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Based on review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow adopted policies related to providing a medical screening examination for one of one patients (PT1), failed to follow adopted Emergency Department policies/and failed to ensure that all applicable Departments adopted uniform policies related to the Emergency Department (ED) registration/triage process, for one of one patients (PT1), and three of ten applicable medical records reviewed (MR2, MR3, MR4), and failed to ensure that the process that all patients receive an initial assessment by a Registered Nurse, as described in the facility's adopted Emergency Department Policies occurs for each patient presenting to the Emergency Department.

Findings include:

Review of "Penn Highlands Clearfield Medical Screening Examination" policy and procedure dated June 2014, revealed, "Procedure: A. Purpose and Extent. The purpose of the 'Medical Screening Examination' is to determine whether or not the patient has a medical emergency ... A Physician or Physician Assistant will perform the Medical Screening Examination for all individuals presenting to the Emergency Services area."

Review of facility policy "Emergency Medical Screening, Treatment, and Transfer Policy", dated June 2014, revealed "... Policy: The Penn Highlands Clearfield ED Physicians are responsible to provide a Medical Screening Exam (MSE) and appropriate treatment to patients coming to the Penn Highlands Clearfield ED for emergency care ... B. NO DELAY IN SCREENING OR EXAMINATION (1) There will be no delay in providing a medical screening examination or follow-up treatment for an emergency medical condition in order to inquire about the patient's method of payment or insurance status. (2) For patients who are enrolled in a managed care plan, prior authorization from the plan shall NOT be required or requested before providing an appropriate MSE and/or necessary stabilizing treatment. Neither the performance of the MSE nor the provision of stabilizing treatment will be conditioned on a patient's completion of a financial responsibility form or the payment of a copayment. (3) Patients who inquire about financial responsibility for emergency care will be encouraged to delay such discussions until after the completion of the MSE and the initiation of stabilizing treatment, if necessary. These patients will also be told that the Hospital will provide a MSE and stabilizing treatment, regardless of their ability to pay ... ."

Review of "VI Utilization of the Emergency Department" policy and procedure dated June 2014, revealed, "A. Admission to the Emergency Department 1. Types and Methods of Admissions/Walk ups A customer who presents to the Emergency Department with a health concern undergoes an initial assessment by a Registered Nurse. A determination is made at that time as to whether the patient's condition is stable or unstable. If it is determined that the customer's condition is stable, they are triaged and escorted to the appropriate treatment area of the Emergency Department. If the customer is unstable they are escorted immediately to the appropriate treatment area of the Emergency Department. The registration clerk places the customer name and birth dated in the 'Patient's Main Index' in the Healthmatic system upon arrival in Registration. If the customer is unstable, and presents to the Emergency Department, the Unit Clerk or RN will initiate the MPI information. Personnel from Registration will come to the Emergency Department to complete registration process and obtain any further information as indicated on the customer chart ... IV. Triage A. Purpose The purpose of Triage in the Emergency Department: 1. Early recognition and assessment of the seriously compromised customer. 2. Immediate intervention in life threatening situations. 3. Expedited care for the non-critical customer. 4. Alleviate fear, anxiety, and tension levels in customers with marked benefit to the nursing staff as a result. 5. More effective follow through on problems. 6. Designated responsibility for liaison with families, friends, and public. 7. More effective overall management, resulting in smooth patient flow and traffic patterns. B. Hours of Triage Patient triage is performed twenty-four hours, seven days per week by an RN. The Charge Nurse is responsible for assigning a Triage Nurse daily. The nightshift Charge Nurse or his/her designee completes the customer triage. ... D. Personnel Coverage Triage is completed by an RN who is responsible for the assessment interview of all customers presenting to the Emergency Department to determine patient acuity level ... F. Roles/Responsibilities 1. Assess the general status of each customer on arrival to the Emergency Department. 2. Assess the customer for life threatening and immediate needs and prioritize accordingly. 3. Obtain pertinent customer history ... H. Triage Designations All customers presenting to the Emergency Department are assessed and triaged by a Registered Nurse using the following categories; ESI 1: Customers that require immediate medical attention re: loss of life or function may be eminent. Customer needs to be seen by the physician within 15 minutes of arrival. ESI2: Customers whose condition requires medical attention within 30 minutes or have the potential to become an ESI level 1. ESI 3: Customers who are stable at the time of assessment and their condition may be seen within one hour of arrival. ESI 4: Customers are stable at the time of their assessment. They are usually non-acute but will require an intervention. ESI 5: Customers are stable at the time of their assessment and require no resources ... J. Communication/Documentation During the triage process the Emergency Department Triage nurse will assess the patient and place the information in the Emergency Department Electronic Documentation Record ... Registration Registration A. Upon arrival to Penn Highlands Clearfield Emergency Department, the customer presents to the registration area of the hospital and presents to the registration clerk. B. Registration Clerk will then place the customer's name, birth date, and chief complaint (if complaint provided by patient) into the Patient Lookup. C. Registration will notify the triage nurse of customers on the tracking board. If customers have shortness of breath, uncontrolled bleeding, chest pain or may be in labor, the triage nurse will immediately and quickly assess the patient and disposition the patient to an appropriate bed via wheelchair and have the accepting RN triage the patient at bedside. D. After completion of a stable triaged patient, the triage nurse will place the registration icon onto the tracking board to notify the registration clerk that the registration can now be completed ... F. Upon completion of the customer treatment and stay in the ED, the customer and/or family will return to the registration area to update personal information and provide insurance information."

