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TRISTAR SKYLINE MEDICAL CENTER 3441 DICKERSON PIKE NASHVILLE, TN 37207 Sept. 17, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy review, medical record review, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) were not discouraged from seeking a Medical Screening Examination (MSE) by asking for payment prior to performing a MSE for 1 of 20 (Patient #20) sampled patients.

Findings include:

Refer to findings at A-2408.
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: A2408
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) were not discouraged from seeking a Medical Screening Examination (MSE) by asking for payment prior to performing a MSE for 1 of 20 (Patient #20) sampled patients.

The findings included:

1. The hospital policy "EMTALA (Emergency Medical Treatment and Labor Act) Tennessee Medical Screening Examination and Stabilization Policy" revealed, "...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and...1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition...The hospital must perform an MSE to determine if an EMC [Emergency Medical Condition] exists...Triage is not equivalent to an MSE...An MSE is the process required to reach, with reasonable clinical confidence, the point which it can be determined whether the individual has an EMC or not. It is not an isolated event...An MSE...will not be delayed to inquire about the individual's method of payment or insurance status, or conditioned on an individual's completion of financial responsibility form...or payment of a co-payment for any services rendered..."

2. Medical record revealed Patient #20 arrived at ED #1 on 9/6/2020 at 7:57 PM via walk-in with the stated complaint of Chest Pain since last night. He had one insurance plan listed on the demographic sheet and the Patient Employer was listed as "DISABLED PATIENT."

The Rapid Initial Assessment on 9/6/2020 at 8:00 PM, revealed Patient #20 stated the chest pain "feels like someone is sitting on my chest." The pain intensity score was rated moderate-6.

A "WAIVER OF RIGHT TO MEDICAL SCREENING EXAMINATION" was signed by Patient #20 and witnessed by Nurse #1 on 9/6/2020 at 8:10 PM.

The Disposition Comments on 9/7/2020 at 8:11 PM, revealed "...PT LPMSE [left prior to MSE] STATING "THIS IS A BUNCH OF BULLSHIT, YALL HAVE SCREWED MY INSURANCE UP AND I'M NOT PAYING A CO PAY" AMBULATED FROM ED IN NAD [no apparent distress]..."

The ambulance run report dated 9/6/2020 revealed Emergency Medical Services (EMS) received a call at 9:37 PM to respond to the home of Patient #20. When EMS arrived at 9:42 PM, Patient #20 informed EMS he had the chest pain on and off for a couple of days with no relief and described the pain as pressure to the left side of his chest. He was transported hospital #2 non-emergency traffic and was monitored during transported. No interventions were needed.

Medical record review revealed Patient #20 arrived at ED #2 on 9/6/2020 at 10:34 PM, with the Chief Complaint of Chest Pain.

The ED #2 History and Physical revealed, "...Chest pain worse with activity times past 48 hours. Strong family history of heart disease. Work-up thus far is negative. However he does have several risk factors given his underlying [DIAGNOSES REDACTED], diabetes, hypertension, tobacco abuse, and obesity. Will admit to MedSurg observation with telemetry..."

The Discharge Summary dated 9/7/2020 revealed, "...Cardiac markers and electrocardiogram did not show signs of acute cardiac injury or ischemia. Chest pain has resolved. He is felt to be medically suitable to discharge...consideration of further cardiac evaluation ...begin taking daily aspirin...given prescription for sublingual nitroglycerin..."

3. In an interview in the conference room on 9/15/20 at 9:15 AM, the Chief Medical Officer (CMO) stated Patient #20 was taken into registration and was asked by the Registrar for a $90.00 co-pay. The CMO stated he believed the Registrar thought the MSE had been completed. The CMO stated the Registrar "asked inappropriately for a co-pay" prior to a MSE being performed.

In an interview in the conference room on 9/15/20 at 10:16 AM, the Patient Access Director (Supervisor for Registration) stated Patient #20 was brought to registration, but the nurse (Nurse #2) did not disclose the MSE had not been performed. The Patient Access Director stated she believed the Registrar assumed the MSE had been completed.

In an interview in the conference room on 9/15/20 at 10:38 AM, the ED Nurse Manager stated she conducted an investigation into the incident with Patient #20 and confirmed the Registrar inappropriately asked for the copay prior to the MSE being performed.

In a telephone interview on 9/15/2020 at 12:07 PM, the Registrar was asked about Patient #20. She stated he had one insurance card with him and when she looked up his information, he had a $90.00 co-pay. When she told the patient, he called his mother and told the Registrar he should not have a co-pay and asked to leave. When asked at what point can she asked for a co-pay, the Registrar stated, "Can ask for co-pay even if they haven't had an MSE. Don't have to wait until they've seen a physician until you ask for a co-pay."