Grove Hill Memorial 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, facility policy, Medical Staff Rules and Regulations, Hospital B, (receiving hospital) MR, and interviews, it was determined Grove Hill Memorial Hospital failed to: 1. Complete an appropriate Medical Screening Examination. 2. Establish an effective policy for stabilizing patients prior to discharge or transfer. 3. Follow policy to ensure stabilizing treatment was provided for a patient who presented to the Emergency Department (ED) with psychiatric complaints. 4. Complete an appropriate transfer. This deficient practice negatively affected one of four patients who presented to the ED with problems of pregnancy including, Patient Identifier (PI) # 8, and one of four patients who presented to the ED with altered mental status, including PI # 2, and had the potential to affect all patients treated at this facility. Findings include: Cross Refer to A 2406, A 2407, 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: 41623 Based on medical record (MR) review, facility policy, Hospital B, (receiving hospital) MR, and interviews, it was determined Grove Hill Memorial Hospital failed to complete an appropriate Medical Screening Exam (MSE) that was 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 for one of four patients who presented to the Emergency Department (ED) with presenting problems of pregnancy. This deficient practice negatively affected Patient Identifier (PI) # 8 and had the potential to affect all patients treated at this facility. Findings include: Facility Policy: EMTALA (Emergency Medical Treatment and Labor Act) Guidelines for Emergency Department Services. Policy Number: 2302 Revised: 08/2017 Policy: ... All patients shall receive a Medical Screening Examination that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis...MEDICAL SCREENING EXAMINATIONS: Medical Screening Exams should include at a minimum the following ...Physical exam of the affected systems and potential systems ...EMERGENCY MEDICAL CONDITIONS: An emergency medical condition is any condition that is a danger to the patient or unborn fetus ... 1. PI # 8 presented to the ED on 9/22/24 at 11:00 AM with complaints of 28 week gestation obstetrical (OB) with abdominal cramping that started at 9:00 AM. Review of the ED Provider Note dated 9/22/24 at 11:23 AM revealed Employee Identifier (EI) # 8, ED Medical Director, documented PI # 8 was aware her OB physician had moved to another hospital and PI # 8 needed to be placed on a fetal monitor and evaluated for preterm labor. Further review of the ED Provider Note dated 9/22/24 at 11:23 AM revealed EI # 8 documented the Final Diagnosis of Round Ligament Pain and cannot rule out preterm labor without fetal and uterine monitoring. EI # 8 documented he/she advised PI # 8 to drive immediately to the hospital where her OB physician was practicing, which was 84 miles away. There was no documentation a pelvic exam to evaluate cervical dilation was performed. Review of the Nursing Note dated 9/22/24 at 11:35 AM revealed a Fetal Heart Tone (FHT) assessment of 165. Review of the ED Discharge Instructions dated 9/22/24 at 11:40 AM revealed PI # 8 was discharged and instructed to drive to another hospital for monitoring. A telephone interview was conducted on 11/6/24 at 10:36 AM with PI # 8 who stated after the doctor had seen her the nurse told her she did not need to come there and needed to go somewhere else... “They discharged me and I went to (Hospital B, receiving hospital) and I lost my baby, I had a miscarriage.” An interview was conducted on 11/6/24 at 12:19 AM with EI # 2, Registered Nurse (RN), who stated when OB patients present to the ED, the patient is triaged, FHT are checked, and the ED physician may do a vaginal exam. An interview was conducted on 11/6/24 at 1:00 PM with EI # 8 who stated PI # 8 had already contacted her OB doctor and was to follow up with him/her. EI # 8 stated PI # 8 was discharged and was planning to go somewhere the next morning. An interview was conducted on 11/7/24 at 10:30 AM with EI # 1, Chief Nursing Officer, who confirmed there was no documentation a pelvic exam was performed as part of the MSE. Review of the Discharge Summary from Hospital B revealed PI # 8 was admitted on 9/22/24 at 4:02 PM with decreased fetal movement and abdominal pain. PI # 8 experienced an Intrauterine Fetal Demise during evaluation and was admitted to Labor and Delivery for induction of labor and delivered a non-viable infant on 9/23/24. The hospital failed to ensure that an appropriate MSE was provided for patient PI # 8 on 9/22/2024 as evidenced by failing to provide PI # 8 a pelvic examination which placed the health of safety of the patient and her unborn child at risk.