1. On the days of the Emergency Medical Treatment And Labor Act(EMTALA) survey based on review of patient medical records, registration slips, review of the hospital's emergency department policies and procedures related to EMTALA, and review employee personnel, and competency files, and interviews, the hospital failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for a patient presenting to the hospital's emergency department with a high fever, listlessness, and congestion for 1 of 21 sampled patients. (Patient #21). Refer to tag A-2406. 2. Based on record review, review of hospital policies and procedures, and interviews, the hospital failed to ensure that stabilizing treatment was provided that was within the capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition for 1 (#21) of 21 sampled patients. Refer to Tag A-2407. 3. Based on reviews of registration forms, hospital policies and procedures, and interviews, the hospital failed to ensure its policies and procedures related to registration processes were adhered to as evidenced by delaying treatment by not providing an appropriate medical screening examination and further medical examination and treatment as required in order to inquire about an individual 's method of payment or insurance status for 1 of 21 sampled patients. As this resulted in the delay of an appropriate medical screening examination and stabilizing treatment of a minor patient who had to travel to another hospital approximately 62 miles away to receive necessary medical treatment. Refer to findings in Tag 2408.

Based on reviews of the Emergency Department log (Control Log), review of hospital policies and procedures , and interview, the hospital failed to ensure a central log was maintained on each individual who " comes to the emergency department " seeking assistance and whether he or she refused , was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred , or discharged for 1 (#21) of 21 sampled patients presenting to the emergency room . The findings are: Hospital policy #A 20, titled, Emergency Department Log(Control Register), effective date 5/05, revised dates 9/09 and 5/12, reads, "An Emergency Department Log (Control Register) is maintained on a continuous basis through Medhoast and does include the following information on each individual seeking care or those individuals dead on arrival: A. Date B. Name C. Number D. Presentation Time E. Sex F. DOB (Date of Birth) G. Acuity H. Triage Time I. Primary Nursing Assessment Time J. PCP K. Chief Complaint L. Diagnosis M. Disposition N. Disposition Time O. Examination P. LOS Q. Services Purpose: To maintain an Emergency Log on a continuous basis. On 3/17/2015 at 2:30 p.m., review of a hand written registration form revealed Patient #21, accompanied by the parents, presented to the hospital's emergency department on 12/26/2014 at 11:55 p.m. with a chief complaint of breathing, fever, cough, and vomiting. The patient's date of birth was listed as 08/20/2013. Review of the hospital's emergency department log dated 12/25/2014 through 12/27/2014 revealed Patient #21 had not been captured on the hospital's emergency department log. On 3/17/2014 at 2:30 p.m., the finding was verified by the hospital's Compliance Officer.

On the days of the Emergency Medical Treatment And Labor Act(EMTALA) survey based on review of patient medical records, registration slips, review of the hospital's emergency department policies and procedures related to EMTALA, and review employee personnel files files and competency files, and interviews, the hospital failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for a patient presenting to the hospital's emergency department with a high fever, listlessness, and congestion for 1 of 21 sampled patients. (Patient #21) The findings include: Hospital policy, titled, The Emergency Department Registration and Collections Policy, effective date, 07/01/2009, reads, Purpose: To provide minimum standard procedures, consistent with the Emergency Medical Treatment and Active Labor Act ("EMTALA"), for registering and obtaining payment from patients who present through the Emergency Department." "Policy: It is the policy that Chester Regional medical center will follow reasonable registration procedures as permitted by EMTALA. Our facility may not delay stabilizing treatment to inquire about a patient's methods of payment or insurance status. Even if it causes no delay, the hospital may not contact the insurance plan for verification or authorization until after it has provided a medical screening examination. Otherwise, reasonable registration processes are appropriate and may include requesting basic patient demographic information as long as these processes do not delay screening or treatment." "Procedure: When a patient arrives to the ED for emergency room treat[sic], the following steps are followed: 1. The patient will tell the registration clerk they are seeking emergency care. Neither the MSE (Medical Screening Exam) nor stabilizing treatment may be delayed in order to inquire about the patient's photo identification. The registration clerk will ask the patient to sign in with their name, complaint and provide a driver's license or other photo identification to verify name and date of birth to ensure that the correct patient is selected from facility Master Patient Index. 