Coosa Valley 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: 41624 Based on medical record (MR) reviews, Medical Staff Bylaws review, Medical Staff Rules and Regulations review, list of current ED (Emergency Department) providers review, hospital policies and procedures review, and interviews with staff, it was determined the facility’s Hospital A (Coosa Valley Medical Center) failed to ensure: 1. Medical screening examinations (MSE) were performed by qualified medical personnel (QMP) as identified in the hospital Rules and Regulations for all patients presenting to the hospital’s ED requesting emergency services. This deficient practice affected nine of 24 MR’s reviewed, including Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6, PI # 13, PI # 15, and PI # 24, and had the potential to affect all patients presenting to the ED seeking a MSE for evaluation of an EMC (emergency medical condition). 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: 41624 Based on medical record (MR) reviews, Medical Staff Bylaws review, Medical Staff Rules and Regulations review, list of current ED (Emergency Department) providers review, hospital policies and procedures review, and interviews with staff, it was determined the facility, Hospital A (Coosa Valley Medical Center) failed to ensure: 1. Medical screening examinations (MSE) were performed by qualified medical personnel (QMP) as identified in the hospital Medical Staff Rules and Regulations for all patients presenting to the hospital’s ED requesting emergency services. This deficient practice affected nine of 24 MR’s reviewed, including Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6, PI # 13, PI # 15, and PI # 24, and had the potential to affect all patients presenting to the ED seeking a MSE for evaluation of an EMC (emergency medical condition). Findings include: Medical Staff Rules and Regulations: Article V: Clinical Departments/Services - General Rules and Responsibilities Section 2: Emergency Department Letter E: Except in the case of scheduled tests/procedures or direct admissions, all persons presenting to the ED or any other department of the hospital requesting treatment or examination shall be provided a MSE in the ED or other appropriate specialized or designated area appropriate to their presenting condition. In the case of Obstetrics (OB) patients who are 20 weeks or more in estimated gestation, medical screening shall be performed in the Labor and Delivery Department pursuant to the policy on Medical Screenings of OB patients. Letter P: ED Physician Procedures 1. The on-duty ED physician shall provide a MSE to all patients... 3. The physician providing the medical examination shall physically examine the patient...The physician’s observation, evaluation of differential diagnoses, testing ordered, and results of all testing shall be recorded in the MR. Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) Policy Number: 17024188 Last Revised: 10/2024 Approved: 10/2024 Purpose: To ensure all individuals that request emergency services receive an appropriate MSE...as required by EMTALA. Definitions: MSE - an exam completed by QMP to determine the presence or absence of an EMC, and includes all necessary testing and on-call services within the capability of the hospital to reach a diagnosis that excludes the presence of an EMC. Policy: Hospital Responsibilities: 1. Treatment of Patients - Any individual who comes and requests must receive a MSE to determine whether an EMC exists... Hospital Policy: OB Patient, Care Area: ED Policy Number: 17015177 Last Revised: 08/2021 Effective: 10/2024 Policy: A. OB patients 20 weeks gestation and greater should go directly to OB unit for evaluation if the presenting problem pertains to the pregnancy. B. OB patients with medical problems not directly relating to the pregnancy will be assessed by ED personnel and the Emergency Room physician. Procedure: 1. On arrival to the ED, the OB patient should have the following observations made and documented: A. Any vaginal bleeding B. Any leakage or rupture of membranes - contact the Labor and Delivery department to evaluate ROM (rupture of membranes), note color and odor, if any fluid is observed. C. Note time of ROM, if applicable. D. Fetal heart tones (FHT) - note rate 2. A vaginal exam should be done by a qualified person. 