Walker 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 a review of medical records (MR), hospital Medical Staff Bylaws, Rules and Regulations, hospital policies and procedures, Columbia Lighthouse Project Protocol, and interviews with the staff it was determined the hospital failed to ensure: 1. The hospital identified and approved individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Services in the hospital bylaws or rules and regulations. 2. An appropriate MSE within the capability of the hospital was provided to determine whether or not an emergency medical condition exists for all patients who presented for emergency services. 3. The risk and benefits of transfer to the individual’s health was explained to the patient prior to transfer to another hospital. Cross Refer 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: 40119 Based on a review of medical records (MR), hospital Medical Staff Bylaws, Rules and Regulations, hospital policies and procedures, Columbia Lighthouse Project Protocol, and interviews with the staff it was determined the hospital failed to ensure: 1. The hospital identified and approved individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Services in the hospital bylaws or rules and regulations. 2. An appropriate MSE within the capability of the hospital was provided to determine whether or not an emergency medical condition exists for all patients who presented for emergency services. This did affect two of nine Obstetric (OB) patients reviewed, including Patient Identifier (PI) # 1 and PI #6, and had the potential to negatively affect all patients who present to the hospital for an emergency medical condition requiring a MSE. Findings include: Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening and Treatment of EMC. Policy Number: BBH CLN.04.01 Reviewed Date: 7/29/2024 Purpose: To ensure individuals presenting to... Facility’s emergency departments receive an appropriate MSE... Policy: ...An individual is deemed to have come to the Dedicated ED if the individual: 1. Presents at a Dedicated ED and requests examination or treatment for a medical condition... Procedure: A. The facility will provide an appropriate MSE within its capability to an individual coming to the Dedicated ED, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists. Hospital Policy: Triage, Registration, and Treatment Policy Number: BBH CLN.04.01.PR.01 Reviewed Date: 7/29/2024 I. Procedure: ...C. MSE 1. An MSE will be provided by Qualified Medical Personnel to any individual who comes to the Dedicated Emergency Department... 2. The MSE will be performed by a physician or other Qualified Medical Personnel. The examination should be specific to the patient’s complaint and presenting symptoms. Hospital Policy: Perinatal Services Policy Number: BBH PS 03.01.PR.01 Effective Date: 1/31/2022 I. Definitions: ... Qualified Medical Person/Personnel (QMP): An individual or individuals determined qualified by Brookwood Baptist Health (BBH) bylaws or rules and regulations...to perform a MSE. In facility, QMP are limited to physicians, physician assistants, nurse practitioners (including nurse midwifes) and registered nurses (RN) who have been deemed qualified to conduct the patient assessment portion of the MSE in conjunction with the OB (Obstetrical) physician. II Procedure: ...B. Medical Screening 1. BBH provides a MSE to all patients presenting for OB evaluation, testing or services within the capabilities of the OB Unit and the ancillary services routinely available to the OB Department (OBED), including the use of on-call physicians. ...b. Patients fewer than 20 weeks gestation will receive a MSE by a QMP in the ED or in the OBED for obstetrical presentations as appropriate. 1. Review of the hospital Medical Staff Bylaws and Rules and Regulations revealed no documentation to identify and approve the individual(s) qualified to perform the MSE for the hospital emergency services in the ED. Further review of the hospital Rules and Regulations revealed documentation a RN may perform a MSE on OB outpatients if credentialed to do so. Further review of the hospital Medical Staff Bylaws revealed the credentials committee reviews and evaluates the qualifications of each practitioner and health professional affiliate then recommends the appropriate services for the practitioner/health professional affiliate. a. PI # 6 presented to the hospital ED on 6/3/25 at 2:49 PM with a chief complaint of Vaginal Bleeding and Contractions in pregnancy. A review of the MR revealed the MSE was performed on 6/3/25 at 3:23 PM by a RN and not a physician. An interview was conducted with Employee Identifier (EI) # 1, Risk Manager, on 11/18/25 at 12:46 PM who confirmed there was no documentation in the hospital bylaws or rules and regulations to identify and approve individual(s) qualified to perform the MSE in