Based on medical record review, document review, and patient and staff interviews, the hospital failed to provide without delay, further examination and treatment to patients # 1, 3, and 5 and arranged to transfer the patients when the benefits did not outweigh the risks after determining the three patients had out of network insurance.
Based on medical record review, document review, and patient and staff interviews, the hospital failed to provide without delay, further examination and treatment to patients # 1, 3, and 5 and arranged to transfer the patients when the benefits did not outweigh the risks after determining the three patients had out of network insurance. The hospital's practice of initiating discussions regarding insurance and payment with the three patients delayed further examination and stabilizing treatment of their emergency medical conditions out of 22 records sampled from May to July 2016. This practice had the potential to delay the care and stabilizing treatment of any individual with an emergency medical condition who presented to the ED seeking care.
Findings include:
OPRMC staff updated the Medicare Hospital/Critical Access Hospital Database worksheet on 8/1/16 revealing the hospital offered the following services: 12 Operating Rooms, 4 Cardiac Catheterization Procedure Rooms, Anesthesia Service, Cardiac Catheterization Laboratory, Cardiac-Thoracic Surgery, CT Scanner, Dedicated Emergency Department, Cardiac, Medical/Surgical, Surgical Intensive Care Units, Magnetic Resonance Imaging (MRI), Neurosurgery Services, Nuclear Medicine Services, Orthopedic Surgery, Post-operative Recovery Rooms, Diagnostic and Therapeutic Radiology Services, Respiratory Care Services, and Inpatient and Outpatient Surgery Surgical Services.
The Multi-Specialty Emergency on-Call Schedule for July - September 2016 revealed the week of July 4 -July 11, 2016 Surgeon Staff L was listed as first call for the General Surgery service, Surgeon Staff M on second call for General Surgery, Physician Staff Q on call for Cardiology and Physician Staff R on call for Interventional Cardiology. The week of July 18-25, 2016 Surgeon Staff P was first call for General Surgery and Surgeon Staff M on second call for General Surgery.
Review of Patient #1's medical record revealed she presented to the emergency department (ED) on 07/09/16 at 9:51 am complaining of sharp right lower quadrant abdominal pain that started two days prior with nausea, vomiting, and diarrhea. Physician Assistant (PA) A documented the patient's abdomen was "exquisitely tender" in the right lower quadrant. At 9:58 am lab tests showed patient # 1's white blood cell count (blood cells that fight infection) was elevated to 23.8 (normal is 4.1 - 11.1). At 10:30 am patient # 1 received intravenous (IV) medication for pain control and IV fluids for hydration. At 11:15 am a CT scan (special type of x-ray) of the patient's abdomen showed findings consistent with acute appendicitis (the appendix is a small appendage of the colon and when blocked with stool, bacteria invade and infection develops. If untreated, the appendix can rupture and cause a life threatening infection).
At 12:10 pm, PA A documented a decision to transfer patient # 1. Further documentation by PA A indicated "The hospital is out of network for her." "In light of this, she is requesting transfer to [Hospital B]." At 12:40 pm the surgeon at Hospital B accepted PA A's transfer request. At 1:00 pm, patient # 1 received an IV antibiotic and the ED nurse documented "Ready to Transfer."
Review of the transfer form indicated patient # 1 had an emergency medical condition "Acute appendicitis." The reason for transfer per documentation on the transfer form was "Patient Requested," but patient # 1 did not sign the form indicating she had requested the transfer. The medical risks and benefits noted for transfer indicated "insurance reasons" per PA A's handwritting and "Deterioration of condition in route" per check mark. The medical benefits of transfer did not outweigh the risks to the patient's health and well being. The mode of transport noted was Advanced Life Support ambulance per check mark. PA A signed the transfer form on 7/9/16 at 1:15 pm. At 2:10 pm, the ED nurse noted patient # 1 "Departed", approximately 4 1/2 hours after arriving at OPRMC requesting care for an emergency medical condition.
Review of Hospital B's medical record showed that patient # 1 arrived at its hospital at 2:45 pm. Two hours and 15 minutes later, patient # 1 was taken to Hospital B's operating room for an emergent appendectomy which concluded at 6:28 pm, nearly 8 1/2 hours after initially presenting to OPRMC with acute appendicitis, a surgical emergency medical condition.
In an interview at 10:05 am on 8/2/16, OPRMC Physician C stated "Patient access informed patient # 1 she was out-of-network." Physician C confirmed he had received education on EMTALA. When asked if OPRMC had the capability to provide care to patient # 1, he stated "other than insurance issues we were capable of caring for her here."
In a document provided by Hospital B on 8/3/16, the transfer nurse was told by a representative from the call center at OPRMC that patient # 1 was told her ED visit would be covered but not the surgery because OPRM was out-of-network (OON) and that was why the patient agreed to be transferred. The document indicated PA A stated that "the patient did not want to be transferred but only agreed because of the fact that she is OON at OPRMC and was told that surgery would not be covered."
In an interview on 8/2/2016 at 1:45 p.m., the Patient Access Manager was asked about the admission process at OPRMC. The Patient Access Manager stated that Registration Staff go in to the patient's area and obtain insurance information from the patient or the patient's family member and they check it with the insurance company. If the insurance is out of network they inform the ED staff and physician."
In an interview on 8/2/16 at 11:30 am, the Director of the Emergency Department stated that "out of network" should be documented as "a patient request" not OON. The Director stated that the OPRMC has had multiple grievances related to billing." "The hospital tries to be more proactive in letting patient's know that their insurance will or won't cover costs."
