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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 observations, interviews, and document reviews, 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 for a patient who sought emergency care. (Patient #5)

Based on observations, interviews, and document reviews, 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 for a patient who sought emergency care. (Patient #5)

Findings include:

Facility policies:

The Obstetrics (OB) Patients Presenting to the emergency department (ED) policy read, patients who are presenting to the ED who are over 20 weeks gestation with OB complaints will register with ED admissions and will go straight up to the Family Center.

The EMTALA Compliance policy read, reasonable registration processes may be implemented and may include asking whether the individual has insurance and the name of the insurer so long as these procedures do not delay the screening examination or necessary stabilizing treatment. Labor means the process of childbirth beginning with the latent or early phase and continuing through the delivery of the placenta. For purposes of this policy, a woman is in "true" labor unless a physician or qualified medical person certifies, after a reasonable period of observation, that she is in false labor.

Reference:

The Patient Access Representative job description read, the patient access representative is a non-clinical staff member. Required education, high school graduate or equivalent.

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

a. Medical record review revealed Patient #5 was a 27 year old, 39 weeks and 6 days pregnant patient who presented to the facility on 8/22/24 at 9:48 a.m. Nursing documentation revealed Patient #5 presented to the family center (obstetrics department) at 10:00 a.m. and reported she had blood in the toilet with clots at 2:00 a.m. and was unsure if her water had broken. A fetal heart rate was not present and Patient #5 was diagnosed with suspected placental abruption (separation of the placenta from the wall of the uterus) and fetal demise (death).

b. On 9/24/24 at 11:35 a.m., ED lobby video footage was reviewed and revealed Patient #5 approached the ED registration desk on 8/22/24 at 9:37 a.m. Patient #5 remained at the registration desk until she was escorted by staff out of camera view at 9:55 a.m.,18 minutes later.

This was in contrast to the EMTALA Compliance policy which read, reasonable registration processes may be implemented as long as these procedures did not delay the screening examination or necessary stabilizing treatment.

c. On 9/25/24 at 2:08 p.m., an interview was conducted with patient access representative (PAR) #1, who registered Patient #5. PAR #1 stated the registration process took 18 minutes because she was a new employee and was being trained. PAR #1 stated when patients greater than 20 weeks pregnant presented to ED registration for unscheduled care, they were registered as a clinical outpatient and a long registration was completed. PAR #1 stated the long registration included more steps than the short registration which was utilized for ED patients.

d. On 9/25/24 at 8:00 a.m., observations were conducted in ED registration. Observations revealed patients who requested to be seen in the ED were registered using a short registration process. Patients were asked to verify their name, date of birth, preferred language, primary care provider, chief complaint, and a copy of their drivers licenses was obtained if it was not in the computer system. Observations of the PAR's computer registration system revealed the long registration contained additional fields, which included guarantor, insurance, contact, provider, demographics, and employer information.

e. On 9/25/24 at 1:15 p.m., an interview was conducted with PAR #2, who trained PAR #1 on 8/22/24 when Patient #5 presented to the facility for care. PAR #2 stated Patient #5 informed them her water had possibly broken and she denied having contractions. PAR #2 stated she thought they had collected Patient #5's insurance card, but was not certain if this had occurred. PAR #2 stated the current process for when individuals greater than 20 weeks pregnant arrived was to register them as a clinical outpatient and their driver's license and insurance information was collected and scanned into the computer before they were sent to the family center. PAR #2 stated this was the process they were trained to perform. PAR #2 stated the process to generate the OB assess clinical outpatient record took longer than the process to generate a record for an ED patient.

PAR #2 stated they were not able to evaluate or assess patients because they were not clinical staff. PAR #2 stated insurance information was not collected for serious, laboring patients. PAR #2 stated laboring patients were sent to the family center to not delay their treatment. PAR #2 stated they asked patients if they felt like they needed to push and they could tell if patients were or were not in distress.

This was in contrast to the PAR job description which read, the PAR was a non-clinical staff member.

This was also in contrast to the EMTALA Compliance policy which read, reasonable registration processes may be implemented and may include asking whether the individual had insurance and the name of the insurer so long as these procedures did not delay the screening examination or necessary stabilizing treatment. A woman was in "true" labor unless a physician or qualified medical person certified, after a reasonable period of observation, that she was in false labor.

f. On 9/30/24 at 1:09 p.m., an interview was conducted with director of patient access (Director) #3. Director #3 stated staff should register OB patients greater than 20 weeks the same way as ED patients. Director #3 stated due to the nature of the computer system, for OB patients, staff were required to tab through and not complete the fields of the long registration to register the patients faster. Director #3 stated staff should not have been accepting insurance information. Director #3 stated staff were trained to tab through the fields during their training phases, but stated the facility did not have the training documented.

This was in contrast to the interview with PAR #2, who stated they were trained to complete the long registration fields and collect insurance information for all family center patients who were not in labor and sent directly to the family center.

Additionally, Director #3 stated the expected time frame to register a late term patient with bleeding and blood clots should have been one to three minutes. Director #3 stated staff asked patients how far along their pregnancy was, their presenting complaint, if their water had broken, and if they were having contractions. Director #3 stated if a patient came to the facility pushing, they would be sent directly to the family center and a short registration would be completed. Furthermore, Director #3 stated they did not know why it was important not to delay treatment because they were not clinical staff.

This was in contrast to the EMTALA Compliance policy which read, a woman was in "true" labor unless a physician or qualified medical person certified, after a reasonable period of observation, that she was in false labor.

g. On 9/30/24 at 11:22 a.m., an interview was conducted with certified nurse midwife (CNM) #4. CNM #4 stated there were many medical emergencies other than labor which could occur in patients greater than 20 weeks pregnant. CNM #4 stated vaginal bleeding in patients greater than 20 weeks could have indicated labor, placental abruption, uterine rupture (a tear in the muscular wall of the uterus), or a placenta previa (a pregnancy complication that occurs when the placenta partially or completely covers the opening to the birth canal). CNM #4 stated no one other than a provider or an OB nurse could determine if these patients were experiencing a medical emergency. CNM #4 stated it was important not to delay treatment in these patients, as staff needed to act quickly to not compromise the health of the mother and the baby.