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Based on findings at A 2406, A 2407, and A 2408, the facility failed to ensure compliance with CFR 489.24.

Based on interviews, record review and document review, the facility failed to conduct an appropriate medical screening exam for 2 of 47 patients sampled: a pregnant patient in possible labor and a psychiatric patient who threatened suicide (Patients #6, #12).

Findings include:

Patient #6

The facility log from St. Rose Dominican Hospital Siena campus (Siena) labor and delivery (L&D) indicated the patient signed in on 8/2/11.

Interview

Interview with the patient on 8/23/11 at approximately 4pm, revealed the following:

- "I was already registered with Siena 2 weeks before. A lady (registrar) I talked to said they accepted our insurance."
- A week prior to 8/2/11, the patient presented to the facility in labor and delivery with complaints of contractions, "they told me I wasn't in labor" and was sent home after exam. The patient indicated staff never mentioned anything about payment. The patient indicated she was already pre-registered to deliver at this facility.
- On 8/2/11 the patient presented to Siena in L&D with ruptured membranes and was instructed to change into a gown, "as usual, they just saw me last week so nothing was different. They were the same nurses I saw when I came in before. Nobody told me anything different. While changing, my husband told me to get dressed because the nurse told him we would be charged an enormous bill if we hook up to machines, and Spring Valley takes Medicaid, and I didn't want to pay any large bill...No, I didn't speak to anyone after that, we just left. No one asked us to stay."
- "I was admitted at Spring Valley and when they examined me I was at 2cm... I had the baby the next morning... a healthy baby boy."
The patient's husband was unavailable for interview.

On 8/18/11 in the afternoon, the L&D Charge Nurse reported on 8/2/11 the patient presented with possible ruptured membranes, was in the triage room changing clothes and significant other was in the room. The nurse received a phone call from the doctor's office stating the patient was sent to the wrong hospital. The nurse then spoke with the significant other and informed of the telephone conversation that the patient should have gone to Spring Valley. The nurse informed the patient and the significant other the doctor's office sent the patient to the wrong hospital as Siena was not contracted with the patient's insurance. The nurse informed the significant other she was unsure if the insurance would cover the hospital stay but they were welcome to stay. The patient had looked uncomfortable when she arrived. The nurse informed the couple three times they did not have to leave and they had a bed available to care for the the patient. The significant other wanted to leave to go to the other hospital, as he did not want to get stuck with the bill. The nurse said, "I know EMTALA. What was I supposed to do ... make them stay? I told them we were willing to provide care."

On 8/18/11 in the afternoon, the Maternal Child Center Manager revealed her L&D nurse reported an issue regarding Patient #6 on 8/2/11. The patient signed in for leaking of fluid. The doctor's office called and informed her the patient and her husband went to the wrong hospital. The L&D nurse informed the patient and her husband that she would like to evaluate the patient prior to leaving. The husband refused and they left for the other hospital. The Manager reported the issue to Risk Management.

On 8/18/11 in the afternoon, the Director of Risk Management at Siena stated she was contacted by the CEO (Chief Executive Officer) on 8/4/11 to investigate a possible EMTALA reported to him from the other hospital, Spring Valley. The patient signed in at approximately 2pm (on 8/2/11). The patient was sent to the facility by the doctor's office and the patient was in the process of changing into a gown. The doctor's office called L&D to inform the patient they were sent to the wrong hospital and needed to go to Spring Valley. The patient's insurance was not contracted with Siena. The L&D nurse informed the patient and significant other of the telephone conversation. The couple wanted to go to Spring Valley because the patient could not afford to get a bill. The L&D nurse informed the patient and significant other they could stay and the facility could provide care. The L&D nurse did not notify Spring Valley of the patient arriving at their facility. The L&D nurse informed the patient several times they could provide the care and treatment at their facility. This visit only took 8 minutes and the patient and the significant other were gone by 2:08pm.

On 8/25/11 at 11am, the Obstetrics (OB) Director at Spring Valley revealed her L&D nurse informed her of the patient's issue upon arrival on 8/2/11 in the afternoon. The OB Director went and spoke to the patient. The OB Director indicated the patient had gone to Siena, pre-registered and had been seen as an outpatient there several times. On this day she reported her membranes were ruptured, she completed paperwork, was told to change her clothes. The patient reported a "nurse" came into the room and told her the insurance "didn't cover her and if the patient stayed there, she would have a really, really big bill. They (patient and significant other) decided to come here." The patient also indicated there was a message left on either hers or her husband's cell phone stating it was the OB doctor's office and for them not to go to Siena. The OB Director indicated she then spoke with the OB doctor who indicated his office would not have instructed the patient as such. They do not tell the patient where to go.