2. Once this information is obtained, registration clerk will enter the patient's information into the MedHost system. This allows the ED staff know that the patient is here and chief complaint. Hospital policy, titled, EMTALA Guidelines, effective date 07/09 and revised 08/09, reads, "Purpose, To ensure that all patients receive an appropriate medical screening examination regardless of their age, sex, race, ethnic origin, or ability to pay for services. Procedure: 1. All patients presenting to Chester Regional Medical Center for a non - scheduled visit and seeking care must be accepted and evaluated regardless of the patient's ability to pay. 2. All patients shall receive a medical screening by a physician, nurse practitioner, or physician's assistant. The medical screening exams completed by a nurse practitioner or physician's assistant will be done under the indirect or direct supervision of a physician. The medical screening shall include provision of all necessary testing and on -call services within the capability of the Hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician's office or clinic. ...." On 3/18/2015 at 4:10 p.m., an interview was conducted with the family member of the patient(Patient 21) identified in the allegation. Family Member 1 reported that her family had just moved to area from out of state when her [AGE] year old son(Patient 21) became ill. Family Member 1 stated that their insurance was Medicaid from the state in which the family had been residing prior to their relocation to South Carolina. Family Member 1 stated that she completed the registration form for her son, and the lady at the desk asked for her identification and insurance card. Family Member 1 stated that when she gave the insurance card to the lady at the registration desk, the lady at the registration desk stated that she couldn't see the doctor because the hospital didn't take that insurance and that she would have to pay to see the doctor. Family Member 1 stated that she told the lady at the registration desk that she couldn't pay and asked where else they might go. Family Member 1 further stated that she and her husband proceeded to take their son to another hospital(Hospital A) some distance away because it was the only hospital that they knew about. Family Member 1 stated that when they arrived to the hospital (Hospital A), their son had a fever of 105 degrees and was immediately taken into the emergency department treatment area where the patient received intravenous fluids, intravenous medications, and medication for fever. The medical record for Patient #21 from another acute care hospital (Hospital A) was reviewed. Review of the medical record revealed that Patient #21 presented to Hospital A ' s ED(Emergency Department) on 12/27/2014 at 1:41 a.m. The patient acuity was (triage- the process of deciding which patient should be treated first based on how sick or seriously injured) was listed as " emergent. " The ED physician documented in part, History: Chief Complaint: patient presents with Shortness of breath ...fever emesis ...Pt(Patient) is a [AGE] year old male. The history provided by the mother and father ...Fever: This is an acute problem ... the symptoms are worsening ...He has been less active. He has been eating less than usual. Urine output has decreased ...coughing congestion, pulling at the affected ear and rhinorrhea, Physical Exam: Initial ED Vital Signs: Heart rate: 186 Temp 105 F (40.6 C(Centigrade)) (Normal Temperature 98 F/37 C) Resp (respirations) 24 Sp02(Oxygen Saturation Level) 94%(percent) ...HENT (Head Eye Nose Throat) ...Bilateral TM ' s ( Tympanic Membranes-ear drum) slightly red and dull ...Pulmonary/Chest:...Occasional congested chest ... " . Further review of the medical record revealed the ED Physician ordered that an intravenous line (IV) and a bolus of Normal Saline was given. Blood work was ordered and drawn for laboratory studies. Medications were administered for the fever, vomiting, and IV (intravenous)antibiotics for infection were also administered. Patient #21 diagnoses were listed as fever, Acute Bronchitis, Bilateral Otitis Media (ear infection), and Nausea and vomiting. The patient was subsequently discharged home with his parents. On 3/17/2015 at 2:00 p.m., the Director of the Emergency Department stated that she had been notified on 12/27/2014 that a family had called to report that they had been turned away from the hospital's emergency room on [DATE] because they were told by the lady at the registration desk that they would have to pay. On 3/17/2015 at 2:15 p.m., Registration Clerk 1 verified that she was the only registration clerk on duty in the hospital's emergency department on 12/26/2014 on the 7 p.m. shift to a.m. on 12/27/2014 when a little boy was brought to the emergency department by his parents. Registration Clerk 1 stated that the emergency department was not real busy that shift so she was in the back treatment area of the emergency department when they arrived. Registration Clerk 1 stated that when she returned to the registration desk, she saw a lady, her husband, and a little boy. Registration Clerk 1 reported that the registration form, a driver's license, and an out of state Medicaid card had been laid in the window. Registration Clerk 1 stated that she noticed the Medicaid card was out of state, but she could not recall which state