Review of the facility's Patient Access policy, dated August 2014, entitled "ED Patient Registration", revealed "Purpose: To provide the Patient Access/PBX Department staff with guidelines to obtain the necessary information when a patient presents to be seen in the E/D. PLAN: 1. Patient presents to the Patient Access department for treatment in the E/D. 2. The clerk is to ask the patient if they are having Chest Pain, Shortness of Breath or Bleeding that needs contained. 3. IF YES to Chest Pain (any heart related complaint), or Shortness of Breath, the clerk is required to call triage (or the E/D if triage is not answering or available) immediately. 4. (If Possible) the clerk may ask for the patient's insurance card and photo ID ... 6. The clerk copies the patient's insurance card and photo ID ... 9. The staff should follow the same policy for every patient that checks into the E/D. a. Ask if Chest Pain (any related complaint), Shortness of Breath, or Bleeding that needs contained. B. Call for triage if chest pain, SOB or bleeding is uncontained. C. Attempt to obtain necessary information from patient 10. The following information should be obtained at check in. (If possible). a. Patient's name b. Patient's birth date c. Copy of patient's photo ID and insurance cards. d. PCP - 1st and last name. (If possible) and the city where doctor practices. If the doctor is out of the area and not a doctor that is recognized. e. Onset of illness or date & time of injury. (If accident, accident info. What happened, where did it happen. Auto acc, who was driving, whose car, where acc happened. Work injury, employer name, address and phone # is required and whether it was reported or not. f. Directory information g. Support person ... 14. The clerk is required to write the time patient was placed on the board (use the time on the phone display screen if possible) and her initials on the info slip. 15. A patient is never delayed going with the Triage nurse or E/D staff for Patient Access to obtain info. A bedside registration can be completed; cards can be taken back to the patient when the chart is delivered to the E/D. 16. Obtaining and verifying info must take place quickly and while waiting for the Triage Nurse or E/D staff to come for the patient. (if possible) ... ."

Review of the facility's Patient Access policy entitled "Triage", dated August 2014, revealed "Purpose: To provide the Patient Access/PBX Department staff with guidelines to call for triage and to facilitate the transfer of information between the Patient Access staff and the Emergency Department staff when a patient presents for treatment in the Emergency Department. Plan: 1. All patients being seen in the Emergency Department (except those arriving by ambulance or presenting through the Emergency Department entrance) will present to the Patient Access Department to check in. 2. The triage nurse is to be watching the tracking board constantly. 3. The Patient Access staff will be required to contact the triage nurse by calling the triage cell phone until the nurse picks up for patients that need seen immediately ... ."

Review of "Registration/PBX Representative Orientation Training Check List" revealed " ... 1st Training Level Emergency Registrations ... Triage (When Open/Closed) Triage Phone ... Questions to Ask E/D Pt's Upon Arrival Handling (Chest Pain, SOB, & Bleeding) ID & Insurance Cards Obtaining info from E/D pts according to the Emtala Laws Instructions to E/D Patients Bed Side Registrations ... ."

A review of a facility document provided for review entitled, "GHP MA HMO Plan Update", no date, revealed "Per ... We do not complete registrations for any patients with the new Geisinger MA HMO plan "Geisinger Health Plan Family". We do not have a contract with GHP for that plan and GHP will not pay for patients having testing done at our facility even with auths or referrals. We are to refer the patient to seek testing at a facility that is contracted with that ins plan. E/D Patients will be explained the situation and asked to sign an ABN (Advance Beneficiary Notice) before they go to triage."

1) A review of the patient's (PT1) medical record (MR1) revealed "... 7/17/2014 ... Chief Complaint: Abdominal Pain ... Acuity: ESI 5 ... Patient has contacted his/her primary care physician prior to coming to the Emergency Department ... Patient left prior to triage ... Patient left without being seen ... ."

