The University of Chicago Medical Center

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 50411 Based on document review and interview, it was determined that for 1 of 5 patients (Pts. #2) inbound emergency transfer records reviewed, the hospital failed to ensure that the acceptance of emergent [emergency department (ED) to ED] transfer requests were not delayed in order to inquire about the individual’s method of payment or insurance status, as required. Findings include: 1. On 10/9/2024, the Hospital’s Transfer Center Training Manual/EMTALA Policy (Revised 9/2011) was reviewed. The training manual/EMTALA policy indicated, “ ... A. Transfers to [this Hospital] ... 2. If the transferring physician indicates that the patient is (a) medically unstable, (b) experiencing an emergency medical condition, and (c) that the patient requires the specialized capabilities of [this Hospital], the [Hospital’s] attending physician shall contact the transfer center. [This Hospital] may not refuse to accept from a transferring hospital an appropriate transfer of an individual with an unstabilized emergency medical condition who requires such specialized capabilities if [Hospital] has the capacity to treat the individual... If capacity is available, the transfer center shall make appropriate arrangements for transfer of the patient without inquiry into whether the patient has the financial resources to pay for such care... Transfer center protocol ... Transfer Center RN: Confirm location of patient ... Emergency department - EMTALA applies...” 2. On 10/9/2024, the transfer center at receiving hospital record for Pt. #2 from 7/29/2023 was reviewed. The record included, “Reason for transfer need for hand surgery evaluation, they have no hand surgery ...ICU [intensive care unit] level of care needed ... Referring Provider: [Physician at Referring Hospital Emergency Room] ...” The record indicated that the transfer request for Pt. #2 was made on 7/29/2023 at 9:16 AM and transfer type was selected as “Inpatient Transfer” for higher level of care, instead of an emergency or EMTALA transfer. The record indicated that 3 approvals were required including: Physician acceptance, financial approval, and capacity approval, as opposed to only requiring physician acceptance in emergent cases. The transfer center/notes at receiving hospital timeline documentation indicated the following: - “9:16 AM - Request began - ICU Level of care needed. - 9:38 AM - transfer type sent to Inpatient Transfer by [E#9 - Patient Logistics Nurse] - 9:40 AM - [MD#9 - Hand Surgeon] - paged plastics-hand - 9:42 AM - call from [MD#9] - if MICU [Medical Intensive Care Unit] accepts they will be happy to do an evaluation of the hand. But is concerned that there may be what is outwardly apparent. - 9:46 AM - Call from [MD#8 - Pulmonary/Critical Care Fellow] - 11:09 AM - call to [Transferring ED Physician] - Dr to Dr complete - entered by [E#9] - 11:12 AM - call from [MD#2-Intensivist/Attending Physician]. [MD#2] approved transfer for Medical Intensive Care Service - 7/31/2023 - 11:32 AM ... Per OPS (payor source), pt. is financially not admissible. Called to OSH [outside hospital] to notify, pt. expired.” 3. On 10/9/2024 at approximately 11:00 AM, the hospital provided an email from Pt. #2’s ED physician at transferring/outside hospital, dated 7/31/2023, which was addressed to the Director of Patient Logistics (E#8). The email included the following: “ ...Upon contacting the transfer center, I was initially told that as we have an ICU at [transferring hospital], the patient should be admitted to our ICU and then could be potentially transferred from there, which is highly atypical for the transfer process for a higher level of care. I explained that I felt this patient needed more emergent transfer particularly for surgical evaluation ... This response is unacceptable coming from someone who is not themselves a hand surgeon nor would in any way, shape or form be involved in this patient’s clinical care. I again emphasized the importance of surgical evaluation for this patient for potential source control of [Pt. #2’s] sepsis. I was eventually begrudgingly transferred to the ICU fellow who accepted the patient stating they would like [Pt. #2] prioritized for immediate transfer. When I stated I would start arranging transportation, the transfer center informed me that the patient could not be transferred until his insurance information had been run. This, as I’m sure you are aware, is a significant EMTALA violation. I called the transfer center back to attempt to explain the illegality of delaying patient’s transfer due to insurance reasons, only to be told that the patient was not yet accepted. This confused me as I had just spoken with an accepting physician. I was then told that no ICU beds were available ...” 4. The clinical record for Pt. #2 from the transferring hospital was reviewed on 10/9/2024. The record indicated that on 7/29/2023 at approximately 7:58 AM, Pt.#2 presented to the ED at [transferring hospital] for evaluation of shortness of breath. The record indicated that Pt.#2 had a wound to the left hand with some bone exposed. The record included a differential diagnosis of bacteremia [bacteria in the blood], septic shock and osteomyelitis [bone infection] of the left hand. A request to transfer Pt.