On 8/25/11 at 2:30pm, the doctor's office OB Representative, who takes care of OB charts, monitors OB appointments, and insurance contracts, revealed the patient was supposed to come in to the office. The Representative verified their OB physicians either go to Siena or Spring Valley. The patient was planned to receive care from her OB doctor at Siena under Medicaid insurance. As of 8/1/11, the patient's insurance converted from Medicaid to Amerigroup and on 8/2/11, the patient was sent to Siena which didn't accept the Amerigroup insurance. The Representative called the hospital as the patient was signing in. The Representative told the L&D nurse the patient was going to have to pay a big bill at Siena, because the insurance the patient was converted to was no longer accepted by Siena, but was accepted by Spring Valley. The L&D nurse responded, "We can't turn her away."

Record Review

There were no documents other than the record of the log at Siena. There was no documented evidence of a medical screening exam conducted at Siena.

The records at Spring Valley indicated the patient arrived on 8/2/11 at approximately 2:55 in the afternoon and revealed the following:

- The admitting diagnoses were: 1. Intrauterine pregnancy at 37 and 6/7 weeks, and 2. Active labor.
- The delivery date and method was spontaneous vaginal with vacuum extraction on 8/3/11 at 11:27am.
- The Apgars were 7/9.

Document Review

The Siena Policy /Procedure, "Medical Screening Examination/Triage of the Pregnant Patient" revised 7/24/06, indicated the following:

- Page 1 of 7 indicated,
"Responsibilities: Registered Nurse with demonstrated and documented competency. Screening must be done by a qualified Registered Labor and Delivery Nurse...The Registered Nurse must communicate the assessment findings to the Obstetrician for determination of patient disposition..."

- Page 3 of 7 indicated,
"When the OB patient presents to OB triage for assessment and disposition, the RN who has demonstrated competencies may perform the Medical Screening Exam (MSE). The RN will utilize standard assessment and evaluation methods...
...The Labor and Delivery Triage Nurse with demonstrated/approved competency may perform an MSE. The OB attending physician is notified of the examination findings...
...The initial assessment and/or treatment of an Emergency Medical Condition will not be delayed in order to obtain financial or insurance information. All patients will receive medical screening and emergency stabilization care regardless of managed care plan requirements or directives...
... Managed care plans or third party payers cannot deny the hospital permission to screen and treat an Emergency Medical Condition."

According to the 1/6/11 Medical Executive Committee Minutes, the 2011 MSE Competent Labor Nurses list, the Siena L&D nurse who was interviewed regarding her 8/2/11 interaction with Patient #6 and the significant other, was included on the 2011 MSE Competent Labor Nurses list.

The facility failed to conduct the medical screening exam to assess the patient's status and communicate those findings to the obstetrician to determine the patient's disposition.

Complaint #29089


20127


Patient #12

Record Review

Patient #12 presented to the emergency department (ED) on 04/07/11 with a chief complaint of suicidal ideation. The patient had taken a half bottle of Fiorinal (an analgesic medication containing aspirin, barbiturate and caffeine) approximately a half hour to an hour prior to arrival at the ED. The patient had superficial cuts on the neck. The physician evaluation revealed the patient presented with suicidal ideation and "gesture". The clinical impression was suicidal ideation and depression. The physician medically cleared the patient and the patient was currently awaiting a mental health evaluation.

Patient #12 was placed on an involuntary mental health hold on 04/07/11 at 4:00 p.m. due to the patient attempted or threatened to commit suicide and mutilated self, attempted or threatened to mutilate self. The patient presented to the ED after taking an overdose of Fiorinal and had self-inflicted wounds to neck and wrist. The patient was very combative upon arrival to the ED and had to be secured by security in the ED lobby.

The patient was medically cleared by the ED physician on 04/07/11 at 7:53 p.m. The patient was certified as being mentally ill and a danger to self and others due to cuts on neck and taking an overdose of medication trying to hurt himself.

