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Based on hospital policies and procedures review, medical record review, hospital internal document review and staff interview, the hospital failed to prevent delay of a patient screening or treatment by unduly discouraging 1 of 22 sampled DED (dedicated emergency department) patients presenting to the hospital's DED for a screening and/or treatment of an emergency medical condition (Patient #16).

Findings include:

Review on 04/22/2015 of the hospital's policy "Emergency Department Patient Evaluation and Treatment" (Dates Reviewed: 11/2014) revealed "Nondiscrimination and No Delay: A medical screening examination and appropriate treatment will be provided without discrimination based on race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing, medical condition, physical or mental handicap, insurance status, economic status, or ability to pay for medical services, except to the extent that a circumstance such as age, sex, pre-existing medical condition, or physical or mental handicap is medically significant to the provision of appropriate medical care to the person. Provision of a medical screening examination and appropriate treatment will not be delayed in order to inquire about the method of payment or insurance status."

Review on 04/22/2015 of the hospital's policy "EMTALA (Emergency Medical Treatment and Labor Act) Policy" (Reviewed: 05/2012) revealed "2. Registration: _____(Hospital Name) may not delay the provision of an appropriate medical screening examination or any necessary stabilizing medical examination and treatment in order to inquire about the individual's method of payment or insurance status. _____(Hospital Name) may, however, follow reasonable registration processes after triage has been completed, but prior to the provision of a medical screening examination, including asking whether an individual is insured and, if so, what the insurance is. Such processes, however, may not unduly discourage individuals from remaining for further evaluation. Further such inquiry shall not delay provision of the medical screening examination. Accordingly, insurance information should only be collected at times when an individual is waiting for an available examination room."

A closed medical record review on 04/22/2015 for patient #16 revealed the patient was a 12 year-old female that presented to the hospital's DED (Hospital A) on 02/20/2015 with her mother for a complaint of "Stepped on a Nail." The review revealed the patient arrived at the DED's main entrance at 0011. No documentation was found in the medical record that the patient was ever triaged by a hospital registered nurse (RN) or was provided a medical screening examination from qualified personnel. The review of the medical record revealed only that the patient had a "Depart Summary and ED (Emergency Department) Discharge Form on 02/20/2015 at 0027 (total of 16 minutes after presenting to the ED). No documentation was found in the medical record that indicated why the patient and her mother left the DED without a medical screening examination or stabilizing treatment on 02/20/2015.

Review on 04/22/2015 of the hospital's internal documentation review revealed the hospital received concerns from patient #16's mother and its accreditation agency related to the hospital's DED registration and nursing staff requiring the patient's social security number before any treatment was provided. The review revealed the patient's mother stated "On this evening 02/20/2015 around 11:30 we took my 12 year-old daughter to _____(Hospital Name) in _____(City). We were treated rudely to begin with. Left standing against a wall holding a check in form. When 15 minutes had passed with me watching them try to erase something on the computer, they finally called me over. I handed them my form a full twenty minutes after I walked through the door with my child in a wheelchair. Never asking why she was there, if she was having trouble breathing, any symptoms, nothing. Just let us stand there twenty minutes before having me "check in". I was admittedly upset with this. The registration woman began asking me questions, one of which was my child's SSN (Social Security Number). I replied, I'm not giving you that, however, I'm giving giving you my permission to treat, her insurance card and a form of payment, to which she replied, let me see if that's good enough. She called the charge nurse over who asked the problem. I said she wants my child's SSN to treat her, which is not a requirement to render care. I'm not giving it, so that's done. The charge nurse then said, let me see if we can even see her. I replied, so you're refusing care for a child based on her SSN? The nurse said we're not refusing to see your child, just don't know if we can see her without her SSN." The documentation further revealed from the patient's mother in the documentation "The charge nurse came back and said "unfortunately, I've spoken to all of the higher ups and they said we needed her SSN to treat her."