the ED. An interview was conducted with EI # 1 and EI # 7, Nursing Operations Director of Labor and Delivery, on 11/18/25 at 1:21 PM. EI # 1 verbalized the hospital did not have a policy for the credentialing of an OB RN. EI # 7 verbalized an OB RN was able to complete the MSE on a patient after a competency evaluation was completed on the OB RN. The competency evaluation for the RN stays in the OB department and is not provided to anyone outside of the OB department for credentialing. EI # 1 and EI # 7 verbalized there was no documentation of the OB RN’s credentialed to perform the MSE for an OB patient. An interview was conducted with EI # 1 on 11/20/25 from 2:15 PM to 2:19 PM who confirmed the MSE was performed by a RN and not a physician for PI # 6. 2. PI # 1 presented to the ED on 10/31/25 at 11:43 PM with complaint of 18 weeks Pregnant and Vaginal Bleeding. Review of the MR dated 10/31/24 revealed there was no documentation a vaginal examination was conducted, no documentation an ultrasound was ordered or performed, and no documentation the on-call OB physician was contacted for consultation. Review of the ED Nurse note dated 11/2/25 at 7:57 AM revealed the patient presented to Labor and Delivery (L&D) via ambulance stretcher after delivering Intrauterine Fetal Demise at home at 7:28 AM. The patient delivered the placenta in ambulance at 7:50 AM. Review of the physician’s note dated 11/2/25 at 7:05 PM revealed the patient was 18 and 6/7 weeks gestation who was admitted for miscarriage. The patient came to the ED late Friday night with complaint of large gush of blood. There was no exam performed. An interview was conducted on 11/19/25 at 5:00 PM with EI # 1, who confirmed there was no documentation a vaginal examination was conducted, no documentation an ultrasound was ordered or performed, and no documentation the on-call OB physician was contacted for consultation on 10/31/25. An interview was conducted on 11/20/25 at 8:35 AM with EI # 3, OB Physician on-call 10/31/25, who verbalized the patient said she/he had presented to the ED on 10/31/25 and was told the on-call OB had been contacted. EI # 3 confirmed she/he had not been contacted on 10/31/25 about the patient. EI # 3 verbalized he/she reviewed the patient’s ED medical record from 10/31/25 and there was no documentation of a vaginal exam, no documentation of a OB consult, and no documentation an ultrasound was conducted. EI # 3 verbalized a vaginal exam should have been completed and if ED physician felt uncomfortable doing a vaginal exam, then the OB on call should have been consulted. 46290”

“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 review of Medical Record (MR), hospital policy and procedure, and staff interviews, it was determined the hospital failed to ensure the risk and benefits of transfer to the individual’s health was explained to the patient prior to transfer to another hospital. This deficient practice did affect one of four patients who was transferred from the hospital, including Patient Identifier (PI) # 3 and had the potential to affect all patients presenting to the hospital Emergency Department (ED) who require a transfer to another hospital. Findings include: Hospital Policy: Refusal of Treatment and Transfers Policy Number: BBH CLN.04.01.PR.02 Reviewed Date: 7/29/24 Procedure: ...B. Transfer of Individual with an Emergency Medical Condition... 1. Transfer Upon Individual Request a. Facility may transfer a medically unstable individual if a physician or Qualified Medical Personnel fully inform the individual or the person acting on the individual’s behalf of the risks of the transfer... 40119 1. PI # 3 presented to the hospital ED on 10/31/25 at 4:57 PM with a chief complaint vaginal bleeding since 4 PM. The patient was 8 weeks postpartum. Review of the ED Provider note dated 10/31/25 at 8:00 PM revealed the patient was 7 weeks postpartum after a cesarean section, had massive amounts of bleeding using 1 pad every 45 minutes, and the patient’s cervix was unable to be visualized on examination. Further review revealed the patient was discussed with the OB/GYN (Obstetrics/Gynecology) at the hospital and it was agreed upon the patient would need to be transferred to OB/GYN services. The patient requested to be transferred to another hospital for the OB/GYN service. Review of the Interhospital Transfer Form dated 10/31/25 at 8:05 PM revealed no documentation the risk and benefits of transfer to the individual’s health was explained to the patient prior to transfer to another hospital. An interview was conducted on 11/20/25 at 2:11 PM with Employee Identifier (EI) # 1, Risk Manager, and EI # 7, Nursing Operations Director of Labor and Delivery, who confirmed there was no documentation the risk and benefits of transfer to the individual’s health was explained to the patient prior to transfer to another hospital.”