Southwest Ms Regional 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: 45467 Based on record review, hospital policy and staff interviews, it was determined the hospital failed to comply with all Emergency Medical Treatment and Labor Act requirements. Specifically, the hospital failed to provide Patient #1 with an appropriate Medical Screening Exam (MSE) for her presenting signs and symptoms, and failed to provide Patient #17 with the medical risks verses benefits of leaving the Emergency Department (ED) prior to completion of stabilizing treatment. This affected two of 20 medical records reviewed. Findings Include: Based on facility staff interviews, medical record reviews, policy and procedure review, the facility failed to provide an appropriate medical screening exam (MSE) to Patient #1 who presented to the Emergency Department seeking an evaluation for vaginal bleeding with abdominal pain and cramping. This affected one of 20 sampled patients. Cross Refer to A2406. Based on medical record review and interview, the hospital failed to document attempts to explain the risks verses benefits of leaving the facility before completion of medical treatment for an identified emergency medical condition. This affected one (Patient #17) of 20 medical records reviewed. Cross Refer to A2407. During exit conference with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Chief Financial Officer (CFO) on 10/31/2024 at 1:45 p.m., survey findings were discussed, no further documents were submitted for review.”

“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: 45467 Based on facility staff interviews, medical record reviews, policy and procedure review, the facility failed to provide an appropriate medical screening exam (MSE) to Patient #1 who presented to the Emergency Department seeking an evaluation for vaginal bleeding with abdominal pain and cramping. This affected one of 20 sampled patients. Findings Include: Review of Patient #l’s medical record revealed Patient #1 presented at the Emergency Department (ED) on 09/14/2024 at 10:43 p.m. with complaint of abdominal pain for one (1) week with cramping, positive home pregnancy test, last menstrual period August 4, 2024, home pregnancy test now negative. Medical record review revealed at 10:49 p.m. a triage assessment with blood pressure (B/P) 130/75; pulse 120; respirations 20; oral temperature 98.9 Fahrenheit; pain level of two (2) on a scale of zero (0) to ten (10) with Zero (0) being no pain and 10 the worse pain; triage acuity level four (4). A Medical Screening Exam (MSE) was initiated at 10:47 p.m. However, the MSE failed to document an assessment of Patient #1’s abdominal cramping, the presence or absence of tenderness, rebound or guarding. Patient #1 was discharged on 09/1412024 at 11:09 p.m. Review of the facility’s policy, “EMTALA Compliance: Medical Screening Examination to Rule Out an Emergent Medical Condition”, dated 05/2024, “ ...to define the Medical Screening Examination process to rule out an emergency medical condition ...part of the Medicare Conditions of Participation, hospitals must abide by the EMTALA Law ...Triage ...Medical Screening Exam ...General Triage Process ...Triage Levels ...”. Review of the facility’s policy, “Triage Assessment/Reassessment”, dated 04/24/2024, “ ...Triage ...Triage Acuity ...Level 1 (Resuscitation) ...Level 2 (Emergent) ...Level 3 (Urgent) ...Level 4 (Less/Semi Urgent) ...Level 5 (Non-urgent) ...”. Medical Screening Examination (MSE): The process required to reach, with reasonable clinical confidence ...determined whether an emergency medical condition does or does not exist ...”. During exit conference with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Chief Financial Officer (CFO) on 10/31/2024 at 1:45 p.m., survey findings were discussed, no further documents were submitted for review.”

“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: 45467 Based on medical record review and interview, the hospital failed to document attempts to explain the risks verses benefits of leaving the facility before completion of medical treatment for an identified emergency medical condition. This affected one (Patient #17) of 20 medical records reviewed. Findings Include: Review of the medical record for Patient #’17 revealed the patient presented to the Emergency Department (ED) on 05/19/2024 at 8:46 p.m. with a complaint of shortness of breath that started several days ago with a cough and sore throat. Patient was triaged at 8:53 p.m. Vital signs: Temperature 98 degrees Fahrenheit; Pulse 109; Respirations 18; blood pressure 128/73, saturation of peripheral oxygen (SPO2) 95 percent (%), pain assessment four (4) on a scale of zero (0) to ten (10) with Zero (0) being no pain and 10 the worse pain; Patient #17 was assigned a triage acuity level of three (3) (urgent). Nurse Practitioner started MSE at 8:53 p.m., chest X-rays ordered and ipratropium-albuterol (DUO-NEB) 0.5 - 2.5 milligrams (mg) per three (3) milliliters nebulizer solution. Bilateral breath sounds diminished, breathing treatment started at 9:01 p.m. by respiratory therapist. Patient left during breathing treatment, stating “really just wanted a ride back to house.” No documented evidence the facility staff attempting to explain the risks verses the benefits of leaving the facility before medical treatment was completed. No policy and procedure provided to document process to obtain or attempt to obtain written and informed refusal of examination, treatment or an appropriate transfer in the case of an individual who leaves without completing treatment. During exit conference with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Chief Financial Officer (CFO) on 1013112024 at 1:45 p.m., survey findings were discussed, no further documents were submitted for review.”