Further review of the hospital's internal documentation revealed "The hospital review revealed multiple breaks in expected hospital process and opportunities for improved patient care and customer service. Violation of hospital policy that requires patients presenting to the emergency department will receive medical screening evaluation without bias. Violation of hospital policy that requires emergency department registration to be completed with application of patient identification arm band. Violation of hospital process that guarantees customers will be treated with respect." The review further revealed the hospital described the events for 02/20/2015 as "Upon entry to ED patient presents to registration window and completes check in form (legal name, DOB (Date of Birth), age, sex, reason for visit, SSN, marital status, family doctor, Ebola virus screening, if necessary would you accept treatment that involves blood product, and if patient is a minor: parent/legal guardian name, relationship, DOB and SSN). Registration typically takes 3-5 minutes. Process ends with signing of consents and registration staff applying armband to patient." Further documentation revealed "Mother of minor patient (#16) presenting to the ED was not registered upon entry. No individuals in line at registration desk upon presentation. Mother and patient were directed to waiting room with registration form. Patient was not in view of registrar or triage nurse during remainder of interaction. The patient was required to wait more than 10 minutes while registrars worked together at computer. When the patient's mother presented to registration, discussion of SSN for minor child ensued per interviews. Per interview the child's SSN was not supplied on the form that mother was provided. The registrar requested the SSN and it became a barrier to administration of care. Registration was delayed with varying accounts of actual conversations but it was clear that registration and access to medical screening was delayed for acquisition of SSN. The patient was registered in system before triage nurse presented to the desk. Patient registration complete when access to care delayed continued." The documentation continued with "Medical Screening was not completed for minor child, identified as patient. Minor child sent to waiting area without medical triage. Potential access to care not impacted by department volume. There were less than 5 other individuals in the waiting area during the entire session. There were no other patients present at registration or triage area. Triage nurse presented and admittedly discussion concerning need for SSN continued. Triage nurse went to have discussion with lead nurse on shift to whether SSN of minor was required for registration."

Interviews on 04/23/2015 at 1505 with the hospital's Chief Nursing Officer, DED Nursing Director and Assistant Chief Nursing Officer revealed that the hospital recognized concerns after the event with patient #16 on 02/20/2015 occurred. The interviews revealed the a formal investigation was conducted at the hospital that included a root cause analysis as well as reports to the hospital's accrediting agency. The interviews revealed that the hospital recognized that the patient's lack or medical screening examination and treatment were related to a delay that came from the conversation of a social security number by the nursing staff and registration in the DED. The interviews also revealed that it was never an expectation for the hospital's staff to have to have a patient's SSN before any treatment was started. The interview also revealed that investigation through staff interviews revealed the staff felt that the mother had the patient's SSN and just refused to give it to them and this was the reason they kept pursuing it. The interviews confirmed this should not have occurred. In addition, the interviews revealed that the hospital recognized the need for improvement and begin to put changes in place through education and training.

Interviews with the triage nurse and registration staff were unable to be completed during the survey due to the staff members no longer employed at the hospital and available for interview.

A closed medical record review for hospital B revealed patient #16 presented to the DED on 02/20/2015 at 0036 through 0604 for treatment related to "Stepped on a Nail." The review of the medical record revealed the patient received a medical screening examination and received treatment of an antibiotic medication, pain medication as needed, and a foot X-ray related to the injury. The patient was discharged from hospital B's DED with reported stable condition and a disposition of "Puncture wound of right foot."

In summary, patient #16 (12 year-old) was brought to hospital A's DED on 02/20/2015 after stepping on a nail at her home. The mother and patient presented to the main lobby of the hospital's DED for evaluation and treatment. The mother completed a quick registration form that included a space for the minor child's social security number (SSN). The mother did not write the patient's SSN on the form and returned it to the registrar. A discussion occurred before the patient was triaged that the hospital needed the child's SSN and this led to an admitted delay of a medical screening examination by hospital A. The mother left the DED of hospital A and took the patient to hospital B for the same complaint where she was medically screened and provided care and treatment of the right foot puncture wound.


NC00104423.