#2 to the receiving hospital was made on 7/29/2023 by transferring hospital ED physician, and Pt #2 was accepted, but no ICU beds were available at that time. The clinical record did not indicate that Pt #2’s emergency medical condition was stabilized. Pt.#2 coded (required cardiopulmonary resuscitation - CPR) at 11:19 AM and again on 12:25 PM. Pt. #2 was pronounced dead/expired at 12:32 PM on 7/29/2023 in the ED. 5. On 10/9/2024, the personnel file of E#9 (Patient Logistics Nurse) was reviewed. E#9’s personnel file included an email dated 8/10/2023 at 3:03 PM, which indicated that the Manager of Patient Logistics (E#16) discussed with E#9 regarding follow up to a potential violation on 7/29/2023. The email included that when an outside hospital ED is asking for a higher level of care transfer, to not make it appear that an ED to ED transfer is pending insurance clearance, and that EMTALA transfers should be doctor to doctor. 6. An interview was conducted with the Medical Director of the Adult ED (MD#1) on 10/07/2024, at approximately 11:40 AM. MD#1 stated MD#1 stated that sometimes they receive transfer requests from other hospitals. MD#1 stated that if it is ED to ED, an ED physician will be the accepting physician, if it’s ED to inpatient or inpatient-to-inpatient transfer, the accepting physician will be the attending on the unit they are requesting transfer to. MD#1 stated that they pretty much accept most transfer requests since the Hospital has a lot of specialty services that other hospitals don’t have. MD#1 stated that they do not check for insurance when an ED-to-ED transfer is requested. 7. On 10/8/2024 at approximately 10:35 AM and on 10/9/2024 at approximately 10:11 AM, interviews were conducted with the Director of Patient Logistics (E#8). E#8 stated that when a transfer request comes in for an ED-to-ED transfer, no insurance verification is done. E#8 stated that when a patient is accepted but there is no bed availability, the patient is then placed on a holding list, which is typically updated daily. E#8 stated that in some instances, an ED-to-ED or ED-to-inpatient transfer is declined based on capacity, the transferring facility is then informed. E#8 stated that for inpatient transfers 3 approvals are required to be completed before a patient will be accepted which includes physician acceptance, financial (insurance) approval, and capacity approval. E#8 demonstrated on the computer that 3 icons that represent these approvals need to turn green for the patient to be accepted. E#8 stated that for emergent transfers [ED-to-ED], only the physician acceptance is required; financial approval is not required, and insurance verification is not done. E#8 stated that capacity approval means that the patient has been accepted but is awaiting bed availability. E#8 stated that E#8 does not recall any complaints/grievance filed in relation to the transfer of Pt. #2. E#8 stated that although Pt. #2’s transfer request was put in as an inpatient transfer, E#8 stated that insurance verification should not have been done. E#8 stated that Pt. #2’s case should have been marked or noted as an EMTALA transfer. 8. On 10/8/2024 at approximately 1:05 PM, an interview was conducted with the Patient Logistics RN (E#9). E#9 stated that no insurance verification is done for emergent cases. E#9 stated that Pt.#2 was from [transferring hospital] and was intubated, septic and on vasopressors (a class of drugs that constrict blood vessels to increase blood pressure in people with low blood pressure or shock). E#9 stated that Pt.#2 was accepted but there were no beds available at that time. E#9 stated that Pt. #2’s insurance was not verified. 9. An interview was conducted with the Director of Regulatory Compliance (E#1) on 10/09/2024, at approximately 11:00 AM. E#1 stated that they were just informed last night [10/08/2024] around 9:00 PM, that the Transfer Center had received an email on 07/31/2023 with a complaint from an ED physician from an outside hospital regarding the transfer request made for Pt. #2. E#1 stated that it was very detailed in explaining the conversation between the referring ED physician and the Transfer Center staff (identified as E#9). E#1 stated that they spoke with E#9 and the Director of Patient Logistics (E#8) last night regarding the email and based on their response, E#1 stated that it appeared that there was an EMTALA violation. E#1 stated that there was documentation in E#9’s personnel file indicating that there was a discussion between E#9 and the Manager (E#16) regarding the complaint which occurred shortly after receiving the email back in 2023; however, the concern was never escalated up to Risk or higher management. E#1 stated that based on the notes from their discussion, it seemed that there was an issue with insurance being mentioned. E#1 stated that for ED to ED transfers, insurance should not be reviewed or requested at all, and that the transfer request should have been accepted. E#1 stated that they will be doing a gap analysis (thorough review) of the transfer center process and at this time were not aware of any other incidents where insurance was asked for emergency transfers. On 10/10/2024, at approximately 11:00 AM, E#1 stated that in Pt. #2’s case, it was considered a “Just Say Yes” transfer, which means even if they didn’t have an ICU bed available at the time, they would have accepted the patient to transfer to the ED. E#1 stated that they should just let the referring hospital know that they have no beds at the time but can still send the patient to the ED. E#1 stated that typically they wouldn’t deny ED-to-ED transfers unless they were on bypass, which they were not at the time Pt. #2’s request came in.