HospitalInspections.org

Based on review of medical records, policies and procedures, patient and staff interviews, and observations during tours, it was determined the hospital discouraged patients from waiting for medical screening exams as evidenced by:

A2406 489.24(r) and 489.24(c) Medical Screening Exam:

1. displaying an Internet web-page that showed the ED wait times at three other system hospitals on a large TV screen in the ED waiting room; and

2. staff offered information to Pt #11 that the ER wait times were shorter at another system hospital and Pt #11 left without a medical screening exam.

The cumulative effect of this system process resulted in the hospital not being compliant with the Special responsibilities of Medicare hospitals in emergency cases.

Based on review of medical records, policies and procedures, medical staff bylaws, patient and staff interviews, and observations during tours, it was determined the hospital discouraged patients to stay for medical screening exams by displaying an Internet web-page on a four foot by three foot T.V. screen showing emergency room (ER) wait times for three system hospitals in the ER waiting room and the emergency department (ED) staff suggested to Pt #11 that the wait time at another system hospital was shorter than at their hospital, thus, Pt #11 left without a medical screening examination (MSE).

On 04/30/10 at 1240 hours, an Immediate Jeopardy (IJ) situation was called while onsite at the hospital. The following conditions existed: potential serious harm to patients who saw evidence of shorter wait times at other ER's could decide to go to another ER without having a MSE; all patients in the ED waiting room had visual access to this information; the hospital notified patients with signage underneath the Internet display which read: "...If you chose to go to one of our other facilities, please stop at the check-in window and allow us to facilitate your visit...." Information from Pt #11's family during an interview on 04/28/10 at 1420 hours, revealed that they were informed by an ED staff member that wait times at another system hospital were shorter and Pt #11 went by private auto to the other hospital without receiving a MSE and subsequently, was admitted as an inpatient at the other hospital.

On 04/30/10 at 1500 hours the IJ was abated. The administration team was notified of this by the Surveyor. The hospital provided a written correction plan and immediately initiated the following with regard to the IJ deficiency: the ED wait times are no longer displayed inside the hospital; the ED staff and ED registration staff currently working were educated to not offer information on ED wait times at other hospitals and all staff coming to work, prior to their shift will be educated on the same information until all staff are educated.

Findings include:

The hospital's policy titled Emergency Medical Treatment and Labor Act EMTALA, dated 11/19/2008, required: "...follow reasonable registration processes for individuals presenting with an emergency medical condition as long as the inquiry does not delay screening or unduly discourage individual from remaining for further evaluation...unreasonable registration processes include the following...any act that will unduly discourage individuals from remaining for further evaluation...."

The hospital's policy titled Scottsdale Healthcare Emergency Services, revised 12/18/09, required: "...The waiting times for patients waiting in the waiting room are posted. If a patient wishes to leave they are asked to stay for a medical screening exam. If the medical screening is denied by the patient, the patient is asked to sign a refusal of medical screening exam. The patient is then asked if they would like to go to another Scottsdale Healthcare facility for emergency care. If the patient wants to do this the triage/welcome check-in nurse will facilitate calling the receiving facility...Leave with notice/patient choice...Pertinent information regarding the patient's decision to leave and the patient's condition will be documented in the nursing care record...."

The hospital's Medical Staff Bylaws dated April 6, 2010, included: "...Federal Regulations (EMTALA)...Physicians may perform medical screening examinations. The following other classes of practitioners may also perform medical screening examinations if qualified by training, experience and competency...Physician Assistants...Nurse Practitioners...Registered Nurses...in the Department of Obstetrics...."

The Associate Vice President of Patient Care Services for the Osborn Campus (Staff RN #2), the ED Director (Staff RN #3) and the past ED educator (Staff RN #5) were all interviewed on 04/23/10 at 0900 hours. Staff #5 confirmed and verified that the hospital's policy titled Scottsdale Healthcare Emergency Services had been reviewed with the ED staff within the last couple of months.

On 04/23/10, the management team explained they have a Television screen with Internet ED wait times of the health-systems 3 hospitals that are posted in the waiting room lobby for patients to view.

On 04/27/10 at 1500 hours, the ED lobby was toured. Upon arrival to the ED lobby the TV screen was observed to be approximately 4 feet by 3 feet with a flat screen. Underneath the TV was a sign which read: "Thank you for choosing...(name) Healthcare System. If you chose to go to one of our other facilities, please stop at the check-in window and allow us to facilitate your visit." The TV had the Internet wait times of 3 hospitals posted. The wait times were updated every three minutes and new wait times would appear. At the time the Surveyors were looking at the TV the wait times posted were as follows: "...Osborn ER...NO WAIT...Shea Main ER...83 min...Shea Kids ER...58 min...Thompson Peak ER...13 min...." At the bottom right hand of the screen was "What Are You Waiting For?"

Pt #11 was chosen after review of the ED log which indicated the patient had left prior to a medical screening examination. Documentation in the medical record indicated the initial triage time was 1931 hours and the comprehensive triage time was 1939 hours. Documentation in the medical record indicated the family brought this elderly patient in with the complaint that the patient "...thinks people are in her apartment...(and its) been going on for 4-5 weeks...." Vital signs were, blood pressure 131/79, pulse 80, respirations 16, pulse oximetry 98% and the patient had no pain. Nursing assigned a triage level for the emergency severity index (ESI) of 2 (on a scale of 1-5 with 1 as the highest acuity). The triage nurse documented the following: "...2007 (hours)- Pts (family) decided to take the pt to (abbreviation for name of other hospital) for medical screening due to our long wait time at (name of hospital)...refusal of medical screening form signed by (family member) (name of other hospital) updated on pt and forms faxed...."

Pt #11 was called on 04/28/10 at 1420 hours. The Surveyor spoke with a family member who was present with the patient for the ED visit on 02/22/10 at 1935 hours. S/he related that Pt #11 was brought into the ED and when they checked in, they were told it would be a 3 hour wait. After sitting in the waiting room for awhile they were called "back to the desk" and informed that there was less than an hour wait at another system hospital. S/he confirmed this was the reason why they took Pt #11 to the other hospital.

Documentation from the second hospital showed that Pt #11 was admitted as an inpatient at the other hospital.