3. The emergency physician will contact the appropriate OB/GYN (gynecological) physician. Hospital Policy: Labor and Delivery Nurse Screening Area: Women’s Policy Number: 16999947 Last Revised: 07/2020 Effective: 07/2020 Policy: It is the policy of this hospital to provide a MSE of all patients presenting for unscheduled OB evaluation, testing, or services within the capabilities of the hospital. Patients 20 weeks gestation or greater, with OB presentations...will receive a MSE in the OB department. Patients less than 20 weeks gestation will be provided a MSE in the ED. Procedure: ...2. Patients presenting for OB conditions at less than 20 weeks gestation will receive a MSE in the ED. 3. All patients presenting for OB MSE will receive at least the standard OB evaluation indicated by the OB Nurse Evaluation Form and performed by a qualified evaluator... Definitions: Qualified OB Evaluator a. A Registered Nurse (RN) who has successfully completed Labor and Delivery orientation, fetal monitoring testing, and is competent in performance of sterile vaginal exams may perform this function. 1. Review of the hospital Medical Staff Bylaws, last amended 12/17/24, revealed no documentation to identify and approve RNs (Qualified OB Evaluator) as individual(s) qualified to perform the MSE for the hospital emergency services in the ED or the OB ED. Review of the hospital Rules and Regulations, last revised 5/14/16, revealed documentation the on-duty physician was to perform the MSE on all patients presenting to the ED. An interview was conducted on 2/27/26 at 6:05 PM with Employee Identifier (EI) # 3, Chief Operating Officer and Chief Nursing Officer, who confirmed the hospital’s Rules and Regulations stated a physician was to perform the MSE on all patients. 2. PI # 1 presented to the ED via private car on 1/26/26 at 6:10 PM with a chief complaint of UTI (Urinary Tract Infection). PI # 1 was 14 weeks pregnant. Review of the triage assessment dated 1/26/26 at 6:16 PM by EI # 5, RN, revealed the patient presented with UTI symptoms. Review of the ED provider, a Certified Registered Nurse Practitioner (CRNP), note dated 1/26/26 at 6:22 PM revealed the patient reported mild, sharp, and constant UTI symptoms. The patient reported “...hurting all over...” Review of the physical examination revealed the patient was positive for bilateral flank pain and low back pain. Tylenol 1 gram, urinalysis, and Fetal heart tones (FHT) monitoring were ordered. Documentation by the ED Nurse revealed the FHT was 146. There was no documentation that a ultrasound was ordered. Patient #1 was discharged to home on 1/26/2026 at 7:38 PM. Review of the ED nurse assessment dated 1/26/26 at 6:54 PM revealed FHT of 146 which was reported to the CRNP. Review of the urinalysis results dated 1/26/26 at 7:24 PM revealed moderate bacteria in the urine. Review of the MR revealed the patient was discharged on 1/26/26 at 7:50 PM with diagnoses of UTI Symptoms, Back Pain, Pain in Round Ligament in Pregnancy, and Bacteriuria with Pregnancy. The MSE was not appropriate as it was performed by a CRNP and not an ED physician as required in the hospital’s Rules and Regulations. An interview was conducted on 2/27/26 at 6:05 PM with EI # 3, Chief Operating Officer and Chief Nursing Officer, who confirmed the MSE was completed by a CRNP, and not a physician as required in the hospital Rules and Regulations. The MR for PI # 1 at Hospital B was reviewed. The section titled, “ED Physican Note,” dated 1/27/26 at 7:58 PM revealed PI # 1 presented to the ED on 1/27/26 with a chief complaint of 14 Weeks Pregnant With Difficulty Urinating, complaint of back pain which subsided after a Gush of Fluid. PI # 1 received an ultrasound (medical imaging used to scan, especially pregnant women to examine the fetus) on 1/27/26 at 9:39 PM with findings of single living fetus with a composite sonographic age of 14 weeks, 2 days, and was admitted to the Maternity Evaluation Unit for further observation. 