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 37971 Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for allegation of abuse, the hospital failed to follow-up on patient allegation of assault while in the emergency room, as required. Findings include: 1. On 01/16/2024 at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the ED (Emergency Department) with a chief complaint of chest pain on 12/17/2023, at 12:33 AM. Pt. #1’s clinical record included the following: -The ED Resident Physician (MD #1) medical decision-making note dated 12/17/2023 at 3:53 AM, included, “ ...During attending evaluation, patient was responding to internal stimuli...patient also had ideations regarding possible assault in the ER by staff despite, ER room doors and windows being completely open for the duration of (Pt. #1) stay in the ER room ...” -The ED Physician (MD #2) addendum to Pt. #1’s clinical record, dated 01/17/2024 at 10:49 AM, included, “ ... When I discussed this with (Pt. #1), the patient was evasive in answering the details of what took place and failed to provide any detail of the events and had no medical concerns following this (Pt. #1’s) thought process during my interview did seem scattered and tangential like there could be some underlying psychiatric component. (Pt. #1) did file a police report and spoke with CPD [Chicago Police Department] while in the department (ED).” 2. On 1/17/2024, the hospital’s policy titled, “Event Reporting” dated 06/2022, was reviewed and included, “ ...It is the policy ...that all medical staff members and employees shall notify the Risk Management and Patient Safety Department of any ...sexual abuse/assault of any patient while receiving care, treatment, and services while on site at the organization/facility or while under the supervision/care of the organization ...events to be reported to the Risk Management and Patient Safety Department ...accusation of abuse by a hospital employee, agent, or medical staff member on a patient of the hospital and should be reported immediately to the Risk Manager ...team will notify the regulatory compliance team ...with involved employee (s) interviews ...” 3. On 1/17/2024, the hospital’s policy titled, “Staff Interaction with Law Enforcement” dated 07/31/2023, was reviewed and included, “ ...This policy defines a cooperative process for maintaining patient centered care while assisting law enforcement officials perform their duties associated with the ...investigation of a patient ...B. Check in process: 1. Regardless of point of entry, all law enforcement will check in with security and be escorted to a unit or bay ...3. Law enforcement can follow ...into bays with medical staff approval ...5. If the patient consents to speak with law enforcement agents, access will be granted ...public safety will escort law enforcement to the appropriate unit/bay ...” 4. On 01/17/2024 at 9:10 AM, the UCPD [University of Chicago Police Department] report dated 12/17/2023 at 3:03 AM, that was a read-out by Deputy Chief (Z #1) included, “ ...Patient [Pt. #1] from ER [emergency room] ...911 call ...CAD [computer aided dispatch] Report ...Officer (Name of Officer) ...spoke with patient [Pt. #1] in ED Room #27 ...ER Technician [E #2] touched [Pt. #1’s] leg inappropriately ...while raising the guard rails moved the legs and nothing happened ...There was no crime or inappropriate touching during the moment.” 5. On 01/17/2024 at approximately 9:15 AM, the Deputy Chief of The University of Chicago Police Department (UCPD) (Z #1), was interviewed. Z #1 stated that there was a 911 call from the patient (Pt. #1) on 12/17/2023 at 3:03 AM, that was automatically responded by the UCPD. Z #1 stated that there was no crime that had occurred at that moment, and the allegation was not true, since the officer spoke with the ER Technician while in the ED. Z #1 stated that she does not have any documentation from the officer, indicating this allegation from Pt. #1 was reported to the ED Manager or to the Director of Risk Management. Z #1 stated that it was mentioned to the ED Charge Nurse (E #5) on-duty in the ED on 12/17/2023. 6. On 01/17/2024 at approximately 10:15 AM, the ED Charge RN (E #5) was interviewed. E #5 stated that she faintly remembers Pt. #1. E #5 stated that she (E #5) does not recall the details of the incident, but remembers the CPD (Chicago police department) talking with Pt. #1 as Pt. #1 was getting discharged and was leaving the ED. 7. On 01/17/2024 at approximately 1:30 PM, the Director of Regulatory Compliance (E #11) was interviewed. E #11 stated that the abuse or assault allegations are reviewed and reported on a weekly basis, but this incident regarding Pt. #1 was not brought to E #11’s attention since the UCPD took the 911-call and addressed it with Pt. #1. 8. On 01/17/2024 at approximately 1:40 PM, the Director of Risk Management (E #6), was interviewed. E #6 stated that as per the hospital’s policy titled, “Staff Interaction with Law Enforcement” the UCPD should have stopped by the public safety desk to report to the hospital’s public safety, documenting in the log, the specific reasons why they were in ED to see Pt. #1. E #6 stated that the UCPD and public safety staff failed to follow the policy and Pt. #1’s allegation of assault was not reviewed.”