COBRA nightmares: Don’t let this happen to you

What to expect when your facility is investigated after a complaint

There’s no denying that a routine review can quickly turn into a bureaucratic nightmare. ED Nursing spoke with several ED nurses who reported the unpleasant realities of a COBRA investigation. When patient charts and procedures are put under the microscope, it can have a devastating effect on ED operations.

"Usually a minimum of three investigators will turn up in the ED unannounced, and say, Notify your CEO that we’re here," reports Stephen A. Frew, a Rockford, IL-based health care attorney and consultant. ED logs, policies and procedures, medical staff credentialing files, minutes of meetings, and medical staff bylaws may also be pulled. "Once the whole huge stack is assembled, [the reviewers] go behind closed doors to identify the things they want to ask more questions about," he says.

The nurse manager of the ED will field questions about operations. "They generally try to accumulate as much information as they can, while giving you no indication of exactly what they’re looking for," says Frew. "During the exit briefing, you may get a clue, but knowing that does you very little good because they’ve probably found a dozen other things by that time."

Next, the ED will receive a citation for violations. ED personnel are given 23 days to completely correct any deficiencies—a tall order. If investigators don’t feel you’ve done enough to correct the problem on their return visit check, things get worse. "I’ve seen hospitals who have flunked two return visits and it’s not pleasant—it’s more like Dante’s Inferno," says Frew.

When reviews don’t go well, the financial cost can be astronomical. Although nurses cannot be held individually liable for COBRA violations, the facility can be fined up to $50,000 per violation. Still, the steep fines pale in comparison to the cost of correcting the problem. After a lengthy investigation, one 400-bed hospital was out of pocket $1.9 million, Frew reports. Sources interviewed by ED Nursing described hiring expensive consultants, weekend marathons of developing new policies and corrective actions, and hiring extra staff to review piles of charts.

A COBRA investigation is also a PR nightmare. Typical headlines may read, "Hospital in Violation of Federal Law," and "Care Denied Patients." "One hospital being investigated had front page stories for 11 consecutive days," notes Frew. As if that weren’t bad enough, the federal government may post a notice in the local newspaper that suggests the hospital constitutes a danger to the public.