On 04/07/11 at 7:35 p.m., Patient #12 was placed on a psychiatric hold for suicide ideation/intent with active plan/attempt. The patient met the criteria for a legal hold. The psychiatric hold orders included supervision/protection to include suicide precautions and medications as needed to include temazepam, diphenhydramine, lorazepam and haloperidol.

The record revealed documentation the patient was assigned a sitter with documentation noted every 15 minutes.

The ED faxed a request for a mental health evaluation on 04/07/11 at 9:20 p.m.

The patient eloped from the facility on 04/08/11 at 9:55 a.m. and the police department was notified at 10:00 a.m.

Interview

On 08/19/11 at 2:00 p.m., a certified nurse assistant (CNA) who worked on the day of the elopement indicated another CNA was assigned to be the sitter on that day. The CNA assigned to be the sitter should have direct observation of the patients.

On 08/19/11 at 2:06 p.m., the registered nurse assigned to care for the patient indicated the patient's wife had been visiting and the patient's personal belongings were signed out to the wife. The patient had gone to the bathroom with the sitter and then the patient was running out the main emergency department door. The patient was still wearing the green hospital gown. Security was notified and the police department was notified.

On 08/19/11 at 2:30 p.m., the Director of Security indicated the patient had eloped and he responded to the call. The patient had come into the emergency department the previous night and was combative with staff. At the time of the elopement, the security guard assigned to the emergency department had walked past the patient to make rounds in the emergency department. The patient ran out of the emergency department, through the waiting room doors and into a waiting car. The police department was notified of the elopement.

The patient had eloped from the hospital prior to the psychiatric evaluation being completed by the state mental health hospital.

Document Review

The facility "Care & Management of the Psychiatric Patient" dated 04/11 documented the following:
- The purpose of the policy was "...To provide a process for the assessment, monitoring, management and care of psychiatric patients at...To establish guidelines for the management of patients with acute psychiatric illness, e.g. suicidal ideations, being evaluated and treated in the acute care setting and to provide safe practices to minimize the risk of harm to self, other patients, visitors and staff by patients who may present a danger to themselves or others..."

- The responsiblities include "...Patient Sitter (Sittter) is responsible for providing continuous, direct observation of one (1) or more patients who meet criteria for Legal 2000 application and are assessed as at risk for harm to self or others...The sitter is responsible for documenting and reporting any unsafe or threatening behaviors and/or verbalizations to the patient's nurse..."

- The policy includes "...When medical clearance and certification is completed, a psychiatric consult is requested by the certifyinng LIP (Licensed Independent Practititioner) and the Legal hold begins...The Psychiatric Consultant may designate the patient safe for psychiatric discharge or requires inpatient psychiatric care...The Clinical Psychologist or appointed designee from the perspective placement facility should evaluate the patient within twenty-four (24) hours or as soon as possible once the patient's medical condition permits...Patients identified as meeting the Legal 2000 criteria will be placed in a green gown, and placed in a designated safe patient environment where special precautions will be taken to include a Sitter, as appropriate, is in constant attendance..."

- The policy includes "...Should an attempt to elope occur, the RN or designee will immediately contact Security, House Supervisor, Department Director/Manager, campus Administrator or Administrator on Call and the appropriate police agency, if appropriate...Should the elopement be successful and the patient has left the property, the appropriate police agency will be notified and will be supplied with pertinent information regarding patient's description, direction of travel and vehicle information..."

The facility failed to complete a medical screening exam pertinent to the stated psychiatric emergency.

Based on interview, clinical record review and document review, the facility failed to ensure a patient received stabilizing medical treatment in the emergency department for 1 of 47 sampled patients (Patient #11).

Findings include:

Patient #11

Record Review

Patient #11 presented to the emergency department on 04/03/11 with a chief complaint of a sore throat that had been present for several days. The emergency department physician conducted a medical screening exam and the clinical impression was peritonsillar abscess.

The patient had been seen at the university health clinic twice and started on antibiotics prior to the emergency department visit.

The emergency department physician indicated the hospital did not have ENT (Ears, Nose, and Throat) physician on-call in the emergency department. Another local hospital was contacted and the patient was transferred to another hospital for ENT services.

The authorization to transfer form was completed with an accepting physician identified at the receiving hospital. The patient was transferred to the accepting hospital via private vehicle.

