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Based on document review and staff interview, the hospital administrative staff failed to ensure Emergency Department (ED) staff followed hospital policies and procedures and provided 1 of 9 transferred patients selected for review, from 10/1/11 to 4/23/12, all available and appropriate stabilizing treatment. Additionally, the hospital staff delayed medical care for 1 of 9 transferred patients, because of the patient's medical insurance, selected for review from 10/1/11 to 4/23/12. The hospital administrative staff identified a monthly average of 193 ER patients with a monthly average of 15 ER patients transferred to another facility.

Failure to follow policies and procedures regarding providing appropriate stabilizing treatment resulted in a delay in a patient receiving care, potentially resulting in avoidable disability, or loss of life or limb.

Findings include:

1. Review of the policy "EMTALA: The Emergency Examination and Transfer Policy", reviewed 8/11, revealed in part, "...If the individual has an Emergency medical Condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the Emergency Medical Condition..."

2. Review of Patient #1's ER medical record, dated 4/13/12, revealed Patient #1 walked into the ED and presented with a 10 centimeter full thickness laceration left knee due to a Chain saw accident. Orthopedic Surgeon A examined the knee, ordered an x-ray and sent Patient #1 to the Operating Room (OR) to irrigate, debride and close the wound. Staff returned Patient #1 from the OR without treatment. Orthopedic Surgeon A documented "...Was instructed the patient needed to be transferred to [other hospital] due to [insurance]. I argued the patient should be washed out here, then could be treated, but was instructed patient should be treated at Iowa City... Had OR ready to go but will transfer patient..."

3. During an interview on 4/24/12 at 2:15 PM, Registered Nurse (RN) A stated Patient #1 presented to the ED due to a knee injury from a chain saw accident. RN A stated Physician's Assistant C saw the patient initially, and then Orthopedic Surgeon A examined the patient. Orthopedic Surgeon A sent the patient to the Operating Room (OR) to have the wound cleansed and closed. RN A stated the patient was turned over to OR nurse B, at the OR desk.

4. During an interview on 4/25/12 at 9:07 AM, RN B stated the ED called and requested the OR staff prepare an OR for Orthopedic Surgeon A. RN B started preparing the OR for Orthopedic Surgeon to perform a wound cleaning and closing. ED staff brought Patient #1 from the ED to the OR desk. RN B stated the OR staff had the OR open and ready for Patient #1, when the OR staff received a phone call informing them Orthopedic Surgeon A had decided to transfer Patient #1, due to some issues with insurance. RN B took the patient back to the ED, and gave report to Physician's Assistant C.

5. During an interview on 4/24/12 at 12:30 PM, Orthopedic Surgeon A acknowledged they examined Patient #1's knee wound in the ED. Orthopedic Surgeon A stated the OR staff made accommodations to take Patient #1 to the operating room to clean and close the laceration to the knee joint. Patient #1 made it to the OR doors, when Orthopedic Surgeon A received a phone call, informing Orthopedic Surgeon A they should transfer Patient #1 to Hospital B, due to Patient #1's insurance. Orthopedic Surgeon A stated they knew what type of insurance Patient #1 had, but could not remember who informed them. Orthopedic Surgeon A stated when a patient presented with Patient #1's insurance, they tried to accommodate the transfer to Hospital B, because of the insurance. Orthopedic Surgeon A stated in orthopedics, the surgeon has 6 hours to perform a surgical washout of the knee. An open cut into the joint was one of the "ortho emergencies", but the surgeon had a 6 hour window to treat the patient.

6. During an interview on 4/25/12 at 10:15 AM, Orthopedic Surgeon D stated they spoke with Orthopedic Surgeon A on the telephone on 4/13/12. Orthopedic Surgeon D stated Orthopedic Surgeon A asked their opinion on how to treat Patient #1's injury. Orthopedic Surgeon D stated, "We always have the same issues when Iowa Cares [insurance] patients come to the ER.... This patient had Iowa Cares. They won't pay the hospital, or me, for my services. I urged [Orthopedic Surgeon A] to try to find out if [Patient #1] had Iowa Cares.... I think insurance has a lot to do with what we do.... In my opinion, we have to transfer the patient. Otherwise, the hospital and surgeon won't get compensated for their time. If the patient has Iowa Cares [insurance], that is the rule."

