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Based on review of the medical record, policies/procedures and physician and staff interview, it was determined the facility failed to comply with 489.24, as required in the EMTALA provider agreement.

Based on medical record reviews, physician/staff interviews and review of facility documents and policies and procedures, the facility failed to provide a medical screening exam for sample patient #1, as required. The failure created the potential for a negative patient outcome.

The findings were:

1. Medical Record Review:

On 4/6/10, the medical record of the patient in the complaint (sample patient #1) was reviewed and revealed the following findings:

The patient was a adult patient who came to the ED (Emergency Department) on a Monday morning at 9:37 a.m. with a chief complaint of back pain. Vital signs were taken by an LPN (Licensed Practical Nurse) at 9:45 a.m..

The nursing note completed by the LPN stated: "Patient states s/he tried to call (his/her provider's) clinic for an appointment but didn't get an answer. The medical provider on duty - Certified Physician Assistant - PA-C was able to make appointment for patient at 13:45 this p.m. Patient was given a choice to go to appointment with (his/her provider) or stay for evaluation here but run the chance of patient's health maintenance organization not paying for visit as it is non-emergent. Patient chose to leave and did so at 9:50 a.m."

The "Emergency Physician Record," a 2-paged document, was blank except for the name, date, age, sex and date of birth, which appeared to have been filled out by the ED nurse, an LPN, who opened the record. The sheet titled "Instructions to the Patient After Emergency Care" was also blank, except for the date, patient name and arrival time, which again appeared to have been filled out by the ED nurse, an LPN, who opened the record. The "face sheet" for the record stated "never seen" under the "admitting diagnosis" section. On the "Emergency Admission Form" the nurse (LPN) stated under "acuity" section, "no charge." The "Emergency Room Charge Sheet," which listed of menu of nurse/physician services with a point system to rank complexity of services, was blank, except for the name, date and provider name in the heading section.

2. Staff Interviews:

Licensed Practical Nurse

On 4/6/10 at approximately 1:10 p.m., the LPN who made initial contact with the patient (sample patient #1) was interviewed. The LPN stated s/he remembered the patient, his/her spouse and the events of the ED visit. S/he stated the patient came in and was complaining of back pain. S/he took the patient's vital signs and helped the patient get into a hospital gown. S/he stated the patient was accompanied by spouse. S/he had previously been to the urgent care clinic in Alamosa, Colorado. S/he attempted to get an appointment with her primary care physician at the local clinic in Antonito, Colorado, but was unable to get through on the telephone to make an appointment. The LPN stated that s/he told the medical provider in the ED (the PA-C) the patient had back pain, had tried to go to his/her clinic doctor, but couldn't get through by telephone. The PA-C got on the phone and made an appointment for the patient to be seen that afternoon at the clinic in Antonito, Colorado. The PA-C apparently told the LPN the patient's insurance was unlikely to pay for the ED visit because it was not an emergency situation. The PA-C told the LPN to tell the patient that s/he could be seen in ED and run risk of incurring non-reimbursable charges or to go to the 1:45 p.m. appointment at the clinic in Antonito. The LPN stated s/he reiterated to the patient that they were not refusing to see him/her, but were trying to save him/her money." Ultimately, the patient decided to leave and go to the clinic appointment. When question by the surveyor, the LPN stated that s/he never made the statement or determination to the PA-C or the patient that "the condition was not a medical emergency." She stated clearly that this was beyond her scope of practice. S/he also validated the PA-C never came in and met, spoke with, or assessed the patient.

Director of Nursing

On 4/7/10 at approximately 1 p.m., the Director of Nursing (DON) was interviewed and provided a written statement of actions taken to investigate and correct the failure of the PA-C to do a medical screening exam on the patient.