Interview

On 08/19/11 at 8:25 a.m., the Chief Medical Officer (CMO) and the Director of the Emegency Physician Group indicated there were 2 physician groups available for ENT call services in the emergency department. The physician indicated the on-call physician schedules for the day was printed out in the morning and posted on the computer terminals. The physicians indicated the emergency department physician had made a call to another local hospital for ENT services and did not call the on-call ENT physician.

Document Review

A review of the "Physician ER (Emergency Room) Call Schedules" for the month of April 2011, revealed the emergency department had an on-call ENT physician available for the entire month of April.


The emergency department physician documented the hospital did not have on-call ENT physician services available and made necessary arrangments to have the patient transferred to a hospital that had ENT physician services available. Upon review of the hospital documents, the hospital did have the available ENT physician services.

Based on interviews, record review and document review, the facility failed to conduct an appropriate medical screening exam for 1 of 47 patients sampled, regarding a pregnant patient in possible labor due to billing/payment/insurance issues (Patient #6).

Findings include:

Patient #6

The facility log from St. Rose Dominican Hospital Siena campus (Siena) labor and delivery (L&D) indicated the patient signed in on 8/2/11.

Interview

Interview with the patient on 8/23/11 at approximately 4pm, revealed the following:

- "I was already registered with Siena 2 weeks before. A lady (registrar) I talked to said they accepted our insurance."
- A week prior to 8/2/11, the patient presented to the facility in labor and delivery with complaints of contractions, "they told me I wasn't in labor" and was sent home after exam. The patient indicated staff never mentioned anything about payment. The patient indicated she was already pre-registered to deliver at this facility.
- On 8/2/11 the patient presented to Siena in L&D with ruptured membranes and was instructed to change into a gown, "as usual, they just saw me last week so nothing was different. They were the same nurses I saw when I came in before. Nobody told me anything different. While changing, my husband told me to get dressed because the nurse told him we would be charged an enormous bill if we hook up to machines, and Spring Valley takes Medicaid, and I didn't want to pay any large bill...No, I didn't speak to anyone after that, we just left. No one asked us to stay."
- "I was admitted at Spring Valley and when they examined me I was at 2cm... I had the baby the next morning... a healthy baby boy."
The patient's husband was unavailable for interview.

On 8/18/11 in the afternoon, the L&D Charge Nurse reported on 8/2/11 the patient presented with possible ruptured membranes, was in the triage room changing clothes and significant other was in the room. The nurse received a phone call from the doctor's office stating the patient was sent to the wrong hospital. The nurse then spoke with the significant other and informed of the telephone conversation that the patient should have gone to Spring Valley. The nurse informed the patient and the significant other the doctor's office sent the patient to the wrong hospital as Siena was not contracted with the patient's insurance. The nurse informed the significant other she was unsure if the insurance would cover the hospital stay but they were welcome to stay. The patient had looked uncomfortable when she arrived. The nurse informed the couple three times they did not have to leave and they had a bed available to care for the the patient. The significant other wanted to leave to go to the other hospital, as he did not want to get stuck with the bill. The nurse said, "I know EMTALA. What was I supposed to do ... make them stay? I told them we were willing to provide care."

On 8/18/11 in the afternoon, the Maternal Child Center Manager revealed her L&D nurse reported an issue regarding Patient #6 on 8/2/11. The patient signed in for leaking of fluid. The doctor's office called and informed her the patient and her husband went to the wrong hospital. The L&D nurse informed the patient and her husband that she would like to evaluate the patient prior to leaving. The husband refused and they left for the other hospital. The Manager reported the issue to Risk Management.

On 8/18/11 in the afternoon, the Director of Risk Management at Siena stated she was contacted by the CEO (Chief Executive Officer) on 8/4/11 to investigate a possible EMTALA reported to him from the other hospital, Spring Valley. The patient signed in at approximately 2pm (on 8/2/11). The patient was sent to the facility by the doctor's office and the patient was in the process of changing into a gown. The doctor's office called L&D to inform the patient they were sent to the wrong hospital and needed to go to Spring Valley. The patient's insurance was not contracted with Siena. The L&D nurse informed the patient and significant other of the telephone conversation. The couple wanted to go to Spring Valley because the patient could not afford to get a bill. The L&D nurse informed the patient and significant other they could stay and the facility could provide care. The L&D nurse did not notify Spring Valley of the patient arriving at their facility. The L&D nurse informed the patient several times they could provide the care and treatment at their facility. This visit only took 8 minutes and the patient and the significant other were gone by 2:08pm.

