HospitalInspections.org

Intakes: TN00028755

Based on policy review, medical record review and interview, it was determined the hospital failed to ensure the Dedicated Emergency Department (DED) provided an appropriate Medical Screening Exam (MSE) prior to seeking authorization for payment for 2 of 21 (Patient's #1 and 13) patients reviewed.

Refer to findings in deficiency V 2408.

Intakes: TN00028755


Based on the Emergency Department Registration policy, medical record review, and interview, the facility failed to provide a Medical Screening Exam (MSE) prior to seeking payment authorization for 2 of 21 (Patient's # 1 and 13) patients reviewed.

The findings included:

1. Review of the hospital's "Emergency Department Registration" policy documented, "III. Policy: It is the policy of [name of hospital] to follow "reasonable" registration procedures: however, a medical screening examination, stabilizing treatment, or appropriate transfer will not be delayed in order to obtain financial information. Therefore, "reasonable" registration processes may include requesting basic demographic information and insurance information as long as these procedures do not delay screening or treatment. Discussion of patient's financial liability including prior authorization (co-payment, deductibles, past due balances) will not occur until medical screening examination and stabilization (if emergency) have been completed...VI Procedure:.C. 1. All hospital staff involved with the registering of emergency department patients or the provision of emergency care services shall be trained during orientation and annually on the EMTALA requirements...2. Medical screening may not be delayed in order to: a. inquire about the individual's ability to pay for services (included obtaining insurance information) b. advise the patient that he/she may be responsible for payment of services rendered if he/she receives treatment c. contact the insurance plan for verification and/or authorization (this can not be done until after medical screening and/or stabilization)...3. Patients will be triaged and receive a medical screening examination...4. The patient is sent back to an examination room...however, the insurance information can not be verified with the insurance company nor can pre-certification be obtained until after the patient has received a medical screening and stabilizing treatment has been initiated. There will be no discussion of patient financial liability (co-pays, deductibles, past due balances, potential financial liability): this information can be discussed after the medical screening examination and stabilization."

2. Medical record for Patient # 1 documented the patient arrived at the emergency department at 8:46 AM on 5/25/11 and triage was begun at 8:53 AM and documented the patient had a pain level of 7 out of 10, with 10 being the worse pain and a blood pressure of 232/123.
The patient presented with the chief complaint of pain to mid and upper back between his shoulder blades since Monday after lifting a tire at work per the Initial Assessment Form. Review of the Adult Assessment form completed by Registered Nurse (RN) #1 documented the following:
"Psychosocial:...Appears to be angry with care giver(s) or others that are present. pt [patient] and his wife upset because the pt work didn't send him somewhere last night when he told them his back was hurting. I asked the pt had his work been notified of his injury and his wife said, "yes they know but they dont seem too concerned about it, that is why we just came on here today". I made it clear to them both that his work has the right to have him see what physician they use for the worker comp [compensation] claims. They both said it dont matter we are going to see the Dr. while we are here. [Emergency Department Registration Clerk #2's name] in reg. [registration] made contact with pat's [patient's] manpower rep. [representative] [name of representative], at [name of company] he states that [Patient # 1] needs to come to his office and make a claim and they will go from there. [Emergency Department Registration Clerk # 2] went into pt's room to clarify with him the fact that his work would not pay for his visit today, and that he would receive a bill, but it may be picked up later by his work. Pt and his wife came out of the room, mad, the wife saying, I thought the pts come first. I asked what she was talking about and the pt stated, "just open the door, we want to leave. I explained to them that we are happy to see them and have the dr [doctor] to treat his back, but it is not up to us to pay for his visit, that is up to his work and following their instructions. Pt and his wife left the department without being seen."
The patient did not receive a MSE by the physician prior to leaving.

During an interview on 9/28/11 at 1:10 PM, ED (Emergency Department) Registration Clerk #2 was asked about Patient #1 ED record. She stated, "This name looks familiar I am not sure...workman's comp we need to notify job, they responsible for bill before they [patient] go into triage room...that's how I was taught...so will know whether to give a drug screen or not...that doesn't prevent them from being seen..workman's comp might want them to be seen by another hospital...they can still be seen, I was taught to contact the employer...when I enter a room I make sure doctor has seen patient...if workman's comp tells me the patient don't need to be here will tell the patient, but it's up to the patient whether they remain here or not..."

During an interview on 9/28/11 at 1:20 PM, the Patient Access Director [supervisor to ED Registration Clerks] was asked how staff in her department were trained on EMTALA law. She stated, "Upon hire and in ER [emergency room] they are trained...I hold monthly staff meetings where hot topics are discussed...we discuss EMTALA bi weekly in our meetings...Staff are trained never to enter a room unless the doctor has seen the ED patient..." The Patient Access Director was asked how she expected her staff to respond to a patient who presents to ED with work related injury. She stated, "Our workers comp are not to be treated any differently...ER (emergency room) clerks would go back and get information after seen by the doctor, first question we are trained to ask is has the doctor been in to see you yet, if patient says no, we leave the room." When asked if she would expect her staff to enter a patient room to share that the workman comp might not pay for the treatment before a physician has completed an exam, she stated, "I don't do it and I don't encourage it to be done because the patient could perceive it as a money problem...I don't want them talking about the bill or money before they see a physician..."

On 9/28/11 at 1:55 PM, RN #1 was interviewed via phone about the above incident. He stated he remembered parts of the case because the patient's wife was upset that his work would not do anything about the injury. He further stated, "While he [patient] was in triage, I asked him if it was work related because some employers require certain tests. I remember [Registration Clerk #2] opened the window to triage and said she had spoken to employer and they wanted patient to come see their doctor not our E.R. The wife said we will stay to be treated. I finished triage and put him in a room. Typically, if stable I won't see them again for an hour. I remember seeing them in the hallway and the wife was upset saying, we're going where someone will take care of him. He was upset saying I'll get treatment even if work won't pay for it."

3. Medical record review for patient #13 documented the patient presented to the ED on 9/16/11 at 2357 and was triaged at 0006 for elevated blood pressure. The patient's blood pressure in triage was 223/86. The patient was placed in a room at 0015 and was reassessed at 0122 but no blood pressure reading done at that time. The patient was noted to be "...RESTING QUIETLY ON STRETCHER. HUSBAND AT BEDSIDE..." At 0125 the patient was noted to ambulate to the restroom independently. Documentation at 0145 revealed, "Patient left the department or not found in room on 9/17/11 at 01:45. Patient disposition is LWOT [Left With Out Treatment]." The medical record further documented "...Vital signs taken 01:45 were:...BP 189/082..." The physician was notified at 01:45 of the patient leaving without treatment.
Further review of the ED record revealed a copy of a Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment form. The form states under "1. Assignment of Insurance Benefits/Promise to Pay:...I understand that I am obligated to pay the account of the Facility in accordance with the regular rates and terms of the Facility. If I fail to make payment when due and the account becomes delinquent or is turned over to a collection agency or an attorney for collection, I agree to pay all collection agency fees, court costs and attorney's fee. I also agree that any patient or guarantor overpayments on the above Facility visit may be applied directly to any delinquent account for which I or my guarantor is legally responsible at the the time of the collection of the overpayment..." The form was signed and dated by the patient on 9/17/11 at 12:00 AM before the patient was triaged at 0006.

This 73 year old patient remained in the ED from 0006 to 01:45 AM without receiving any treatment, delayed in receiving an MSE or having her blood pressure monitored.

During an interview in the administration conference room on 9/28/11 at 3:40 PM, the CNO (Chief Nursing Officer) verified all forms were signed prior to the patient receiving an MSE.