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Based on review of policies and procedures and medical records, the hospital administrative staff failed to enforce policies/procedures to ensure that patients received stabilizing treatment within the hospital's capabilities, without regard to their insurance status in 1 of 60 medical records (Patient #1) selected for review from May 1, 2011 to August 15, 2011. The hospital administration identified an average of 82 patients per month who presented to the ER with Iowa Cares insurance.

Failure to enforce policies that ensure all patients with an emergency receive stabilizing treatment within the hospital's capabilities may result in a patient not receiving appropriate care and potentially lead to delay of life saving treatment or death.

Findings include:

1. Review of the "EMTALA Patient Transfer to Another Acute Care Facility" policy, updated 7/10, revealed in part, "The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care of the patient."

"Rationale: Wheaton Franciscan Healthcare (WFH) is committed to promoting the health and well being of patients who come to WFH seeking emergency care and treatment regardless of the patient's ability to pay."

2. Review of a second policy, "EMTALA: Medical Screening and Stabilization Treatment" updated 7/10, revealed in part, "....The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and, when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care of the patient."

"...The medical screening examination and stabilizing treatment must be nondiscriminatory relative to race, national origin and/or handicaps, and be rendered regardless of the ability to pay. Medical screening and stabilizing treatment must be consistent with what the Hospital would provide to any patient presenting with the same signs and symptoms."

3. The hospital failed to follow these policies and did not provide Patient # 1 with stabilizing treatment within its capabilities prior to transfer to Hospital AA.

4. Review of the medical record revealed on 8/6/11 at 12:05 AM, Patient #1 presented to the ER complaining of rectal bleeding and pain. Patient #1's demographic sheet documented patient #1's insurance as Iowa Cares.

ER Physician A documented in the Clinician History of Present Illness Physical Exam:
Consultations - "Plan: I spoke with Dr. (hospital on-call surgeon) shortly after the patient arrived and I offered him admission at Covenant or transfer to [Hospital AA] given his Iowa Care status, and he chose to go - he "just wants it fixed."

Documentation on the Patient Transfer Form specified:
"Medical Condition: Patient Unstable - The patient has been examined an EMC (Emergency Medical Condition) has been identified. The patient is not stable ..., but the transfer is medically indicated and in the best interest of the patient..." "Reason for Transfer - Medically indicated, MD Requested, and Insurance Requested."

5. Review of Patient #1's Iowa EMS (Emergency Medical Service) Report, revealed on 8/6/11 at 1:52 AM, Paramedic Specialist B arrived to the ER to transport the patient to the Receiving Hospital AA. The Paramedic documented "Patient is primarily to be transported to Receiving Hospital AA due to his insurance status of Iowa Cares.... RN A reports that Physician D was called for a surgical consult and stated that these types of injuries tamponade themselves, therefore, there was no need for surgical intervention prior to transport." ... "... There is bright red blood soaking the sheets that patient laying on and blood covers the slide board after patient is moved over to the ambulance cot." Further documentation revealed Patient # 1 continued to deteriorate during the transfer. Refer to Tags A2407 and A2408 for further details.

Based on document review and interviews, the hospital failed to provide stabilizing treatment within its capabilities to 1 (Patient # 1) out of 60 cases reviewed from May 1, 2011 to July 15, 2011. The hospital administration identified an average of 82 patients with Iowa Cares insurance per month who present to the ER seeking medical care.

Failure to provide stabilizing treatment within the hospital's capabilities has the potential to result in a patient with an emergency not receiving appropriate care and potentially leading to delay of life saving treatment or death.

Findings include:

1. Review of Patient #1's medical record revealed on 8/6/11 at 12:05 AM, Patient #1 presented to the ER complaining of rectal bleeding and pain.

At 12:30, RN A documented in the Nursing Continuation Notes: "Patient #1 has feeling of pressure in his rectum. ER Physician A at bedside and patient expelled about 350 ml (milliliter) of bright red blood with clots."

