University of Alabama Hospital

“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: 41623 Based on medical record (MR) review, Medical and Dental Staff Rules and Regulations review, policies and procedures review, video surveillance footage review, Hospital B, receiving hospital, MR review, and staff interviews, it was determined the facility failed to ensure that individuals coming to the emergency department (ED) were provided a medical screening examination appropriate to the individuals presenting signs and symptoms within the capability and capacity of the hospital’s ED to include ancillary services routinely available to the hospital’s ED to determine whether or not an emergency medical condition existed. This affected one of twenty MRs reviewed including Patient Identifier # 1, and had the potential to affect all patients presenting to this ED. Findings include: Refer to A 2406 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: 41623 Based on medical record (MR) review, Medical and Dental Staff Rules and Regulations review, policies and procedures review, video surveillance footage review, Hospital B’s Emergency Department (ED) MR review, and staff interviews, it was determined the facility failed to ensure that individuals coming to the ED were provided a Medical Screening Examination (MSE) appropriate to the individuals presenting signs and symptoms within the capability and capacity of the hospital’s ED to include ancillary services routinely available to the hospital’s ED to determine whether or not an emergency medical condition existed. This affected one (1) of twenty (20) MR reviewed including Patient Identifier (PI) # 1, and had the potential to affect all patients presenting to the ED with complaints and signs and symptoms of headaches, cervical spine pain, blurred vision, sinus pressure, and prior medical history of Subdural Hematoma (SDH - a type of bleeding in the brain that can happen after a head injury). Findings include: Hospital Policy: Medical & Dental Staff Rules and Regulations Approved 7/24/23 ... 11.3 A ... MSE will be conducted on every patient who comes to the Hospital...requesting emergency examination or treatment of an emergency medical condition... Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy. Policy Number: Not Listed Revised: 5/17/24 Purpose: To set for the guidelines for UAB (University of Alabama Birmingham) Hospital to comply with the Emergency Medical Treatment... Policy: ...B. Emergency Department Medical Screening Examination (MSE). 1. UAB Hospital shall provide a MSE for every person who comes to the Hospital Campus and makes a request for examination of treatment of an Emergency Medical Condition. ...3. Within the capability of UAB Hospital, the MSE shall determine whether or not an Emergency Medical Condition exists... 1. PI # 1 presented to the ED on 9/1/24 at 2:15 PM with complaints of headache, cervical spine pain, blurred vision, and prior medical history of SDH. Review of the Triage assessment conducted on 9/1/24 at 2:51 PM revealed Employee Identifier (EI) # 12, Registered Nurse (RN), documented vital signs including blood pressure of 131/85, pulse 102, respirations 18, temperature 97.9, oxygen saturation 96 %, and a pain level of 7 out of 10. Review of the Nurse Assessment dated 9/1/24 at 4:44 PM revealed EI # 10, Licensed Practical Nurse (LPN), documented PI # 1 was upset due to having to wait for imaging, EI # 8, RN, Charge Nurse, was notified. Review of the Nurse Assessment dated 9/1/24 at 5:57 PM revealed EI # 10 documented PI # 1 stated he/she was leaving and would be back in an ambulance. Review of the Nurse Assessment dated 9/1/24 at 6:12 PM revealed EI # 11, RN, documented PI # 1 left without being seen (LWBS). PI # 1 was in the ED for a total of four (4) hours and fifty seven (57) minutes. There was no MSE documented. A review of the video recordings was conducted on 9/25/24 at 1:30 PM with EI # 3, Director of Emergency Services, the following is a summary of the video review: On 9/1/24 at 2:10 PM, PI # 1 entered the ED accompanied by an adult female and a dog on a leash and walked to the registration desk. At 2:43 PM was taken to the triage area. At 2:52 PM, PI # 1 returned to the ED waiting area. At 5:58 PM, PI # 1 exited the ED. Review of Hospital B, receiving hospital, medical record revealed PI # 1 arrived at the ED on 9/1/24 at 7:36 PM. Review of the Triage Assessment dated 9/1/24 at 7:36 PM revealed PI # 1 complained of a headache and blurred vision which started three (3) days prior to arrival. PI # 1 complaints also included a history of Subdural Hematoma with surgery eighty two (82) days prior to arrival, nausea, photophobia, and joint pain. The vital signs were blood pressure 125/82, heart rate 89, respirations 89, temperature 97.9, oxygen saturation 98 %, and a pain level of 8 out of 10. Review of the MSE dated 9/1/24 and signed at 9:49 PM revealed PI # 1 was seen by the provider at 7:45 PM. Diagnostic test were ordered including a Cervical Spine x-ray and Computerized Tomography (diagnostic computerized procedure that produces images inside the body) of the head. PI # 1 was discharged from Hospital B ED on 9/1/24 a 9:51 PM with diagnoses including Acute Left Cervical Radiculopathy and Episodic Tension-Type Headache. An interview was conducted on 9/26/24 at 8:55 AM with EI # 8, RN, who stated he/she was contacted by EI # 10, LPN, to come speak to PI # 1 due to him/her having to wait in the lobby. EI # 8 stated he/she was busy at the time of the call and did not speak to PI # 1. An interview was conducted on 9/26/24 at 9:25 AM with EI # 10, LPN, who stated he/she remembered PI # 1 was upset that he/she had to wait and frustrated because nobody would come out to speak to him. An interview was conducted on 9/26/24 at 1:45 PM with EI # 4, Senior Director Emergency Services, who confirmed PI # 1 did not have a MSE performed and no diagnostic tests were ordered. The facility failed to ensure that their policy and procedure, and Medical and Dental Staff Rules and Regulations were followed as evidenced by failing to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital’s emergency department including ancillary services ( Clinical laboratory tests, CT scans, and other diagnostic tesst and procedures) routinely available to the ED to determine whether or an emergency medical condition existed for patient #1 on 9/26/2024.”

