EMTALA in Iowa

Excerpted from a Des Moines Register article:

"Hospital accused after boy loses fingers"

In a rare move, the federal government has threatened to pull Medicare funding from a Cedar Rapids hospital accused of denying care to emergency-room patients who were uninsured.

The Iowa Department of Inspections and Appeals began investigating Mercy Medical Center earlier this year in response to a complaint that an uninsured child was denied emergency care and subsequently had two of his fingers amputated.

The case involving the child began the night of Jan. 29, when the youth's grandparents took him to Mercy's emergency room for treatment of two seriously injured fingers. Under federal regulations, Mercy was required to either assess the injury and provide appropriate treatment or stabilize the child and transfer him to another hospital for treatment. But after the child's grandparents informed the staff that they were uninsured, the staff allegedly bandaged the injured fingers and sent the family home with no surgical consultation.

About an hour after the family arrived home, the grandparents noticed the fingers hadn't stopped bleeding. The family returned to the emergency room, where the child's fingers were rebandaged, but again there was no surgical consultation. Eventually, the family took the child to University Hospitals in Iowa City, where the two injured fingers had to be amputated.

A few days before that incident, a different patient had come to Mercy's emergency room complaining of pain and swelling in his jaw. A nurse diagnosed an abscess, indicating an infection in the jaw.

The oral surgeon who was on call at the time allegedly refused to come to the emergency room and see the patient and asked that he be transferred to a different hospital for treatment. At the time, the emergency room's written schedule of on-call doctors allegedly stated "No trauma calls" for that particular surgeon.

In March, the state inspections department completed its investigation of the two incidents and referred its findings to the federal Centers for Medicare and Medicaid Services. The federal agency concluded that there was an immediate and serious threat to the health and safety of Mercy's emergency-room patients and, on May 18, it threatened to cut off Medicare funding for the hospital. Within a week, the hospital implemented a formal plan of correction.

Last week, federal officials determined that the threat to patient safety no longer existed. To verify ongoing compliance with federal regulations, a state inspection of the hospital will take place sometime before Aug. 16.

In the meantime, the Centers for Medicare and Medicaid Services is referring the matter to its Office of Inspector General , which has the ability to impose civil fines against hospitals for violating federal health care regulations. The agency also is referring the case to its Office for Civil Rights , which investigates allegations of illegal refusal of health care services.

David Werning, spokesman for the inspections department, said that so far this year there have been five investigations into denial of emergency care at Iowa hospitals. All five have resulted in federal officials threatening to shut off Medicare funding because of regulatory violations. In each case, the hospitals submitted plans of correction that resulted in them keeping their Medicare funding.

Werning said the Mercy case is unusual in that it involved two instances of denial of care for physical injuries, as opposed to the more common complaint of denial of psychiatric services. Also, he said, the decision by authorities to verify compliance through another inspection this summer underscores the serious nature of the matter.

"The Centers for Medicare and Medicaid Services wants to be very sure that their message has been received by Mercy Medical Center," Werning said.