Medical Center Enterprise

“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: 49797 Based on a review of the facility Bylaws, Rules and Regulations, medical record (MR) review, facility policy and procedure, and interviews with staff it was determined the hospital failed to: 1. Provide an appropriate medical screening examination (MSE) within the capability of the hospital’s obstetrics (OB) department to determine whether an emergency medical condition exists for all patients who presented to the Emergency Department (ED) seeking care for an OB related condition. 2. Ensure the patients received an appropriate transfer from the facility. These deficient practices affected 10 of 14 patients that presented to the OB department for an MSE, and one of two patient transfers from the facility. Findings Include: Cross Refer to findings at A 2406 and A 2409.”

“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: 49797 Based on a review of medical records (MR), facility Bylaws, Rules and Regulations, facility policy and procedure, and interviews with the staff it was determined the hospital failed to provide an appropriate medical screening examination (MSE) within the capability of the facilities obstetrics department to determine whether an emergency medical condition exists for all patients who presented to the Emergency Department (ED) seeking care for an Obstetric (OB) related condition. This did affect 10 out of 14 OB patients, to include Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 6, PI # 7, PI # 8, PI # 10, PI # 16, PI # 19, PI # 20, and had the potential to affect all OB patients served by the facility. Findings include: A review of the facility Bylaws, Rules and Regulations revealed no documentation of who is qualified to perform the MSE. Facility policy: Qualified Medical Personnel Audience: Labor and Delivery Policy /Procedure # Ld060 Revision date: 4/17/24 I. Purpose: A. To provide a procedure to ensure appropriate medical screening and timely medical intervention for patients seeking care for emergency obstetrical conditions. II. Criteria A. Alabama State Board of Nursing allows Registered Nurses (RNs) to perform Medical Screening Exams. B. Criteria for those qualified to perform the MSE in Labor and Delivery: 1. Labor and Delivery RN licensed to practice in Alabama. a. Must have at least 6 months Labor and Delivery nursing experience... f. Approved yearly by the Board of Trustees to function in this capacity. 2. A physician... Facility Policy Title: Evaluation and Treatment of Pregnant Patients Presenting to the Emergency Department in a Facility with an OB Department. Audience: ED Nursing, OB Nursing, ED Registration. Policy number: none listed Revision date: 4/17/24 I. Purpose: To establish a systematic approach in evaluation and treatment of the pregnant patient presenting to the Emergency Department in hospitals with an OB department. II. Policy: The obstetric patient presenting to the ED for emergency care is provided base upon her current medical condition and in consideration of her gestational age, III. Procedure: ...4) Patients presenting with pregnancy 20 weeks or greater and an obstetrical complaint are transported to Labor and Delivery via wheelchair or stretcher accompanied by clinical personnel as determined by the ED RN... Examples of obstetrical complaints (*may include but not limited to) 1. Uterine contractions.. 4. Abdominal pain- for possible uterine rupture, abruption and epigastric pain. 5. Vaginal discharge... 8. Pelvic pressure.. F. Patients with pregnancy 20 weeks or greater presenting only with obstetrical complaints are transported to obstetrical department for evaluations. 1. PI # 1 presented to the facility ED on 1/22/25 at 3:20 PM with a chief complaint of lower abdominal cramps for three days and vaginal discharge 5 days ago. A review of the MR revealed the MSE was performed on 1/22/25 at 3:57 PM by an RN and not a physician. 2. PI # 2 presented to the facility ED on 1/23/25 at 2:11 AM with a chief complaint of pelvic pain and abdominal pain for one week. A review of the MR revealed the MSE was performed on 1/23/25 at 2:40 AM by an RN and not a physician. 3. PI # 3 presented to the facility ED on 1/23/25 at 12:50 PM with a chief complaint of leaking and decreased movement. A review of the MR revealed the MSE was performed on 1/23/25 at 1:06 PM by an RN and not a physician. 4. PI # 6 presented to the facility ED on 2/4/25 at 12:32 PM with a chief complaint of vaginal bleeding. A review of the MR revealed the MSE was performed on 2/4/25 at 12:58 PM by and Licensed Practical Nurse (LPN) and not a physician. 5. PI # 7 presented to the facility ED on 3/13/25 at 10:05 AM with a chief complaint of bleeding this morning with pain. A review of the MR revealed the MSE was performed on 3/4/25 at 10:34 AM by an RN and not a physician. 6. PI # 8 presented to the facility ED on 3/17/25 at 7:12 AM with a chief complaint of cramping in abdomen and lower back. A review of the MR revealed the MSE was performed on 3/17/25 at 7:54 AM by an RN and not the physician. 7. PI # 10 presented to the facility ED on 4/17/25 at 9:38 PM with a chief complaint of abdominal and back cramping, pelvic pressure since 1:30 PM today. A review of the MR revealed the MSE was performed on 4/17/25 at 10:58 PM by an RN and not a physician. 8. PI # 16 presented to the facility ED on 7/1/25 at 2:00 PM with a chief complaint of nausea, vomiting, light headed, abdominal cramping. A review of the MR revealed the MSE was performed on 7/1/25 at 3:15 PM by an RN and not a physician. 9. PI # 19 presented to the facility ED on 4/28/25 at 1:57 PM with a chief complaint of a fall and labor pains. A review of the MR revealed the MSE was performed on 4/28/25 at 2:05 PM by an RN and not a physician. 10. PI # 20 presented to the facility ED on 5/18/25 at 4:24 AM with a chief complaint of abdominal pain. A review of the MR revealed the MSE was performed on 5/18/25 at 5:00 AM by an RN and not the physician. An interview was conducted on 7/10/25 at 12:00 PM with Employee Identifier # 1, Chief Quality Officer who confirmed the RN’s and LPN’s performed the MSE, not the physician, and the facility’s Bylaws, Rules and Regulations did not contain who was considered a qualified medical professional to perform the MSE.”

“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: 49797 Based on medical record (MR) review, hospital policy and procedure, and interviews with staff it was determined the facility failed to ensure patients received an appropriate transfer from the facility. This affected Patient Identifier (PI) # 13, one of two medical records containing transfers, and had the potential to affect all patients transferred from this facility. Findings include: Facility Policy Title: EMTALA Policy Version: 6 Revision date: 7/14/22 Introduction: The purpose of this policy is to define the relevant terms and provide an overview of the Emergency Medical Treatment and Labor Act (EMTALA)... IV. Transfer of Individuals A. Transfer Requirement If the patient is determined to have an Emergency Medical Condition (EMC)following an Medical Screening Exam and either: (a) the patient requests a Transfer; or (b) the treating physician determines that the hospital has exhausted it capabilities to stabilize the patient’s EMC, and that the benefits of an appropriate transfer outweigh the risks of such transfer, the hospital shall take reasonable steps to initiate an appropriate transfer... 1. PI # 13 presented to the facility ED on 5/30/25 at 8:13 AM with a chief complaint of mouth swelling and toothache. A review of the MR revealed the patient was transferred to an outside facility via Emergency Medical Service ground. The MR contained no documentation of the physician certification, risk and benefits, patient consent to transfer, and medical records being sent to the accepting facility. An interview was conducted on 7/10/25 at 12:11 PM with Employee Identifier # 1, Chief Quality Officer, who confirmed there is no documentation of the physician certification, risk and benefits, patient consent to transfer, and medical records sent to accepting facility for PI # 13.”