3. PI # 2 presented to the ED via private car on 1/24/26 at 1:47 PM with a chief complaint of vaginal bleeding and cramping. PI # 2 was 5 weeks pregnant. Review of the MR revealed PI # 2 received a MSE at 2:00 PM by a CRNP and not a physician as required in the hospital Rules and Regulations. There was no documentation in the MR to indicate the patient was assessed for vaginal bleeding. Additionally, there was no documentation that a vaginal examination was performed, and no pelvic ultrasound was ordered. An interview was conducted on 2/26/26 at 10:40 AM with EI # 2, ED Manager, who confirmed the ED policy for OB patients included a vaginal exam be conducted by a qualified provider. An interview was conducted on 2/27/26 at 6:05 PM with EI # 3, who confirmed the MSE was completed by a CRNP, and not a physician. The facility failed to ensure their policy and procedure was followed for PI # 2 on 1/24/26 as evidenced by failing to: 1. observe and document any vaginal bleeding; and ; 2. ensure that a vaginal examination was performed by a qualified person as stated in the facility’s policy. 4. PI # 3 presented to the ED via private car on 1/24/26 at 5:02 PM with a chief complaint of spotting. PI # 3 was 12 weeks pregnant. Review of the MR revealed PI # 3 received a MSE at 5:13 PM by a CRNP and not a physician as required in the hospital Rules and Regulations. An interview was conducted on 2/27/26 at 6:05 PM with EI # 3, who confirmed the MSE was completed by a CRNP, and not a physician. 5. PI # 4 presented to the ED via private car on 1/23/26 at 4:22 PM with a chief complaint of back pain. PI # 4 was 18 weeks pregnant. Review of the MR revealed PI # 4 received a MSE at 4:25 PM by a CRNP and not a physician as required in the hospital Rules and Regulations. An interview was conducted on 2/27/26 at 6:05 PM with EI # 3, who confirmed the MSE was completed by a CRNP, and not a physician. 6. PI # 5 presented to the ED via private car on 1/27/26 at 7:05 PM with a chief complaint of back pain radiating into the right leg. Review of the MR revealed PI # 5 received a MSE at 7:12 PM by a CRNP and not a physician as required in the hospital Rules and Regulations. An interview was conducted on 2/27/26 at 6:05 PM with EI # 3, who confirmed the MSE was completed by a CRNP, and not a physician. 7. PI # 6 presented to the ED via private car on 1/27/26 at 8:51 AM with a chief complaint of vaginal bleeding and cramping since 1/16/26. Review of the MR revealed PI # 6 received a MSE at 10:39 AM by a CRNP and not a physician as required in the hospital Rules and Regulations. An interview was conducted on 2/27/26 at 6:05 PM with EI # 3, who confirmed the MSE was completed by a CRNP, and not a physician. 8. PI # 13 presented to the ED via private car on 9/16/25 at 6:52 PM with a chief complaint of sharp abdominal pain and a dull headache. Review of the MR revealed PI # 13 received a MSE at 7:34 AM by a CRNP and not a physician as required in the hospital Rules and Regulations. An interview was conducted on 2/27/26 at 6:05 PM with EI # 3, who confirmed the MSE was completed by a CRNP, and not a physician. 9. PI # 15 presented to the ED via private car on 11/8/25 at 1:29 PM with a chief complaint of head injury, neck pain, foggy headedness, and “...my heart is racing...” Review of the MR revealed PI # 15 received a MSE at 1:30 PM by a CRNP and not a physician as required in the hospital Rules and Regulations. An interview was conducted on 2/27/26 at 6:05 PM with EI # 3, who confirmed the MSE was completed by a CRNP, and not a physician. 10. PI # 24 presented to the ED on 2/15/26 with a chief complaint of abdominal pain and contractions, and was registered on the OB Central Log at 5:28 AM. PI # 24 was 36 weeks pregnant. Review of the MR revealed PI # 24 received a MSE at 5:33 AM by an RN in the Labor and Delivery Unit and not a physician. An interview was conducted on 3/2/26 at 12:30 PM with EI # 1, Director of Quality, who confirmed the MSE was completed by an RN, and not by a physician. The surveyor requested a list of providers currently performing MSEs in the ED. Review of the list provided on 2/26/26 at 11:10 AM revealed there were three CRNP’s who were performing the MSEs for patients presenting to the ED. EI # 2 and EI # 1 confirmed CRNP’s were included on the list of providers performing MSEs.”