Baptist Health Brookwood 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 hospital policy and procedures, Hospital Rules and Regulations, video recordings, Emergency Department (ED) Log, ED staffing sheets, main ED and Freestanding ED (FED) patient census reports, Hospital B (receiving hospital) Medical Record (MR) review, and interviews, it was determined the facility failed to ensure: 1. All individuals who presented to the ED seeking emergency care for a medical condition received an appropriate medical screening examination. This had the potential to affect all patients presenting to the ED. Findings include: Refer to Tag A 2406.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 41623 Based on review of video recordings from Brookwood Baptist Memorial Hospital (Hospital A) Freestanding Emergency Department (FED) Log, Hospital B (receiving hospital) medical record review, facility policy and procedures, and interviews, it was determined the hospital failed to ensure a patient who presented to the ED for emergency treatment was entered into the ED Log. This affected one of 21 MRs reviewed including Patient Identifier (PI) # 21 and had the potential to affect all patients seeking emergency treatment at this hospital. Findings include: Facility Policy: EMTALA Policy Number: 0324 Revised: 05/09 ...Purpose: This purpose of this policy is to set forth policies and procedures for ... complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). ...Central Log: 1. The Hospital must maintain a central log of individuals who “come to the emergency department,” and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE (Medical Screening Examination)... 1. PI # 21 presented to Hospital A FED on 5/18/24 by private car. Review of the video recordings of the FED entrance and FED lobby from 5/18/24 was conducted on 6/6/24 at 4:00 PM with Employee Identifier (EI) # 1, Vice President of Quality, and EI # 3. A summary of the video recordings is as follows: At 7:58 AM a black car drove under the awning of the FED entrance and stopped. A female wearing a pink tee shirt got out of the driver’s side and entered the FED. At 7:59 AM the female driver addressed the ED receptionist, identified as EI # 7, Patient Registration. The female driver walked toward the reception desk, retrieved a wheelchair, and rolled it outside to the open passenger side door. At 8:00 AM an ED staff member, identified as EI # 4, RN, entered the lobby and walked outside to the car and stood next to the female driver and the opened car door. At 8:01 AM the female driver got back into the car and drove away. EI # 4 walked back into the ED to the receptionist desk and addressed EI # 7 and EI # 5, Respiratory Therapist who had just entered the lobby with another wheelchair. No other staff or patients were in the lobby at the time of the recordings. Review of the FED Log from 5/18/24 revealed no documentation EI # 21 had been entered into the log. Review of the FED patient census report for 5/18/24 revealed at 9:00 AM the FED had one patient and 11 open rooms. Review of PI # 21’s MR from Hospital B, receiving hospital, revealed PI # 21 arrived to the ED on 5/18/24 at 9:18 AM with complaints including fever, weakness and nausea and vomiting. PI # 21’s temperature was 101, pulse was 95, blood pressure was 127/55, and respirations were 18. Further review of PI # 21’s Hospital B ED documentation revealed the ED physician documented PI # 1 had a WBC (White Blood Count) of 16,800 and the patient was admitted to the hospital with diagnoses including Sepsis, Liver Abscess, and Acute Kidney Injury. An interview was conducted on 6/6/24 at 4:55 PM with EI # 4 who stated when he/she got to the lobby the family member had already retrieved a wheelchair and taken it to the car. EI # 4 further stated that he/she did not remember the patient or anything that was said, adding “we see so many people, I don’t remember exactly”. An interview was conducted on 6/6/24 at 5:12 PM with EI # 5, Respiratory Therapist, who stated he/she did not remember anything about that day on 5/18/24. An interview was conducted on 6/7/24 at 11:10 AM with EI # 8, ED Charge Nurse, who stated after reviewing the video from 5/18/24 that in his/her opinion that anyone who comes in and asks for a wheelchair is seeking emergency care. An interview was conducted on 6/7/24 at 12:10 PM with EI # 7, Patient Registration, who stated he/she did not remember anything about a patient needing help getting out of the car on 5/18/24 or anything the family member or nurse said. An interview was conducted on 6/7/24 at 2:15 PM with EI # 1, Vice President of Quality, who confirmed the hospital failed to enter a patient in the ED log who presented for emergent care.”