it was. Registration Clerk 1 stated that she handed the Medicaid card back to the lady and stated that the Medicaid care from that state was not in the hospital's network, and she would probably have to pay. Registration Clerk 1 reported that she told the lady that "we will treat him, but you will probably have to pay." Registration Clerk 1 stated the lady said, "I can't pay. Is there anyone else who would take the card." Registration Clerk 1 stated that she told the lady that maybe someone in Rock Hill would take it and maybe that an Urgent Care in Rock Hill would take the out of state Medicaid insurance. Registration Clerk 1 failed to follow the hospital's own policies and procedures for registering patients who present to the emergency department seeking medical care. Registration Clerk 1's deviation from following the hospital's emergency department registration policies and procedures resulted in the patient leaving the hospital without receiving triage or a medical screening examination to determine whether or not an emergency medical condition existed for Patient 21 on 12/26/2014. Review of Registration Clerk 1's personnel file revealed that the registration clerk had not received EMTALA training since the registration clerk's transfer to this hospital from another hospital. Review of the personnel file of the 5 remaining emergency department registration clerks revealed that EMTALA training had been sporadic prior to December 2014, but all registration clerks had been educated on EMTALA after 12/26/2014.

Based on record review, review of hospital policies and procedures, and interviews, the hospital failed to ensure that stabilizing treatment was provided that was within the capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition for 1 (#21) of 21 sampled patients. The findings are: Hospital policy, titled, The Emergency Department Registration and Collections Policy, effective date, 07/01/2009, reads, Purpose: To provide minimum standard procedures, consistent with the Emergency Medical Treatment and Active Labor Act ("EMTALA"), for registering and obtaining payment from patients who present through the Emergency Department." "Policy: It is the policy that Chester Regional medical center will follow reasonable registration procedures as permitted by EMTALA. Our facility may not delay stabilizing treatment to inquire about a patient's methods of payment or insurance status. Even if it causes no delay, the hospital may not contact the insurance plan for verification or authorization until after it has provided a medical screening examination. Otherwise, reasonable registration processes are appropriate and may include requesting basic patient demographic information as long as these processes do not delay screening or treatment." The hospital failed to adhere to their own policies and procedures as evidenced by failing to ensure that stabilizing treatment was provided for Patient #21 on 12/26/2014 that was within the capabilities of the staff and facilities available at the hospital to provide further medical examination and treatment as required to stabilize the medical condition. Cross Reference to A 2406: The hospital failed to triage and failed to provide an appropriate medical screening examination and stabilizing treatment to a patient presenting to the hospital's emergency department with a high fever, listlessness, and congestion who left the hospital's emergency department when informed by the hospital's registration clerk that the hospital would would not accept the patient's insurance and the patient would have to pay for the services for 1 of 21 sampled patients. (Patient 21)

Based on record review of registration forms, hospital policies and procedures, and interviews, the hospital failed to ensure its own policies and procedures related to its registration processes were adhered to as evidenced by delaying treatment by not providing an appropriate medical screening examination and further medical examination and treatment as required in order to inquire about an individual's method of payment or insurance status for 1 of 21 sampled patients. This resulted in the delay of an appropriate medical screening examination and stabilizing treatment of a minor patient who had to travel to another hospital which was approximately 62 miles away to receive the necessary medical treatment. The findings are: Hospital policy, titled, The Emergency Department Registration and Collections Policy, effective date, 07/01/2009, reads, Purpose: To provide minimum standard procedures, consistent with the Emergency Medical Treatment and Active Labor Act ("EMTALA"), for registering and obtaining payment from patients who present through the Emergency Department." "Policy: It is the policy that Chester Regional medical center will follow reasonable registration procedures as permitted by EMTALA. Our facility may not delay stabilizing treatment to inquire about a patient's methods of payment or insurance status. Even if it causes no delay, the hospital may not contact the insurance plan for verification or authorization until after it has provided a medical screening examination. Otherwise, reasonable registration processes are appropriate and may include requesting basic patient demographic information as long as these processes do not delay screening or treatment." "Procedure: When a patient arrives to the ED for emergency room treat[sic], the following steps are followed: 1. The patient will tell the registration clerk they are seeking emergency care. Neither the MSE (Medical Screening Exam) nor stabilizing treatment may be delayed in order to inquire about the patient's photo identification. The registration clerk will ask the patient to sign in with their name, complaint and provide a driver's license or other photo identification to verify name and date of birth to ensure that the correct patient is selected from facility Master Patient Index. 