ER Physician A documented in the Clinician History of Present Illness Physical Exam:
... GU (Genitourinary system) - ...There is blood at the rectum, but no lacerations or foreign body is noted.. After examining him initially, he had the urge to have a BM (bowel movement), so we placed a chux (pad) and a bedpan, and asked him to go ahead. He passed about 400 -500 ml (milliliter) of blood and stool, then felt much better, but refused further rectal exam."

Consultations - "Plan: I spoke with (hospital on-call surgeon) shortly after the patient arrived and I offered him admission at Covenant or transfer to [Hospital AA] given his Iowa Care status, and he chose to go - he "just wants it fixed." His Hgb (hemoglobin) is 13.9. He bled another 200 ml. His BP (blood pressure) hasn't changed, and his pulse is high, but it's dropped to 100 a couple times when his anxiety lessened, so I don't believe it's from shock".

ER Physician A documented on the Patient Transfer Form:
"Medical Condition: Patient Unstable - The patient has been examined an EMC (Emergency Medical Condition) has been identified. The patient is not stable ..., but the transfer is medically indicated and in the best interest of the patient..."

"Reason for Transfer - Medically indicated, MD Requested, Insurance Requested".

2. Review of Patient #1's Iowa EMS (Emergency Medical Service) Report, revealed on 8/6/11 at 1:52 AM, Paramedic Specialist B arrived to the ER to transport the patient to the Receiving Hospital AA.

The Iowa EMS Report also revealed:
Narrative - "Patient is primarily to be transported to Receiving Hospital AA due to his insurance status of Iowa Cares.... RN A reports that Physician D was called for a surgical consult and stated that these types of injuries tamponade themselves, therefore, there was no need for surgical intervention prior to transport." "...Patient is lying on his belly in ER #5. Patient is complaining of severe thirst and being very hot. RN A reports the patient's blood pressures have been stable. Patient is diaphoretic. His skin is pale, cool and moist. RN A states patient has had some anxiety but that no Ativan (medication used to reduce anxiety) has been ordered. An emergency release of blood products is requested for transport due to patient being tachycardiac (fast heart rate), Hgb below normal, his agitation and skin condition. RN A states that the ER physician (Physician A) and Surgeon D did not believe patient needed blood products." "... There is bright red blood soaking the sheets that patient laying on and blood covers the slide board after patient is moved over to the ambulance cot." "...During transport, patient becomes more tachycardiac and his heart rate increases from low 120's to low to mid 130's. He becomes more diaphoretic and agitated/fidgety. Patient continues to complain of sever thirst .... He also complains of being very hot (despite his skin being very cold and clammy) ... at times appears to be groggy."

Paramedic Specialist B documented the following vitals during transport to Receiving Hospital AA:
2:45 AM BP 131/80, P 126
3:00 AM BP 122/79, P 122
3:15 AM BP 108/76, P 130
3:25 AM BP 100/62, P 132

"...Patient condition deteriorates throughout transport with blood pressures trending down, heart rate trending up and patient's objective condition also appearing worse....When patient is transferred from the ambulance cot to the ... bed the bath blankets and sheet covering patient are soaked in blood ..."

3. During an interview on 8/16/11 at 8:30 AM, ER Physician A reported that a complete examination was performed on the patient when he presented to the ER including physical exam, blood work, and abdominal x-rays. "I did not do an internal rectal exam because the patient was in so much pain and refused to allow me to do the exam. I knew that the patient would need sedation in order to complete the medical screening exam." "Because of the patient's insurance status I felt that the patient would be better served at [Hospital AA]."

4. Review of call schedules, available to ER Physician A, for 8/6/11 revealed a general surgeon, anesthesiologist, and surgical nurses were on call and available to provide further examination and stabilizing treatment to Patient #1.