In an interview on 8/2/16 at 1:30 pm OPRMC Physician F stated there had been "numerous conversations regarding this matter of 'out of network' insurance for patients." "If the patient requires admission and is out of network we tell them we will admit and treat, or transfer and find a hospital in network and let them choose."
In an interview on at 11:55 am, ED registered nurse D stated she "thought patient # 1 was going to stay." "The patient asked for assistance from staff about whether to stay or transfer to another hospital." "Registration was sent back in to talk with the patient to make a transfer decision."
In an interview on 8/3/16 at 10:30 am, PA A stated that patient # 1 presented with abdominal pain and was diagnosed with appendicitis. "The admission/registration clerk informed PA A that [patient # 1] was OON." PA A stated that the patient "didn't know why the appendectomy could not be performed at OPRMC." "PA A stated, "since this happened, I saw an e-mail, we as providers, we will not talk to patients (about their insurance status), the registration staff will handle these issues."
Review of the medical record revealed patient # 5, a [AGE] year old female (MDS) dated [DATE] at 11:17 am complaining of chest tightness, shortness of breath, sweating, and jaw pain (warning signs of a heart attack) that began at 10:00 am on 7/10/16. Documentation by Advanced Practice Registered Nurse (APRN) O indicated the patient reported "she is having 'a little bit of chest pain currently'." At 11:50 am, lab testing showed the patient had a normal Troponin level (troponins are proteins in the blood released when the heart muscle has been damaged and are measured by blood testing that is repeated two more times over the next 6 to 24 hours following signs of a heart attack). At 12:06 pm, patient # 5 received nitroglycerin and aspirin.
At 1:15 pm, APRN O documented that "I discussed with the patient admission to the hospital for her chest pain with further evaluation with the cardiologist." "Patient agrees to admission however her insurance does not cover her admission to this hospital, patient requests transfer to [Hospital B] for further treatment and inpatient care." At 1:40 pm the OPRMC transfer center contacted Hospital B. At 2:33 pm, the physician at Hospital B accepted APRN O's transfer request.
Review of the transfer form indicated Patient # 5's emergency medical condition (EMC) Diagnosis was "Chest Pain." The Medical Benefits of transfer was check marked "Other" and in handwriting "patient request." The Medical Risks boxes checked were "Deterioration of condition in route", "Risk of trafffic delay/accident resulting in condition deterioration or death" and "Other" without any written explanation.
The section of the transfer form indicating the patient's consent to transfer was check marked and read "I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer." "I have been informed of the risks and benefits of this transfer." The box indicating "the patient requested the transfer" was not checked and the reason "the patient requested transfer" was blank. Documentation by the ED nurse indicated patient # 5 left the hospital by an ambulance equipped with advanced life support at 3:59 pm.
The evidence in patient # 5's medical record does not support the medical benefits of transfer outweighed the risks. The hospital's capabilities included an on-call cardiologist and additional testing of the patient's troponin levels. Nearly 4 1/2 hours after presenting to the ED at 11:17 am, the hospital transferred patient # 5 delaying further examinaton and stabilizing treatment based on Patient # 5's insurance.
During a phone interview on 8/3/2016 at 2:30 pm, patient # 5 stated the hospital notified me that my insurance would not cover hospitalization at this hospital. Patient #5 stated she could not afford the out of pocket costs and agreed to be transferred to another hospital for care where the insurance would cover costs.
Review of the medical record revealed Patient #3 (MDS) dated [DATE] at 4:06 pm complaining of abdominal pain which began yesterday morning, 7/20/16. Documentation in the medical record indicated patient # 3 stated his pain was located in the right upper part of his abdomen. Further documentation showed his pain worsened with food and drink. "Pain is dull and mild but constant." The patient did have some nausea and vomiting and mild constipation. At 4:18 pm, lab testing revealed patient # 3 had an elevated white blood cell count of 18.7 (normal is 4.1 - 11.1), and an elevated bilirubin level 2.2 (normal is 0.0 - 1.0), (bilirubin testing is part of a group of tests to check the health of the liver).
At 5:05 pm, a CT scan (special type of x-ray) of patient # 3's abdomen/pelvis revealed multiple dilated small bowel loops with evidence of at least a partial distal small bowel obstruction (condition in which digested material is prevented from passing normally through the bowel), related...likely to a stone within the distal ileum. At 5:30 pm, the radiologist notified ED physician F of a critical result, pneumobilia (abnormal accumulation of air around the liver, gallbladder and pancreas from a puncture or perforation) and a gallstone ileus (obstruction of the bowel due to one or more gallstones).
ED physician F documented that "According to patient's insurance patient is out of network for this hospital so patient will be transferred to Hospital C at his request." "This is what significantly delayed his disposition." At 6:30 pm, ED physician F documented the patient's disposition decision was "Transfer", reason "out of network here."
Review of the transfer form indicated the medical benefits of transfer were "Insurance related purposes." The medical risks of transfer were "Deterioration of condition in route" and "Risk of traffic delay/accident resulting in condition deterioration or death." The section of the transfer form indicating "patient consent for transfer" read as indicated by a check mark "I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer." "I have been informed of the risks and benefits of this transfer."
The box on the transfer form indicating "the patient requested the transfer" including the statement "I make this request upon my own suggestion and not that of the hospital, physician or anyone associated with the hospital" was not checked. The space on the transfer form for the patient to document the reason(s) they requested the transfer was blank.
At 9:56 pm, a delay of 6 hours after patient # 3 presented to the ED with an emergency medical condition, the patient was transferred to Hospital C for stabilizing treatment when the medical benefits of transfer did not outweigh the risks.