2. Once this information is obtained, registration clerk will enter the patient's information into the MedHost system. This allows the ED staff know that the patient is here and chief complaint. This information is shown on the master ED MedHost monitor at ED nurses station. 3. Once patient is created in MedHost, patient accounting information is registered into PULSE, our registration software. An account is created with forms such as patient rights and responsibilities,consent to treat, ....etc." On 3/17/2015 at 2:30 p.m., review of a hand written registration form revealed Patient 21, accompanied by the parents, presented to the hospital's emergency department on 12/26/2014 at 11:55 p.m. with a chief complaint of breathing, fever, cough, and vomiting. The patient's date of birth was listed as 08/20/2013. On 3/17/2014 at 2:30 p.m., the finding was verified by the hospital's Compliance Officer. On 3/18/2015 at 4:10 p.m., an interview was conducted with the family member of the patient(Patient 21) identified in the allegation. Family Member 1 stated that when she gave the insurance card to the lady at the registration desk, the lady at the registration stated that she couldn't see the doctor because the hospital didn't take that insurance and that she would have to pay to see the doctor. Family Member 1 stated that she told the lady that she couldn't pay and asked where else they might go. Family Member 1 stated that the lady at the registration desk told her there was an Urgent Care in Rock Hill. Family Member 1 stated that the lady at the registration desk called into the back of the emergency department to ask what the name of the Urgent Care was and someone responded. Family Member 1 stated that they proceeded to take their son to another hospital(Hospital A) some distance away because it was the only hospital that they knew. Family Member 1 stated that when they arrived to the hospital(Hospital A), their son had a fever of 105 degrees and was immediately taken into the emergency department treatment area where the patient received intravenous fluids, intravenous medications, and medication for fever. On 3/17/2015 at 2:00 p.m., the Director of the Emergency Department stated that she had been notified on 12/27/2014 that a family had called to report that they had been turned away from the hospital's emergency room on [DATE] because they were told by the lady at the registration desk that they would have to pay. The Emergency Department Director stated that she recognized the seriousness of the allegation and had reported the allegation up the hospital's chain of command. The Emergency Department Director stated that the registration clerks in the Emergency Department are under the Patient Access Manager's supervision. On 3/17/2015 at 12:15 p.m., an interview was conducted with Registration Clerk 1. Registration Clerk 1 stated that the emergency department was not real busy that shift so she was in the back treatment area when they arrived (Patient #21 and family). Registration Clerk 1 stated that when she returned to the registration desk, she saw a lady, her husband, and a little boy. Registration Clerk 1 reported that the registration form, a driver's license, and an out of state Medicaid card had been laid in the window. Registration Clerk 1 stated that she noticed the Medicaid card was out of state, but she could not recall which state it was. Registration Clerk 1 stated that she handed the Medicaid card back to the lady and stated that the Medicaid care from that state was not in the hospital's network and she would probably have to pay. Registration Clerk reported that she told the lady that "we will treat him, but you will probably have to pay." Registration Clerk 1 stated the lady said, "I can't pay. Is there anyone else who would take the card." Registration Clerk 1 stated that she told the lady that maybe someone in Rock Hill would take it and maybe that an Urgent Care in Rock Hill would take the out of state Medicaid insurance. Registration Clerk 1 stated that she asked the nurses , who were back in the emergency department treatment area, if they knew the name of that Urgent Care in Rock Hill, and then she told the lady the name of the Urgent Care. Registration Clerk 1 stated the lady said, "I will just go to Rock Hill then." Registration Clerk 1 verified that she had worked as a registration clerk for approximately twenty five years prior to coming to this hospital three years ago. Registration Clerk 1 stated, "I knew better." The facility failed to ensure that their own policies and procedures were followed as evidenced by failing to ensure that an appropriate medical screening examination and stabilizing treatment was provided for Patient #21 on 12/26/2014 regardless of the patient ' s ability to pay for services.