On 8/25/11 at 11am, the Obstetrics (OB) Director at Spring Valley revealed her L&D nurse informed her of the patient's issue upon arrival on 8/2/11 in the afternoon. The OB Director went and spoke to the patient. The OB Director indicated the patient had gone to Siena, pre-registered and had been seen as an outpatient there several times. On this day she reported her membranes were ruptured, she completed paperwork, was told to change her clothes. The patient reported a "nurse" came into the room and told her the insurance "didn't cover her and if the patient stayed there, she would have a really, really big bill. They (patient and significant other) decided to come here." The patient also indicated there was a message left on either hers or her husband's cell phone stating it was the OB doctor's office and for them not to go to Siena. The OB Director indicated she then spoke with the OB doctor who indicated his office would not have instructed the patient as such. They do not tell the patient where to go.

On 8/25/11 at 2:30pm, the doctor's office OB Representative, who takes care of OB charts, monitors OB appointments, and insurance contracts, revealed the patient was supposed to come in to the office. The Representative verified their OB physicians either go to Siena or Spring Valley. The patient was planned to receive care from her OB doctor at Siena under Medicaid insurance. As of 8/1/11, the patient's insurance converted from Medicaid to Amerigroup and on 8/2/11, the patient was sent to Siena which didn't accept the Amerigroup insurance. The Representative called the hospital as the patient was signing in. The Representative told the L&D nurse the patient was going to have to pay a big bill at Siena, because the insurance the patient was converted to was no longer accepted by Siena, but was accepted by Spring Valley. The L&D nurse responded, "We can't turn her away."

Record Review

There were no documents other than the record of the log at Siena. There was no documented evidence of a medical screening exam conducted at Siena.

The records at Spring Valley indicated the patient arrived on 8/2/11 at approximately 2:55 in the afternoon and revealed the following:

- The admitting diagnoses were: 1. Intrauterine pregnancy at 37 and 6/7 weeks, and 2. Active labor.
- The delivery date and method was spontaneous vaginal with vacuum extraction on 8/3/11 at 11:27am.
- The Apgars were 7/9.

Document Review

The Siena Policy /Procedure, "Medical Screening Examination/Triage of the Pregnant Patient" revised 7/24/06, indicated the following:

- Page 1 of 7 indicated,
"Responsibilities: Registered Nurse with demonstrated and documented competency. Screening must be done by a qualified Registered Labor and Delivery Nurse...The Registered Nurse must communicate the assessment findings to the Obstetrician for determination of patient disposition..."

- Page 3 of 7 indicated,
"When the OB patient presents to OB triage for assessment and disposition, the RN who has demonstrated competencies may perform the Medical Screening Exam (MSE). The RN will utilize standard assessment and evaluation methods...
...The Labor and Delivery Triage Nurse with demonstrated/approved competency may perform an MSE. The OB attending physician is notified of the examination findings...
...The initial assessment and/or treatment of an Emergency Medical Condition will not be delayed in order to obtain financial or insurance information. All patients will receive medical screening and emergency stabilization care regardless of managed care plan requirements or directives...
... Managed care plans or third party payers cannot deny the hospital permission to screen and treat an Emergency Medical Condition."

According to the 1/6/11 Medical Executive Committee Minutes, the 2011 MSE Competent Labor Nurses list, the Siena L&D nurse who was interviewed regarding her 8/2/11 interaction with Patient #6 and the significant other, was included on the 2011 MSE Competent Labor Nurses list.

The facility failed to conduct the medical screening exam to assess the patient's status and communicate those findings to the obstetrician to determine the patient's disposition, prior to any discussion of billing/payment/insurance issues.

Complaint #29089

Based on interviews, record review and document review, the facility failed to conduct an appropriate medical screening exam for 2 of 47 patients sampled: a pregnant patient in possible labor and a psychiatric patient who threatened suicide (Patients #6, #12).

Findings include:

Patient #6

The facility log from St. Rose Dominican Hospital Siena campus (Siena) labor and delivery (L&D) indicated the patient signed in on 8/2/11.