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 41623 Based on Grove Hill Memorial Hospital medical record (MR) review, Hospital B, receiving hospital, MR review, Medical Staff Rules and Regulations, hospital policy, and interviews with staff, it was determined the hospital failed to: 1. To establish an effective EMTALA policy to ensure that stabilizing care was provided as required for patients prior to discharge or transfer. 2. To follow policy to ensure stabilizing treatment as required was provided for a patient who presented to the Emergency Department (ED) with psychiatric complaints. This deficient practice affected one of four patients reviewed who presented to the ED with altered mental status including Patient Identifier (PI) # 2 and had the potential to affect all patients who present to this hospital with psychiatric complaints. Findings include: Grove Hill Hospital Article XVI Rules and Regulations ... 16.4 Emergency Services ... 16.4-2 ... All patients will be cared for under the rules of EMTALA (Emergency Medical Treatment and Labor Act)... Hospital Policy: Psychiatric Evaluation Policy Number: 1015 Revised: 09/2023 ... Any patient accessing care at this facility who requires psychiatric treatment shall be managed through referral and transfer to a behavioral health facility and/or management through consultive psychiatric services on a temporary basis, until the patient’s clinical condition has stabilized to allow for psychiatric facility transfer. When the attending physician deems it necessary for the patient to have a psychiatric screen/evaluation, one of the following will be contacted ... AltaPoint Telehealth Southwest Alabama Mental Health ... Primary Mental Health Nurse Practitioner ... 1. PI # 2 presented to Grove Hill Memorial Hospital ED on 9/5/24 at 8:05 AM via EMS with complaints of wandering in the woods because “he thinks terrorist are trying to get him.” Review of the ED Provider Note dated 9/5/24 at 8:49 PM revealed the ED physician documented “... presents with a (complaint of) walking through the woods and behaving in a strange manner ... Patient denies symptoms otherwise but admits to history of ADHD (Attention Deficit/Hyperactivity Disorder) and multiple personality disorder...Does not indicate a desire to harm self or others.” Review of the ED Provider Note, Risk Assessment, dated 9/5/24 at 8:49 PM revealed the ED physician documented “In review of patient’s acute illness as a potentially lethal threat, necessity for admission considered for this patient. In my clinical judgement, this visit was emergent...” Review of the Urine Drug Screen collected on 9/5/24 at 8:32 PM revealed the test was positive for the presence of Tetrahydrocannabinol (THC- marijuana) and negative for the presence of six other tested substances. There was no documentation stabilizing treatment for the psychiatric emergency medical condition was provided, to include a psychiatric evaluation. Further review of the ED Provider Note date 9/5/24 at 8:49 PM revealed a discharge diagnosis of Substance Abuse with plans to discharge home and follow up with his/her primary care provider. Review of the ED Summary, Patient Education Documents dated 9/5/24 at 3:05 PM revealed the nurse documented PI # 2 requested to be admitted to the hospital for two days. The nurse documented the ED physician was notified of the patient’s request and the ED physician stated he/she “had no reason to admit patient”. An interview was conducted on 11/6/24 at 2:50 PM with Employee Identifier (EI) # 9, ED Physician, who stated he/she remembered PI # 2 had taken something with THC that did not show up on the drug screen. EI # 9 further stated he/she was asked about admitting PI # 2 to the hospital but that his condition with the drugs was self-limiting. An interview was conducted on 11/6/24 at 8:53 AM with EI # 1, Chief Nursing Officer, who confirmed there was no documentation a psychiatric evaluation was performed and PI # 2 was discharged to home after his/her request for admission to the hospital. Review of the Hospital B ED Provider documentation dated 9/12/24 at 11:46 AM revealed PI # 2 presented to the ED on 9/12/24 at 11:15 AM with law enforcement for psychiatric admission medical clearance due to paranoid delusions, homicidal ideation, and multiple psychosis. PI # 2 was admitted to Hospital B’s psychiatric unit with diagnoses including Bipolar Disorder Manifest as Mania with Psychotic Features, Positive Urine Drug Screen, and Homicidal Ideations. The facility failed to ensure that stabilizing care was provided as required for Patient #2 on 9/5/2024, for his identified emergency psychiatric condition.”

