four hours had elapsed without a medical screening examination or further re-assessments of the patient prior to the patient leaving the emergency department. Review of the hospital's form, "ER Patient Daily Location List, revealed between the hours of 3:01 p.m. and 7:00 p.m. on 7/18/2013, no patients had presented to the hospital's emergency department. On 07/19/13 at 12:10 p.m., the Chief Nursing Officer verified the findings. This deficient practice resulted in a delay in providing Patient #33 a medical screening examination (self pay) to determine if an emergency medical condition existed on 7/18/2013.

On the days of the EMTALA investigation the facility failed to ensure that the patient care was not delayed by way of inquiring about an individual's ability to pay prior to receiving a Medical Screening Examination for 1 of 34 sampled patient records (#34).

The findings include:

Cross Reference to A 2406: The hospital failed to provide a medical screening examination to determine the existence of an emergency medical condition before requesting financial information for 1 of 1 patient with self - pay financial status. (Patient #34)

On 07/15/2013 at 3:00 p.m., Observations of the Emergency Department (ED) patient waiting area revealed a large blue laminated sign posted in the hospital's emergency department and in the Registrar area, that reads, "EFFECTIVE MARCH 1, 2013 EMERGENCY ROOM $35.00 CO-PAY IS EXPECTED AT TIME OF SERVICE." On 07/17/2013 at 1015, Registrar #2, stated, "Patient comes to the window, and fills out a slip. The Registrar does a quick registration form and sends the slip to the triage area by placing the slip in the door outside of Registration. We only ask self pay patients for the $35.00 co-pay, and this is after an Emergency Medical Screening (EMS) by the physician. If the patient cannot pay, we set up a promissory note with a promise to pay."

On 7/17/2013 at 11:00 a.m., review of hospital policy and procedure, titled, EMERGENCY DEPARTMENT REGISTRATION, effective date October 1, 2012, reads, "...Registering an Emergency Department Patient at Desk (Walk-in), ...Greet patient at window, Have patient sign registration slip...Sign patient name, time of arrival, and complaint on triage clipboard...inform triage nurse of patient's arrival...after triage, call patient into the registration area...ask patient for insurance cards, driver's license and other identification as needed...verify insurance information...sign into eMedic...enter insurance information...print results...If self pay, advise patient of their financial responsibility...collect any payment the patient may be able to pay...have patient sign a promissory note...advise patient of charity program..."

On 07/18/2013 at 4:00 p.m., the Director of Financial Services reported that the process for registering a patient in the emergency department is, "...We do a quick name, chief complaint and date of birth of the patient. Generate a quick form for the nurse to be able to access the patient record for triage in the electronic medical record (EMR). The registration clerk goes to the door and lets the nurse know a patient is here for triage. The patient is generally called into the triage area within 5 minutes, except for chest pain, bleeding, shortness of breath, asthma, or allergic reactions. They are called back immediately prior to quick form... Expectations are regarding co-pays-we like to get co-pays when registration is complete-after triage if no emergency, the patients are asked to pay prior to seeing the physician for an Emergency Medical Screening..."

The hospital staff requested a method of payment ($285.00 cash) from Patient #34 prior to a medical screening examination. This deficient practice resulted in a delay in treatment, and Patient #34 did not receive a medical screening examination as required on 7/18/2013.