5. During a phone interview on 8/18,11 at 9:00 AM, Hospital AA's ER Physician E stated that "ER Physician A told me that Patient #1 would need immediate treatment for rectal bleeding. ER Physician A also reported that the patient would need surgery as soon as possible and he was concerned that the patient's condition would worsen enroute." "The ambulance cot was soaked with bright red blood and the patient was obviously very ill upon arrival." "The patient required blood and IV fluids in order to stabilize. The patient was in surgery within an hour of arriving at [Hospital AA].

6. Patient # 1's medical record lacked evidence of further examination or stabilizing treatment within the hospital's capabilities prior to transfer to Hospital AA.

Based on document review and staff interviews, the hospital's Emergency Room (ER) administrative staff failed to ensure ER staff did not base decisions to provide stabilizing treatment on a patient's ability to pay for 1 of 60 ER patients selected for review from May 1, 2011 to August 15, 2011. The ER administrative staff identified an average of 82 patients per month who presented to the ER with Iowa Cares insurance.

A hospital basing care decisions on a patient's ability to pay could result in a patient with an emergency medical condition not receiving appropriate care, potentially leading to delay of life saving treatment or death.

Findings include:

1. Review of the "Iowa Care" policy and procedure, updated 8/10, revealed in part, "...Covenant Medical Center,...are not network providers for the Iowa Medicaid expansion program called Iowa Care. As a result, Iowa Care enrollees receive no benefits or coverage for healthcare services obtained from WFH-Iowa facilities and providers." On page 3 of the policy, under section "What to do if an Iowa Care patient has been identified:" specifies ..."3. Notify clinical staff (i.e. the nurse assigned to the patient or the charge nurse) that the patient has Iowa Care." ..."7. Collect $250.00 deposit towards services."

2. During an interview on 8/16/11 at 8:30 AM, ER Physician A stated "I sent the patient to [Hospital AA] because of Iowa Care Insurance. I knew the patient had Iowa Care because the nurse told me." "I talked with the patient and his wife about their options and that if they chose not to transfer to [Hospital AA] they would be responsible to pay for all of the hospital bill." ER Physician A stated "I spoke with Surgeon D on the phone to discuss the case. We felt that Patient #1 was stable." ER Physician A agreed that the hospital had the capability, personnel, expertise, and facilities to perform the necessary surgery on the patient. "We agreed that the patient would need surgery but because he had Iowa Cares he should go to [Hospital AA]." ER Physician A also stated that hospital administration encourages and pressures ER physicians to send all Iowa Care patients to [Hospital AA]. "The pressure is unspoken and unwritten but it is there."

3. During an interview on 8/16/11 at 10:20 AM, ER Registered Nurse A stated "I was not present when ER Physician A discussed the transfer with the patient. But, I was the one to tell him the patient had Iowa Care. The admissions clerk notifies the nursing staff and the nurse tells the physician. This is done for all Iowa Care patients. It is up to the doctor to discuss transfer or payment options with the patient or family."

4. During an interview on 8/16/11 at 3:00 PM, Admissions Manager C stated "after the MSE the admissions clerk completes the registration process including asking the patient about insurance. If the patient has Iowa Cares insurance the admission clerk will notify the nurse taking care of the patient. I don't know what the nurse does with that information."

5. Review of the medical record revealed Patient #1 presented to the ER on 8/6/11 at 12:05 AM complaining of rectal bleeding and pain. ER Physician A arranged transfer to Hospital AA and on the Patient Transfer Form documented "Medical Condition: Patient Unstable - The patient has been examined an EMC (Emergency Medical Condition) has been identified. The patient is not stable ..., but the transfer is medically indicated and in the best interest of the patient ..."

6. Review of Patient #1's Iowa EMS (Emergency Medical Service) Report, revealed on 8/6/11 at 1:52 AM, Paramedic Specialist B arrived to the ER to transport the patient to the Receiving Hospital AA and that Patient # 1 continued to deteriorate.

7. 3 1/2 hours after presenting to the ER where the capability for stabilizing treatment was available, Patient # 1 arrived at Hospital AA's ER in circulatory shock, with a rapid heart rate, continued bleeding and severe pain at approximately 3:30 AM.