7. During an interview on 4/25/12 at 7:50 AM, ED Physician B stated Patient # 1 had an open joint wound and could see air going into the joint with movement of the knee. Orthopedic Surgeon A arranged for Patient #1 to undergo surgical care of the wound. "I believed we needed to treat the patient. I did not want the patient transferred, [s/he] had a serious injury and we needed to treat [them]." Orthopedic Surgeon A made the arrangements to transfer Patient #1 to Hospital B. ED Physician B stated Patient # 1 needed treatment sooner rather than later. "If we had 6 hours to washout the injury, by the time Patient #1 got to Hospital B, we had probably used up 4 of those hours. If the patient's wound had gotten infected, [they] could have lost [the] leg."

8. Documentation in the medical record revealed Patient # 1's injury occurred around 3:00 PM. Patient # 1 departed the ED at 6:03 PM and arrived at Hospital B's ED at 7:52 PM, nearly five hours into the window of time for treating the orthopedic emergency.

Based on document review and staff interview, the hospital emergency department (ED) staff failed to provide all available and appropriate stabilizing treatment for 1 of 9 transferred patients out of 40 records selected for review from 10/1/2011 to 4/23/12. The hospital administrative staff identified a monthly average of 15 ED patients that require transfer.

Failure to provide appropriate stabilizing treatment could potentially result in disability, or the loss of the patient's life or limb.

Findings include:

1. Review of the policy "EMTALA: The Emergency Examination and Transfer Policy", reviewed 8/11, revealed in part, "...If the individual has an Emergency Medical Condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the Emergency Medical Condition..."

2. Review of Patient #1's ED medical record revealed Patient #1 presented to the ED on 4/13/12 at 3:24 PM after an accident with a chain saw that cut into the patient's left knee. The Nursing Documentation at 3:24 PM revealed the patient had a 10 centimeter (cm), full thickness laceration across the left knee. At 3:35 PM Orthopedic Surgeon A examined the patient's knee, and at 3:40 PM staff obtained an x-ray of the knee. At 4:06 PM the patient received an intravenous antibiotic. Orthopedic Surgeon A dictated a report and noted that when moving Patient # 1's knee, "there is some intraarticular air noted." "With flexion (bending the knee), the medial femoral condyle is evident (bone is visible)." At 4:30 PM staff took the patient to the Operating Room (OR) per order of Orthopedic Surgeon A, and the patient returned from the OR, untreated, at 5:10 PM with written order " is going to be transferred to [Hospital B]". Orthopedic Surgeon A's documentation on the Doctor's order and progress record at 5:00 PM which revealed the following in part, "...Was instructed patient needed to be transferred to [Hospital B] due to [insurance]...I argued the patient should be washed out here, then could be treated, but was instructed patient should be treated at [Hospital B]...Had OR ready to go but will transfer patient..." At 5:05 PM ED Physician B documented a progress note on the "ER Physician Record" revealed in part, "...I examined patient and believe this is an open joint with bone involvement and that it represents a limb threatening emergency. I feel he should not be transferred." Review of the "Patient Consent/Request for Transfer" form revealed in part, "... The reason for Transfer: "Patient has [name of insurance] ...Benefits of Transfer: Insurance ... Risk of Transfer: Infection.

3. During an interview on 4/24/12 at 2:15, Registered Nurse (RN) A stated Patient #1 presented to the ED due to a knee injury from a chain saw accident. RN A stated Physician's Assistant C saw the patient initially, and then Orthopedic Surgeon A examined the patient. Orthopedic Surgeon A sent the patient to the Operating Room (OR) to have the wound cleansed and closed. RN A stated the patient was turned over to OR nurse B, at the OR desk.

4. During an interview on 4/25/12 at 9:07 AM, RN B stated the ED called and requested the OR staff prepare an OR for Orthopedic Surgeon A. RN B started preparing the OR for Orthopedic Surgeon to perform a wound cleaning and closing. ED staff brought Patient #1 from the ED to the OR desk. RN B stated the OR staff had the OR open and ready for Patient #1, when the OR staff received a phone call informing them Orthopedic Surgeon A had decided to transfer Patient #1, due to some issues with insurance. RN B took the patient back to the ED, and gave report to Physician's Assistant C.

5. During an interview on 4/25/12 at 11:00 AM, Physician's Assistant C stated Patient #1 came to the ED and "I did the initial screening." Physician's Assistant C asked ED Physician B to look at the patient's wound. ED Physician B examined the patient, and since Orthopedic Surgeon A was in the ED, Orthopedic Surgeon A also examined the patient. Both physicians agreed Patient #1's wound required cleaning and closure in an OR. Physician's Assistant C stated "I had already ordered the antibiotic and the patient was then sent to the pre-surgical area. I later received a phone call from [Orthopedic Surgeon A's name] saying the patient would be coming back to the ED for transfer to another hospital." Physician's Assistant C stated the ED staff understood the reason Orthopedic Surgeon A decided to transfer Patient #1 was because of Patient #1's insurance. Physician Assistant C acknowledged the hospital had the capabilities to care for Patient # 1's wound.

