Shelby Baptist Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46290 Based on Medical Record (MR) review, hospital policies and procedures, and staff interviews it was determined the hospital failed to: 1. Provide an appropriate Medical Screening Exam (MSE) within the capability of the hospital ‘s emergency department (ED) to determine whether or not an emergency medical condition (EMC) existed for all patients who presented for emergency services. 2. Ensure the patient consented to the transfer per the hospital policy. 3. Ensure the physician signed a certification the medical benefits expected from the transfer outweighed the risk of the transfer to the patient. This affected Patient Identifier (PI) # 7, one of five medical records reviewed who presented to the ED with a complaint of abdominal pain and vomiting, and had the potential to affect all patients who require emergency services at the hospital. Cross reference to A 2406 and A 2409 for findings.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 46290 Based on Medical Record (MR) review, and hospital policy and procedure review it was determined the hospital failed to provide an appropriate Medical Screening Exam (MSE) within the capability of the hospital’s emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition (EMC) existed for all patients who presented for emergency services. This deficient practice affected one of five MR’s reviewed including Patient Identifier (PI) # 7 who presented to the ED with complaints of 7 (seven) months pregnant, abdominal pain and vomiting, and had the potential to affect all patients served by the hospital’s ED. Findings include: Hospital Policy: Emergency Medical Treatment Labor Act of 1986 (EMTALA) Policy number: BBH CLN .04.01 Revised: 9/10/2024 Purpose: To ensure individuals presenting to the facility emergency department receive an appropriate Medical Screening Examination ... Procedure: A. The facility will provide an appropriate MSE within its capability to any individual coming to the hospital’s Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists. Review of the medical record revealed that PI # 7 presented to the Emergency Department (ED) on 3/14/26 at 2:32 PM with complaints of vomiting, fatigue, weakness, and lower abdominal pressure. Review of the nursing assessment dated 3/14/26 at 2:33 PM revealed PI # 7 was reportedly 7 months pregnant. There was no vaginal bleeding or leakage of fluid reported and had no diarrhea or urinary symptoms. Initial vital signs included a heart rate (HR) of 137 and a blood pressure (BP) of 96/52. Review of the ED provider notes dated 3/14/26 at 3:02 PM revealed the patient was actively vomiting and had tenderness across his/her lower abdomen. PI # 7 tested positive for influenza (a contagious respiratory illness caused by influenza that infect the nose throat, throat and lungs) had leukocytosis (high white blood cell count), and had 3+ ketones (acids your liver makes when it breaks down fat for energy instead of using glucose), small leukocytes, and few bacteria seen on their urinalysis. The Ultrasound of the abdomen showed no signs of appendicitis. The electrocardiogram (EKG) showed sinus tachycardia at a rate of 143 (normal pulse rate of 60-100). Fetal heart tones were measured at 147. Review of the vital sign reevaluation dated 3/14/26 at 6:00 PM revealed PI # 7 had a repeat BP of 91/48 and HR 124. Review of the MR revealed there was no documentation a transvaginal ultrasound (medical test that uses sound waves to create clear pictures of the uterus, ovaries, and other pelvic organs) cervical examination (physical examination of the lower part uterus (the cervix) performed by a healthcare provider to check for signs of labor) prior to transfer, blood cultures (laboratory test that checks the blood for bacteria or germs), and a computed tomography (CT Scan- medical imaging test that uses special x-ray equipment to make detailed pictures of the body ) and/or magnetic resonance imaging (MRI-medical imaging test that produces detailed images of almost every internal structure in human body) were performed to evaluate for sepsis (is the body’s extreme response to an infection), placental abruption (when the placenta detaches from the uterus during pregnancy, can cause abdominal bleeding and abdominal cramp) and ovarian torsion (abnormal condition where an ovary twists on its attachment to other structures, blood flow is decreased) as part of an MSE. As this resulted in an inappropriate MSE for patient #7 on 3/14/2026. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 46290 Based on Medical Record (MR) review, hospital policies and procedures, and staff interviews it was determined the hospital staff failed to ensure: 1. The patient consented to the transfer consent per the hospital policy. 2. The physician signed a certification the medical benefits expected from the transfer outweighed the risk of the transfer to the patient. This deficient practice affected one of four patients requiring a transfer to another hospital, including Patient Identifier (PI) # 7, and had the potential to affect all patients requiring a transfer from this hospital’s Emergency Department (ED). Findings include: Hospital Policy: Statement on Emergency Medical Treatment and Active Labor Act (EMTALA) Policy Number: BBH CLN.04.01 Effective Date: 9/10/2024 Purpose: To ensure individuals presenting to... Facility’s emergency departments receive ... appropriate transfer ... Procedure: ...B ... the facility will provide an individual who is determined to have an emergency medical condition ...an appropriate transfer of the individual to another medical facility ... Hospital Policy: Refusal of Treatment and Transfers Policy Number: BBH CLN.04.01.PR.02 Effective Date: 9/10/2024 Procedure: ...B. Transfer Upon Individual Request... b. Once the physician or other Qualified Medical Personnel informs an individual or individual’s representative if the risks and benefits of a transfer, the transfer may then occur if the individual or individual’s representative: ...(vii) the written patient consent or physician certification to transfer... Hospital Policy: Informed Consent Process Policy Number: 1225 Revision Date: 10/25 Purpose: This policy outlines the informed consent process. Policy: ...14. Any other procedures, treatment or test for which the physician determines that a specific explanation to the patient is required... B. Informed consent must include an interactive discussion and explanation of the procedure, risk, benefits, and alternatives relative to the procedure/surgery/treatment/test... J. All signatures must be dated and timed, including the patient/legal representative signature. Procedure: A. Obtaining signature: 1. Identify the patient using two patient identifiers. 2. Prior to the signing of any informed consent, the patient will acknowledge a discussion has occurred with the physician... as appropriate. 3. The signature is the patient’s legal name... 1. PI # 7 presented to the ED on 3/14/26 at 2:32 PM with complaint of seven months Pregnant, Emesis, Fatigue, Weakness, Lower Abdominal Pressure, Nausea and Vomiting (N/V). Review of the triage note dated 3/14/26 at 2:32 PM revealed the patient complain of being seven months pregnant and does feel the baby. The patient’s pulse rate was 137 and blood pressure reading was 96/52. Review of the laboratory results dated 3/14/26 revealed the patient had an elevated white blood cell (WBC) count of 17.8, normal range 4.0 to 10.8, and a positive flu test. Review of the physician note dated 3/14/26 at 3:02 PM revealed the patient complained of nausea and vomiting, pain across the lower abdomen and lower back. The patient’s WBC was elevated, and flu test was positive. The patient would be transferred to another hospital for Obstetrics Gynecologist (OB/GYN) services. Review of the nurses note revealed the patient was transferred to the receiving hospital at 3/14/26 at 6:53 PM by ambulance. Review of the MR revealed no documentation the patient consented to the transfer and the physician signed a certification the medical benefits expected from the transfer outweighed the risk of the transfer to the patient. An interview was conducted on 6/4/26 at 3:05 PM with Employee Identifier (EI) # 1, Regional Clinical Quality ED, who confirmed there was no documentation the patient consented to the transfer per the hospital policy and the physician signed a certification the medical benefits expected from the transfer outweighed the risk of the transfer to the patient.”