The statement, dated 4/7/09 stated the following:
"Plan of Correction-EMTALA Complaint," stated the following:

"LPN discussed concerns with DON the day of occurrence about (Sample Patient #1). LPN stated the patient and his/her family were upset the PA-C called the patient's provider (and) had made appointment for patient to be seen at the clinic in Antonito, Colorado. The patient had been checked into the Emergency Room, (s/he) had a nursing assessment done and (his/her) vital signs taken. The patient was not seen by the PA-C. The PA-C told LPN to have the patient go to the clinic to see (his/her) provider. Later on, the PA-C stated that (s/he) wanted to save the patient an emergency room charge because the insurance (s/he) had in the past had refused payment for this type of complaint in other cases. The following actions were done, prior to the investigation by the CDPHE (Colorado Department of Public Health and Environment, the State Agency):
-LPN was advised that PA-C must always do a medical screening before it is determined what is to be done with the patient.
-The nursing staff was advised that a Medical Screening must be done by the provider when the patient presents to the Emergency Department. If there is no Medical Screening and the patient is not seen this is an EMTALA violation.
-The nursing staff was told to call the DON or the Administrator on Duty if there was an issue with a medical screening and that they can tell the provider that a patient must have a medical screening done.
-The providers were reminded that at this institution a provider must do the Medical Screenings and the nursing staff does NOT provide Medical Screenings.
-The PA-C was advised by the Emergency Department Medical Director, that when a patient presents to the ED it is not up to the providers to be concerned with cost and insurance issues. Medical Screenings/assessments must always be done by providers.
-The CEO (Chief Executive Officer) requested the nursing staff be educated about EMTALA-the DON made up EMTALA tests for the licensed nursing staff to take.
-The CEO discussed in the Medical Staff Meeting in September about EMTALA regulations and that the nursing staff will be educated. The DON stated the ED Medical Staff will also be required to take the EMTALA test."

3. Policy/Procedure Review:

Review of Emergency Department (ED) policies/procedures on 4/6/10, revealed the following, in pertinent parts:

Emergency Department Policy/Procedure - "Purpose and Objectives"
"Purpose: One purpose of this hospital is to provide quality care for all patients who arrive at the Emergency Department 24 hours a day regardless of age, race, religion or ability to pay, as defined by federal and state laws.
- All patients will receive evaluation by the Emergency Department physician...."

Emergency Department Policy/Procedure - "Scope of Service"
"Policy:
The Emergency Department of this hospital is a Level IV Trauma Emergency Medical Service Department. This hospital has a 5 bed Emergency Department with 24-hour per day care.
Patient Population:
The patient population served by the Emergency Department consists of newborn, pediatric, adolescent, adult and geriatric patient requiring or seeking medical care.
Scope and Complexity of Patient Care Needs:
-All patients that present to Conejos County Hospital's premises for a non-scheduled visit and are seeking care shall receive a medical screening exam by an Emergency Department physician that includes providing all necessary testing and on-call services within the capability of Conejos Hospital to reach a diagnosis...
Staffing:
-A minimum of (1) Emergency Department physician, Physician Assistant or Nurse Practitioner is on-duty at all times...."

Emergency Department Policy/Procedure - "EMTALA Guidelines for Emergency Department Services"
"Policy:
-All patients presenting to Conejos County Hospital's Emergency Department and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay...
-All patients shall receive a medical screening exam that includes providing all necessary testing and on call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician or clinic.
-The triage of a patient for managed care contracts without a medical screening exam is not acceptable under EMTALA..."

Emergency Department Policy/Procedure - "Emergency Department Patient Registration"
"Policy:
-This hospital will provide emergency medical screening and stabilizing treatment, as necessary, to all individuals 'coming to the Emergency Department,' without delaying care to inquire about the patient's ability to pay.
-All patient will be evaluated by the Triage Nurse prior to being seen by the Admitting Department Clerk. The Triage Nurse serves as the Admitting Department Clerk in the Evening and week-end hours.
Procedure:
...Note: No financial information will be requested at this time...
-After the physician has medically screened the patient and provided any necessary emergency treatment, the Admitting Department Clerk will finish the registration process. At this time the registration will be completed, including insurance information...."