A review of a facility documents revealed that PT1 presented to the ED on July 17, 2014, and left without being seen. The document stated that the patient was informed by registration that the hospital did not accept [their] insurance so the patient left per registration. Documents also stated that the patient was sent in from a physician's office for evaluation of acute pancreatitis with complaints of abdominal pain. Stated was told by registration [their] insurance wasn't accepted by the hospital, so the patient left per registration.

A review of the Patient Access, "E/D Sign in Log", dated July 17, 2014, revealed documentation of [PT1] presenting to registration desk, with complaint of abdominal pain, "not even triaged ... Pt left when I explained that we don't have a contract with her insurance, would have to sign an ABN or not ... ."

An interview was conducted on September 30, 2014, at 1:00 PM with EMP5. EMP5 revealed "... The patient presented to the ER, I asked for [their] name and birthdate and what [their] complaint was, [they] said abdominal pain. I do not remember if I asked or if [they] presented [their] insurance card, but [they] had an insurance that we do not contract with ... ." EMP5 also stated [they] advised the patient that [they] could sign the ABN and they would bill the insurance, and if not paid, [they] would be responsible.

2) A review of the patient's (PT1) medical record (MR1) revealed "... 7/17/2014 ... Chief Complaint: Abdominal Pain ... Acuity: ESI 5 ... Patient has contacted his/her primary care physician prior to coming to the Emergency Department ... Patient left prior to triage ... Patient left without being seen ... ."

An interview with EMP6 on September 30, 2014, at 1:45 PM was conducted. EMP6 stated that the patient (PT1) was not triaged. Stated "I did the charting, but [they were] not triaged." Related to an acuity level of "5' being assigned to this patient (PT1, MR1), EMP6 stated "it was done on discharge."

An interview with EMP7 on September 30, 2014, at 2:40 PM, revealed that triage should occur within 15 minutes, and that is the goal. EMP7 also stated that acuity would be assigned, and vital signs, and chief complaint would be included in triage. EMP7 also stated that the nurses are to be notified by phone of every patient that presents to the ED.

A review of 10 medical records (MR2-MR11) revealed documented evidence of photocopied insurance information within the electronic record. Three of ten medical records, MR2, MR3 and MR4 revealed a time entry (prior to the time of triage) and the initials of a registration staff member on the photocopied insurance information.

MR2 dated August 1, 2014, revealed that the patient was registered at 2:45 PM and was triaged at 2:52 PM. The photocopied insurance information within MR2 revealed the initials of a registration staff member and a time of "14:45."

MR3 dated August 8, 2014, revealed that the patient was registered at 12:06 PM and was triaged at 12:26 PM. The photocopied insurance information within MR3 revealed the initials of a registration staff member and a time of "12:02."
MR4 dated August 16, 2014, revealed that the patient was registered at 11:34 AM and was left without being seen at 12:25 PM. The photocopied insurance information within MR4 revealed the initials of a registration staff member and a time of "11.32."
Interview with EMP12 was conducted on September 30, 2014, at 1:30 PM and confirmed the registration time, triage time and the entries on the photocopied insurance information for MR2, MR3, and MR4.
3) An interview with (EMP4) on September 30, 2014, at 10:35 AM, revealed that registration staff ask the patient's chief complaint, specifically if they are having chest pain, shortness of breath, or are bleeding. Stated that if there is an urgent need, the nurse is called. Stated that when an ED patient presents, registration gets their name, date of birth, and chief complaint. Stated that if it is urgent, they call back for a nurse. Stated if nature of complaint is not urgent, the registration staff gets the patient's name, date of birth, why they presented, when their symptoms first occurred. Stated that registration staff places patient information on the ED Board, which notifies the nurses that a patient is there. Stated that the registration staff then proceeds with full registration, unless the triage nurse comes out. (EMP4) continued by stating that the patient is on the tracking board, and then the registration staff ask about insurance.

An interview was conducted on September 30, 2014, at 1:00 PM with EMP5, and revealed "When someone presents to the registration desk, I ask them if they are here for the Emergency Department and tell them to have a seat in front of me. I get their name, birthdate, accident, injury, phone number, length of pain, the physician and type of insurance. As I am typing the information in, after the birthdate goes in the system, in that order, they are placed on the board for triage. If they come in with chest pain, shortness of breath, bleeding, I am dialing the phone for triage. If not for those three things, I am telling them either to go to waiting area or bench until somebody comes out and gets them from the Emergency Department."

A telephone interview with EMP7 on October 1, 2014, at 1:40 PM, revealed "I talked to staff and what use to happen was that triage was notified for every patient. Now, only notified of chest pain, shortness of breath. Registration will notify triage nurse if on tracking board. I didn't realize this was happening. We will get this fixed today."