6. During an interview on 4/24/12 at 12:30 PM, Orthopedic Surgeon A acknowledged they examined Patient #1's knee wound in the ED. Orthopedic Surgeon A stated the OR staff made accommodations to take Patient #1 to the operating room to clean and close the laceration to the knee joint. Patient #1 made it to the OR doors, when Orthopedic Surgeon A received a phone call, informing Orthopedic Surgeon A they soul transfer Patient #1 to Hospital B, due to Patient #1's insurance. Orthopedic Surgeon A stated they knew what type of insurance Patient #1 had, but could not remember who informed them. Orthopedic Surgeon A stated when a patient presented with Patient #1's insurance, they tried to accommodate the transfer to Hospital B, because of the insurance. Orthopedic Surgeon A stated in orthopedics, the surgeon has 6 hours to perform a surgical washout of the knee. An open cut into the joint was one of the "ortho emergencies", but the surgeon had a 6 hour window to treat the patient.

7. During an interview on 4/25/12 at 7:10 AM, the ED Medical Director stated that Patient # 1 had an open knee wound (bone exposed), that required surgical cleansing in the OR. "Apparently, the standard of care is to do that in six hours."

8. During an interview on 4/25/12 at 7:50 AM, ED Physician B stated Patient # 1 had an open joint wound and could see air going into the joint with movement of the knee. Orthopedic Surgeon A arranged for Patient #1 to undergo surgical care of the wound. "I believed we needed to treat the patient. I did not want the patient transferred, [s/he] had a serious injury and we needed to treat [them]." Orthopedic Surgeon A made the arrangements to transfer Patient #1 to Hospital B. ED Physician B stated Patient # 1 needed treatment sooner rather than later. "If we had 6 hours to washout the injury, by the time Patient #1 got to Hospital B, we had probably used up 4 of those hours. If the patient's wound had gotten infected, [they] could have lost [the] leg."

9. Documentation in the medical record revealed Patient # 1's injury occurred around 3:00 PM. Patient # 1 departed the ED at 6:03 PM and arrived at Hospital B's ED at 7:52 PM, nearly five hours into the window of time for treating the orthopedic emergency.

Based on document review and staff interview, the hospital emergency department (ED) staff delayed stabilizing treatment due to insurance for 1 of 9 transferred patients out of 40 records selected for review from 10/1/11 to 4/23/12. The hospital administrative staff identified a monthly average of 15 ED patients that required transfer.

Delaying stabilizing treatment for an emergency medical condition could potentially result in disability, or the loss of the patient's life or limb.

Findings include:

1. Review of the policy "EMTALA: The Emergency Examination and Transfer Policy", reviewed 8/11, 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."

2. Review of Patient #1's ED medical record revealed Patient #1 presented to the ED on 4/13/12 at 3:24 PM after an accident with a chain saw that cut into the patient's left knee. The Nursing Documentation at 3:24 PM revealed the patient had a 10 centimeter (cm), full thickness laceration across the left knee. At 3:35 PM Orthopedic Surgeon A examined the patient's knee, and at 3:40 PM staff obtained an x-ray of the knee. At 4:06 PM the patient received an intravenous antibiotic. Orthopedic Surgeon A dictated a report and noted that when moving Patient # 1's knee, "there is some intraarticular air noted." "With flexion (bending the knee), the medial femoral condyle is evident (bone is visible)." At 4:30 PM staff took the patient to the Operating Room (OR) per order of Orthopedic Surgeon A, and the patient returned from the OR, untreated, at 5:10 PM with written order " is going to be transferred to [Hospital B]". Orthopedic Surgeon A's documentation on the Doctor's order and progress record at 5:00 PM which revealed the following in part, "...Was instructed patient needed to be transferred to [Hospital B] due to [insurance]...I argued the patient should be washed out here, then could be treated, but was instructed patient should be treated at [Hospital B]...Had OR ready to go but will transfer patient..." At 5:05 PM ED Physician B documented a progress note on the "ER Physician Record" revealed in part, "...I examined patient and believe this is an open joint with bone involvement and that it represents a limb threatening emergency. I feel he should not be transferred." Review of the "Patient Consent/Request for Transfer" form revealed in part, "... The reason for Transfer: "Patient has [name of insurance] ...Benefits of Transfer: Insurance ... Risk of Transfer: Infection.