Interview

Interview with the patient on 8/23/11 at approximately 4pm, revealed the following:

- "I was already registered with Siena 2 weeks before. A lady (registrar) I talked to said they accepted our insurance."
- A week prior to 8/2/11, the patient presented to the facility in labor and delivery with complaints of contractions, "they told me I wasn't in labor" and was sent home after exam. The patient indicated staff never mentioned anything about payment. The patient indicated she was already pre-registered to deliver at this facility.
- On 8/2/11 the patient presented to Siena in L&D with ruptured membranes and was instructed to change into a gown, "as usual, they just saw me last week so nothing was different. They were the same nurses I saw when I came in before. Nobody told me anything different. While changing, my husband told me to get dressed because the nurse told him we would be charged an enormous bill if we hook up to machines, and Spring Valley takes Medicaid, and I didn't want to pay any large bill...No, I didn't speak to anyone after that, we just left. No one asked us to stay."
- "I was admitted at Spring Valley and when they examined me I was at 2cm... I had the baby the next morning... a healthy baby boy."
The patient's husband was unavailable for interview.

On 8/18/11 in the afternoon, the L&D Charge Nurse reported on 8/2/11 the patient presented with possible ruptured membranes, was in the triage room changing clothes and significant other was in the room. The nurse received a phone call from the doctor's office stating the patient was sent to the wrong hospital. The nurse then spoke with the significant other and informed of the telephone conversation that the patient should have gone to Spring Valley. The nurse informed the patient and the significant other the doctor's office sent the patient to the wrong hospital as Siena was not contracted with the patient's insurance. The nurse informed the significant other she was unsure if the insurance would cover the hospital stay but they were welcome to stay. The patient had looked uncomfortable when she arrived. The nurse informed the couple three times they did not have to leave and they had a bed available to care for the the patient. The significant other wanted to leave to go to the other hospital, as he did not want to get stuck with the bill. The nurse said, "I know EMTALA. What was I supposed to do ... make them stay? I told them we were willing to provide care."

On 8/18/11 in the afternoon, the Maternal Child Center Manager revealed her L&D nurse reported an issue regarding Patient #6 on 8/2/11. The patient signed in for leaking of fluid. The doctor's office called and informed her the patient and her husband went to the wrong hospital. The L&D nurse informed the patient and her husband that she would like to evaluate the patient prior to leaving. The husband refused and they left for the other hospital. The Manager reported the issue to Risk Management.

On 8/18/11 in the afternoon, the Director of Risk Management at Siena stated she was contacted by the CEO (Chief Executive Officer) on 8/4/11 to investigate a possible EMTALA reported to him from the other hospital, Spring Valley. The patient signed in at approximately 2pm (on 8/2/11). The patient was sent to the facility by the doctor's office and the patient was in the process of changing into a gown. The doctor's office called L&D to inform the patient they were sent to the wrong hospital and needed to go to Spring Valley. The patient's insurance was not contracted with Siena. The L&D nurse informed the patient and significant other of the telephone conversation. The couple wanted to go to Spring Valley because the patient could not afford to get a bill. The L&D nurse informed the patient and significant other they could stay and the facility could provide care. The L&D nurse did not notify Spring Valley of the patient arriving at their facility. The L&D nurse informed the patient several times they could provide the care and treatment at their facility. This visit only took 8 minutes and the patient and the significant other were gone by 2:08pm.

On 8/25/11 at 11am, the Obstetrics (OB) Director at Spring Valley revealed her L&D nurse informed her of the patient's issue upon arrival on 8/2/11 in the afternoon. The OB Director went and spoke to the patient. The OB Director indicated the patient had gone to Siena, pre-registered and had been seen as an outpatient there several times. On this day she reported her membranes were ruptured, she completed paperwork, was told to change her clothes. The patient reported a "nurse" came into the room and told her the insurance "didn't cover her and if the patient stayed there, she would have a really, really big bill. They (patient and significant other) decided to come here." The patient also indicated there was a message left on either hers or her husband's cell phone stating it was the OB doctor's office and for them not to go to Siena. The OB Director indicated she then spoke with the OB doctor who indicated his office would not have instructed the patient as such. They do not tell the patient where to go.