“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 hospital policy and procedures, Hospital Rules and Regulations, video recordings, Freestanding Emergency Department (FED) Log, FED staffing sheets, main ED and FED patient bed census reports, Hospital B (receiving hospital) Medical Record (MR) review, and interviews, it was determined the Hospital A failed to ensure a patient who presented to the FED for emergent care failed to provide a 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 of 21 MRs reviewed including Patient Identifier (PI) # 21 and had the potential to affect all patients presenting to this hospital for emergent care. Findings include: Hospital Policy: EMTALA Policy Number: 0324 Revised: 05/09 ...The purpose of this policy is to set forth policies and procedures for ... complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA)... Definitions: ...B. “Comes to the Emergency Department.” For purposes of this policy, an individual is deemed to have “come to the emergency department” if the individual: 1. Presents at a dedicated emergency department, and requests examination or treatment for a medical condition, or has such a request made on his or her behalf... V. Procedure: ...B. Medical Screening Examination: 1. The Hospital shall provide a medical screening examination to any individual who “comes to the emergency department,: as defined above... Brookwood Baptist Medical Center Rules & Regulations Revised: 5/2022 ...7. The Hospital shall provide a medical screening examination for every person who comes to the Hospital and requests examination or treatment to determine, within reasonable clinical confidence, whether such person has an emergency medical condition... 1. PI # 21 presented to Hospital A FED on 5/18/24 by private car. An interview conducted on 6/6/24 at 1:44 PM with the spouse of PI # 21, he/she stated “I pulled in under the roundabout and went in to get some help to get (PI# 21) out of the car. I told the receptionist that I needed some help, the receptionist called a nurse and while (he/she) was on the phone, the receptionist asked me how I got (PI # 21) in the car. I told (him/her) my son had helped me. I grabbed the wheelchair and went out to the car. The nurse followed me out and said if (he/she) has a fever and throwing up then (he/she) needs to go somewhere else... The Freestanding ED refused to see (PI # 21) so I drove him to (Hospital B) myself where (he/she) was found to be septic and is still on antibiotics for it.” Review of the Hospital A video recordings of the FED entrance and FED lobby from 5/18/24 was conducted on 6/6/24 at 4:00 PM with Employee Identifier (EI) # 1, Vice President of Quality, and EI # 3, Security Officer. EI # 3 stated the times on the camera had not been adjusted to the actual time. A summary of the video recordings is as follows: At 7:58 AM a black car was seen pulling under the awning of the FED entrance and stopped. A female wearing a pink tee shirt got out of the driver’s side and entered the facility. At 7:59 AM the female driver entered the FED lobby, addressed the FED receptionist, identified as EI # 7, Patient Registration. The female driver retrieved a wheelchair from in front of the receptionist desk and rolled it outside to the open passenger side door. At 8:00 AM an FED staff member, identified as EI # 4, RN, entered the lobby and walked outside to the car and stood next to the female driver and the opened car door. At 8:01 AM the female driver got back into the car and drove away. EI # 4 walked back into the facility to the receptionist desk and addressed EI # 7 and EI # 5, Respiratory Therapist who had just entered the lobby with another wheelchair. No other staff or patients were in the lobby at the time of the recordings. Review of the FED Log from 5/18/24 revealed no documentation PI # 21 was entered into the log and there was no medical record for review. Review of the FED Staffing Sheet dated 5/18/24 revealed at 9:00 AM the FED was staffed with two RNs, one Respiratory Therapist, and one Physician. Review of the Hospital A FED patient census report for 5/18/24 revealed the FED had one patient and 11 open rooms from 8:00 AM to 9:00 AM and four patients and eight open rooms from 9:00 AM to 10:00 AM. Review of the Hospital A Main ED patient census report for 5/18/24 revealed the ED had 16 patients and five open rooms from 8:00 AM to 9:00 AM and 16 patients and five open rooms from 9:00 AM to 10:00 AM. Review of PI # 21’s MR from Hospital B, receiving hospital, revealed PI # 21 arrived to the ED on 5/18/24 at 9:18 AM with complaints including fever, weakness and nausea and vomiting. PI # 21’s temperature was 101, pulse was 95, blood pressure was 127/55, and respirations were 18. Further review of PI # 21’s Hospital B ED documentation revealed the ED physician documented PI # 1 had a WBC (White Blood Count-measures the number of white blood cells in the blood, crucial for fighting infection) of 16,800 (normal white blood cell count 4,500 to 11,000) and the patient was admitted to the hospital with diagnoses including Sepsis (Life threatening emergency, body improperly responds to an infection, leading to organ dysfunction, potentially death) , Liver Abscess (Pus filled mass in the liver), and Acute Kidney Injury (Kidney stops working properly). An interview was conducted on 6/11/24 at 6:10 PM with EI # 10, FED Physician, who stated he/she was on duty on 5/18/24 but did not see PI # 21 or perform a MSE because he/she was not aware the patient was at the FED. An interview was conducted on 6/7/24 at 2:15 PM with EI # 1, Vice President of Quality, who confirmed the hospital failed to perform a MSE on a patient who presented for emergent care. The facility failed to ensure that there policy and procedure was followed as evidenced by failing to provide a medical screening examination for Patient #21 on 5/18/24, once a request was made for an examination to determine with reasonable clinical confidence, whether and emergency medical condition existed as stated in the facility’s policy.”