3. During an interview on 4/25/12 at 9:07 AM, RN B stated the ED called and requested the OR staff prepare an OR for Orthopedic Surgeon A. RN B started preparing the OR for Orthopedic Surgeon to perform a wound cleaning and closing. ED staff brought Patient #1 from the ED to the OR desk. RN B stated the OR staff had the OR open and ready for Patient #1, when the OR staff received a phone call informing them Orthopedic Surgeon A had decided to transfer Patient #1, due to some issues with insurance. RN B took the patient back to the ED, and gave report to Physician's Assistant C.

5. During an interview on 4/25/12 at 9:30 AM, RN C stated Orthopedic Surgeon A called them on 4/13/12 and discussed obtaining an inpatient bed for Patient #1 after surgery. Orthopedic Surgeon A stated Patient #1 had Iowa Cares Insurance, would spend the night at The Finley Hospital, and then require transfer to Hospital B for inpatient antibiotic treatment. Orthopedic Surgeon D overheard the conversation, and spoke with Orthopedic Surgeon A. "This was an uncommon case ... the patient should not have been taken to the OR. The ER should have caught the patient had Iowa Cares [Insurance], and the options [for transfer] should have been discussed in the ER."

6. During an interview on 4/24/12 at 12:30 PM, Orthopedic Surgeon A acknowledged they examined Patient #1's knee wound in the ED. Orthopedic Surgeon A stated the OR staff made accommodations to take Patient #1 to the operating room to clean and close the laceration to the knee joint. Patient #1 made it to the OR doors, when Orthopedic Surgeon A received a phone call, informing Orthopedic Surgeon A they should transfer Patient #1 to Hospital B, due to the fact Patient #1 had Iowa Cares Insurance. Orthopedic Surgeon A stated they knew Patient #1 had Iowa Cares Insurance, but could not remember who informed them. Orthopedic Surgeon A stated when a patient presented with Iowa Cares Insurance, they tried to accommodate the transfer to Hospital B, because of the insurance. Orthopedic Surgeon A stated in orthopedics, the surgeon has 6 hours to perform a surgical washout of the knee. An open cut into the joint was one of the "ortho emergencies", but the surgeon had a 6 hour window to treat the patient.

7. During an interview on 4/25/12 at 10:15 AM, Orthopedic Surgeon D stated they spoke with Orthopedic Surgeon A on the telephone on 4/13/12. Orthopedic Surgeon D stated Orthopedic Surgeon A asked their opinion on how to treat Patient #1's injury. Orthopedic Surgeon D stated, "We always have the same issues when Iowa Cares [insurance] patients come to the ER.... This patient had Iowa Cares. They won't pay the hospital, or me, for my services. I urged [Orthopedic Surgeon A] to try to find out if [Patient #1] had Iowa Cares.... I think insurance has a lot to do with what we do.... In my opinion, we have to transfer the patient. Otherwise, the hospital and surgeon won't get compensated for their time. If the patient has Iowa Cares [insurance], that is the rule."

8. During an interview on 4/25/12 at 7:50 AM, ED Physician B stated Patient #1 had an open joint wound and ED Physician B could see air going into the joint with movement of the knee. Orthopedic Surgeon A arranged for Patient #1 to undergo surgical care of the wound. "I believed we needed to treat the patient. I did not want the patient transferred, [s/he] had a serious injury and we needed to treat [them]." Orthopedic Surgeon A made the arrangements to transfer Patient #1 to Hospital B. ED Physician B stated it took approximately 1 hour and 45 minutes to drive from The Finley Hospital to Hospital B. ED Physician B stated Patient # 1 needed treatment sooner rather than later. "If we had 6 hours to washout the injury, by the time Patient #1 got to [Hospital B], we had probably used up 4 of those hours. If the patient's wound had gotten infected, [they] could have lost [the] leg."

9. Documentation in the medical record revealed Patient # 1's injury occurred around 3:00 PM. Patient # 1 departed the ED at 6:03 PM, and arrived at Hospital B's ED at 7:52 PM, nearly five hours into the window of time for treating the "orthopedic emergency."

10. Review of the statutorily mandated 5-Day QIO review, the hospital staff and physicians delayed the definitive treatment of Patient #1's Emergency Medical Condition, by transferring Patient #1 to Hospital B, because of Patient #1's insurance.