“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: 41623 Based on review of hospital policies, medical record reviews, Emergency Department (ED) logs, ED census reports, video review, and interviews, it was determined the hospital failed to ensure a patient who presented to the ED for emergency care received a Medical Screening Examination. This affected one of twenty patiens reviewed including Patient Identifier # 1, and had the potential to affect all patients presenting to this ED. Findings include: Refer to A 2406 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: 41623 Based on review of hospital policy, medical record (MR) review, review of the Medical & Dental Staff Rules and Regulations, review of Emergency Department (ED) census report, video recordings and, ED Logs reviews, and interviews with staff, it was determined the hospital failed to ensure a patient presenting to the ED for emergent care received an appropriate Medical Screening Examination (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 existed. This affected one (1)of twenty (20) MR reviewed including Patient Identifier (PI) # 1, and had the potential to affect all patients presenting to the ED with complaints of abdominal pain, nausea, vomiting, and diarrhea. Findings include: Hospital Policy: Medical & Dental Staff Rules and Regulations Approved: 7/24/23 ... 11.3 A ... MSE will be conducted on every patient who comes to the Hospital...requesting emergency examination or treatment of an emergency medical condition... Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy. Policy Number: None Listed. Revised: 5/17/24 Purpose: To set forth guidelines for UAB (University of Alabama Birmingham) Hospital to comply with the Emergency Medical Treatment Act... Policy: ...B. Emergency Department Medical Screening Examination (MSE). 1. UAB Hospital shall provide a MSE for every person who comes to the Hospital Campus and makes a request for examination of treatment of an Emergency Medical Condition. ...3. Within the capability of UAB Hospital, the MSE shall determine whether or not an Emergency Medical Condition exists... 1. PI # 1 presented to the ED on 6/24/24 at 6:26 AM with complaints including abdominal pain, nausea, vomiting, and diarrhea. Review of the Triage assessment dated 6/24/24 at 6:41 AM revealed Employee Identifier (EI) # 9, Registered Nurse (RN), documented PI # 1 had been seen at the ED for the same complaint three times in the month of June. The vital signs documented included a blood pressure of 148/91, heart rate of 88, respirations of 16, and a temperature of 97.7. EI # 9 assigned a Tracking Acuity of three. Review of the Nurse Assessment dated 6/24/24 at 7:14 AM revealed EI # 8, RN, documented PI # 1 was informed he/she “needed a driver present to receive narcotics, patient has been here (for the) past two days and told the same, patient stated (spouse) dropped (him/her) off and would be back. RN repeated (spouse) must be present. Patient got up (and) ambulated out of ED lobby...Patient walked to parked car in handicap spot in front of ED, got in driver’s side and drove away.” Further review of the MR revealed no documentation of a MSE and no documentation of an order for narcotics. There was no documentation PI # 1 signed a refusal of treatment or a refusal to sign. An interview was conducted on 7/10/24 at 1:15 PM with EI # 11, Doctor of Osteopathic Medicine, who confirmed he/she was working on the morning of 6/24/24 when PI # 1 presented to the ED but did not see PI # 1. EI # 11 further stated no MSE was performed, and no narcotics were ordered. An interview was conducted on 7/10/24 at 1:45 PM with EI # 8, who stated he/she had seen PI # 1 in the ED many times before and told PI # 1 he/she had to have a driver before any medications were given. EI # 8 confirmed PI # 1 did not see the provider and did not have any medications ordered. An interview was conducted on 7/10/24 at 2:15 PM with EI # 9, who stated he/she remembered PI # 1 coming to the ED on 6/24/24, but did not remember much other than he/she documented the triage assessment. A Zoom meeting was conducted on 7/11/24 at 8:15 AM with EI # 1, Chief Executive Officer, who stated PI # 1 presented to the ED on 6/24/24, signed in, and had vital signs taken at the registration desk by the technician. EI # 1 stated PI # 1 was not seen by the triage nurse who documented the assessment obtained from the registration documentation. A review of the video recordings conducted on 7/11/24 at 9:00 AM revealed the following: On 6/24/24 at 6:25 AM, PI # 1 entered the ED entrance. At 6:26 AM, PI # 1 walked to the Registration Desk. At 6:28 AM, the Registration technician performed a blood pressure assessment on PI # 1. At 6:30 AM, PI # 1 sat in a chair in the ED waiting room. No other patients were visible in the ED waiting room. At 6:54 AM, a staff member, identified by EI # 2, Director of Highlands ED, as EI # 8, was seen addressing PI # 1 in the ED waiting area. At 6:55 AM, PI # 1 exited the ED. There were no video recordings of PI # 1 entering the triage area, no video of EI # 9 performing a triage assessment, and no video of PI # 1 entering the patient treatment area to have a MSE performed. Review of the 6/24/24 ED bed census report revealed the ED had 10 patients at 6:00 AM with 14 open beds and at 7:00 AM the ED had 10 patients with 14 open beds. An interview was conducted on 7/11/24 at 2:28 PM with EI # 2, who confirmed the hospital failed to ensure a MSE was performed on a patient presenting with abdominal pain and confirmed the ED had beds available and was sufficiently staffed with RNs and Providers on 6/24/24. The facility failed to ensure that their policy and procedure, and Medical and Dental Staff Rules and Regulations were followed as evidenced by failing to ensure that an appropriate medical screening examination was provided that was within the capability (sufficiently staffed with RNs and ED Providers) and capacity (ED open beds available) of the hospital’s emergency department including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for patient #1 on 6/24/2024.”