On 8/25/11 at 2:30pm, the doctor's office OB Representative, who takes care of OB charts, monitors OB appointments, and insurance contracts, revealed the patient was supposed to come in to the office. The Representative verified their OB physicians either go to Siena or Spring Valley. The patient was planned to receive care from her OB doctor at Siena under Medicaid insurance. As of 8/1/11, the patient's insurance converted from Medicaid to Amerigroup and on 8/2/11, the patient was sent to Siena which didn't accept the Amerigroup insurance. The Representative called the hospital as the patient was signing in. The Representative told the L&D nurse the patient was going to have to pay a big bill at Siena, because the insurance the patient was converted to was no longer accepted by Siena, but was accepted by Spring Valley. The L&D nurse responded, "We can't turn her away."

Record Review

There were no documents other than the record of the log at Siena. There was no documented evidence of a medical screening exam conducted at Siena.

The records at Spring Valley indicated the patient arrived on 8/2/11 at approximately 2:55 in the afternoon and revealed the following:

- The admitting diagnoses were: 1. Intrauterine pregnancy at 37 and 6/7 weeks, and 2. Active labor.
- The delivery date and method was spontaneous vaginal with vacuum extraction on 8/3/11 at 11:27am.
- The Apgars were 7/9.

Document Review

The Siena Policy /Procedure, "Medical Screening Examination/Triage of the Pregnant Patient" revised 7/24/06, indicated the following:

- Page 1 of 7 indicated,
"Responsibilities: Registered Nurse with demonstrated and documented competency. Screening must be done by a qualified Registered Labor and Delivery Nurse...The Registered Nurse must communicate the assessment findings to the Obstetrician for determination of patient disposition..."

- Page 3 of 7 indicated,
"When the OB patient presents to OB triage for assessment and disposition, the RN who has demonstrated competencies may perform the Medical Screening Exam (MSE). The RN will utilize standard assessment and evaluation methods...
...The Labor and Delivery Triage Nurse with demonstrated/approved competency may perform an MSE. The OB attending physician is notified of the examination findings...
...The initial assessment and/or treatment of an Emergency Medical Condition will not be delayed in order to obtain financial or insurance information. All patients will receive medical screening and emergency stabilization care regardless of managed c

Based on interviews, record review and document review, the facility failed to conduct an appropriate medical screening exam for 1 of 47 patients sampled, regarding a pregnant patient in possible labor due to billing/payment/insurance issues (Patient #6).

Findings include:

Patient #6

The facility log from St. Rose Dominican Hospital Siena campus (Siena) labor and delivery (L&D) indicated the patient signed in on 8/2/11.

Interview

Interview with the patient on 8/23/11 at approximately 4pm, revealed the following:

- "I was already registered with Siena 2 weeks before. A lady (registrar) I talked to said they accepted our insurance."
- A week prior to 8/2/11, the patient presented to the facility in labor and delivery with complaints of contractions, "they told me I wasn't in labor" and was sent home after exam. The patient indicated staff never mentioned anything about payment. The patient indicated she was already pre-registered to deliver at this facility.
- On 8/2/11 the patient presented to Siena in L&D with ruptured membranes and was instructed to change into a gown, "as usual, they just saw me last week so nothing was different. They were the same nurses I saw when I came in before. Nobody told me anything different. While changing, my husband told me to get dressed because the nurse told him we would be charged an enormous bill if we hook up to machines, and Spring Valley takes Medicaid, and I didn't want to pay any large bill...No, I didn't speak to anyone after that, we just left. No one asked us to stay."
- "I was admitted at Spring Valley and when they examined me I was at 2cm... I had the baby the next morning... a healthy baby boy."
The patient's husband was unavailable for interview.

On 8/18/11 in the afternoon, the L&D Charge Nurse reported on 8/2/11 the patient presented with possible ruptured membranes, was in the triage room changing clothes and significant other was in the room. The nurse received a phone call from the doctor's office stating the patient was sent to the wrong hospital. The nurse then spoke with the significant other and informed of the telephone conversation that the patient should have gone to Spring Valley. The nurse informed the patient and the significant other the doctor's office sent the patient to the wrong hospital as Siena was not contracted with the patient's insurance. The nurse informed the significant other she was unsure if the insurance would cover the hospital stay but they were welcome to stay. The patient had looked uncomfortable when she arrived. The nurse informed the couple three times they did not have to leave and they had a bed available to care for the the patient. The significant other wanted to leave to go to the other hospital, as he did not want to get stuck with the bill. The nurse said, "I know EMTALA. What was I supposed to do ... make them stay? I told them we were willing to provide care."