“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: 41623 Based on medical record (MR) review, facility policy, Medical Staff Rules and Regulations, Hospital B, (receiving hospital) MR, and interviews, it was determined Grove Hill Memorial Hospital failed to complete an appropriate transfer for one of four patients who presented to the Emergency Department (ED) with problems of pregnancy. This deficient practice negatively affected Patient Identifier (PI) # 8 and had the potential to affect all patients treated at this facility. Findings include: Facility Policy: EMTALA (Emergency Medical Treatment and Labor Act) Guidelines for Emergency Department Services. Policy Number: 2302 Revised: 08/2017 ...Grove Hill Memorial Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable as per EMTALA... If a patient is to be transferred for medical necessity the following guidelines must be followed: 1. A physician certification that the risks of transferring the patient are outweighed by the potential benefits... a. The receiving hospital must give acceptance in advance... b. Patient gives written consent for transfer. c. The patient must be transferred by an appropriate medical transfer vehicle. The patient may not be transferred in a private passenger vehicle unless the patient refuses to be transported by ambulance... Copies of the medical record...will accompany the patient when transferred... Grove Hill Memorial Hospital Article XVI: Rules and Regulations ...16.4 Emergency Services ...17.2-12 The following elements are required for each transfer: a. appropriate transfer forms b. MD (Doctor of Medicine) orders include written transfer order, appropriate mode of transportation, personnel to accompany patient... c. MD documented specific Risks/Benefits discussed. d. Physician to physician acceptance with documented names and times. e. MD certification that the benefits outweigh the risks... 1. PI # 8 presented to the ED on 9/22/24 at 11:00 AM with complaints of 28 week gestation obstetrical (OB) with abdominal cramping that started a 9:00 AM. Review of the ED Provider Note dated 9/22/24 at 11:23 AM revealed EI # 8 documented the Final Diagnosis of Round Ligament Pain and cannot rule out preterm labor without fetal and uterine monitoring. EI # 8 documented he/she advised PI # 8 that he/she needed to drive immediately to the hospital where her OB physician was practicing, which was 84 miles away. Review of the ED Discharge Instructions dated 9/22/4 at 11:40 AM revealed PI # 8 was discharged and instructed to drive to another hospital for monitoring. There was no documentation an accepting physician was contacted and accepted the patient, no documentation another hospital was contacted for acceptance, and no documentation a transfer was arranged by qualified personnel. A telephone interview was conducted on 11/6/24 at 10:36 AM, PI # 8 was asked if a transfer was arranged, PI # 8 responded, “no, they just told me I did not need to be there. They discharged me and I went to (Hospital B, receiving hospital) and I lost my baby, I had a miscarriage.” An interview was conducted on 11/6/24 at 12:19 AM with EI # 2, Registered Nurse (RN), who was asked about the process for when OB patients arrived in the ED. EI # 2 responded “we don’t check them. We triage them like we do other patients, we check FHT and the doctor may do a vaginal exam. We either send them home or transfer them. If we can get an ambulance, we will send them by ambulance. EI # 2 was then asked if he/she remembered when PI # 8 was in the ED. EI # 2 stated PI # 8 was supposed to go see his/her OB doctor but wanted to see another OB doctor. EI # 2 stated he/she faxed everything to the hospital and EI # 2 called a nurse to let them know that PI # 8 may be coming. An interview was conducted on 11/6/24 at 1:00 PM with EI # 8 who was asked if he/she remembered when PI # 8 was in the ED. EI # 8 stated PI # 8 had already made contact with her OB doctor before he/she came to the ED and was to follow up with him/her. EI # 8 stated PI # 8 was discharged and was planning to go somewhere the next morning. An interview was conducted on 11/7/24 at 10:30 AM with EI # 1, Chief Nursing Officer, who stated Grove Hill Memorial Hospital had closed the OB Department on 8/17/24 and any OB patient who required further OB services was to be transferred to another facility. EI # 1 stated PI # 8 was not transferred and confirmed there was no documentation of an accepting physician and no documentation transportation by qualified personnel was offered or arranged.”