On 8/18/11 in the afternoon, the Maternal Child Center Manager revealed her L&D nurse reported an issue regarding Patient #6 on 8/2/11. The patient signed in for leaking of fluid. The doctor's office called and informed her the patient and her husband went to the wrong hospital. The L&D nurse informed the patient and her husband that she would like to evaluate the patient prior to leaving. The husband refused and they left for the other hospital. The Manager reported the issue to Risk Management.

On 8/18/11 in the afternoon, the Director of Risk Management at Siena stated she was contacted by the CEO (Chief Executive Officer) on 8/4/11 to investigate a possible EMTALA reported to him from the other hospital, Spring Valley. The patient signed in at approximately 2pm (on 8/2/11). The patient was sent to the facility by the doctor's office and the patient was in the process of changing into a gown. The doctor's office called L&D to inform the patient they were sent to the wrong hospital and needed to go to Spring Valley. The patient's insurance was not contracted with Siena. The L&D nurse informed the patient and significant other of the telephone conversation. The couple wanted to go to Spring Valley because the patient could not afford to get a bill. The L&D nurse informed the patient and significant other they could stay and the facility could provide care. The L&D nurse did not notify Spring Valley of the patient arriving at their facility. The L&D nurse informed the patient several times they could provide the care and treatment at their facility. This visit only took 8 minutes and the patient and the significant other were gone by 2:08pm.

On 8/25/11 at 11am, the Obstetrics (OB) Director at Spring Valley revealed her L&D nurse informed her of the patient's issue upon arrival on 8/2/11 in the afternoon. The OB Director went and spoke to the patient. The OB Director indicated the patient had gone to Siena, pre-registered and had been seen as an outpatient there several times. On this day she reported her membranes were ruptured, she completed paperwork, was told to change her clothes. The patient reported a "nurse" came into the room and told her the insurance "didn't cover her and if the patient stayed there, she would have a really, really big bill. They (patient and significant other) decided to come here." The patient also indicated there was a message left on either hers or her husband's cell phone stating it was the OB doctor's office and for them not to go to Siena. The OB Director indicated she then spoke with the OB doctor who indicated his office would not have instructed the patient as such. They do not tell the patient where to go.

On 8/25/11 at 2:30pm, the doctor's office OB Representative, who takes care of OB charts, monitors OB appointments, and insurance contracts, revealed the patient was supposed to come in to the office. The Representative verified their OB physicians either go to Siena or Spring Valley. The patient was planned to receive care from her OB doctor at Siena under Medicaid insurance. As of 8/1/11, the patient's insurance converted from Medicaid to Amerigroup and on 8/2/11, the patient was sent to Siena which didn't accept the Amerigroup insurance. The Representative called the hospital as the patient was signing in. The Representative told the L&D nurse the patient was going to have to pay a big bill at Siena, because the insurance the patient was converted to was no longer accepted by Siena, but was accepted by Spring Valley. The L&D nurse responded, "We can't turn her away."

Record Review

There were no documents other than the record of the log at Siena. There was no documented evidence of a medical screening exam conducted at Siena.

The records at Spring Valley indicated the patient arrived on 8/2/11 at approximately 2:55 in the afternoon and revealed the following:

- The admitting diagnoses were: 1. Intrauterine pregnancy at 37 and 6/7 weeks, and 2. Active labor.
- The delivery date and method was spontaneous vaginal with vacuum extraction on 8/3/11 at 11:27am.
- The Apgars were 7/9.

Document Review

The Siena Policy /Procedure, "Medical Screening Examination/Triage of the Pregnant Patient" revised 7/24/06, indicated the following:

- Page 1 of 7 indicated,
"Responsibilities: Registered Nurse with demonstrated and documented competency. Screening must be done by a qualified Registered Labor and Delivery Nurse...The Registered Nurse must communicate the assessment findings to the Obstetrician for determination of patient disposition..."

- Page 3 of 7 indicated,
"When the OB patient presents to OB triage for assessment and disposition, the RN who has demonstrated competencies may perform the Medical Screening Exam (MSE). The RN will utilize standard assessment and evaluation methods...
...The Labor and Delivery Triage Nurse with demonstrated/approved competency may perform an MSE. The OB attending physician is notified of the examination findings...
...The initial assessment and/or treatment of an Emergency Medical Condition will not be delayed in order to obtain financial or insurance information. All patients will receive medical screening and emergency stabilization care regardless of managed care p