Hawkins County 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: 51701 Based on review of facility policy, facility documentation, medical record review and interviews, the facility failed to provide an appropriate and ongoing Medical Screening Examination (MSE) for one (1) patient (Patient #1) who presented to the Emergency Department (ED) with a Foreign Body in the left eye of 19 ED records reviewed. The findings include: Patient #1 entered Facility A’s ED on 1/13/2024 (no time) with a complaint of a Foreign Body in his eye. Patient #1 was registered. The ED Physician spoke with Patient #1 and said he would be glad to see the patient and try to remove the foreign body. The ED Physician told the patient Facility B had an ophthalmologist on call and if he preferred, he could go to Facility B. Patient #1 left Facility A’s ED and went to Facility B’s ED by private vehicle. The patient had not been evaluated at Facility A. There was no Medical Screening Examination (MSE). The patient’s electronic registration at Facility A was canceled. The patient was not listed on Facility A’s Central ED Log. Patient #1 arrived at Facility B’s ED on 1/13/2024 at 2:22 PM, and presented with a metal shaving in his left eye. A black metallic foreign body was removed by a Physician Assistant. The patient was discharged at 5:04 PM. Cross Refer to 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: 51701 Based on review of facility policy, facility documentation, and interviews, the facility failed to maintain a Central Emergency Department (ED) Log for one (1) patient (Patient #1) who presented to the ED with a Foreign Body in the left eye of 19 ED records reviewed. The findings include: Review of the facility policy, “Emergency Medical Treatment And Labor Act (EMTALA),” reviewed 9/22/2023, revealed “...The hospital shall keep a central log of all patients who come to the hospital’s DEDs seeking examination or treatment for a medical condition...The central log may consist of several logs...The central log includes the patient’s name and indicates if the patient was discharged, transferred, admitted and treated, stabilized and transferred, the patient refused treatment or was refused treatment...” Review of facility documentation revealed Facility A self-reported the incident on 1/22/2024 at 11:33 AM. As a result of the incident, Facility A developed an action plan for Quality Assurance and Performance Improvement. Facility A failed to recognize a Central Log had not been maintained when Patient #1’s encounter was deleted. Facility A’s action plan did not include any quality assurance performance improvement measures to maintain a Central ED log. During an interview on 9/29/2025 at 12:31 PM, with Facility A’s Patient Access Manager, they stated the patient encounter at Facility A was canceled since Patient #1 was not evaluated. The Patient Access Manager stated canceling the patient’s encounter would ensure Patient #1 would not be billed and shared the ED Central Log is electronically built from patient registration encounters. During an interview on 9/29/2025 at 3:00 PM, with Facility A’s Quality and Risk Manager, they stated the patient was registered but the encounter was deleted since the patient left and went to Facility B and confirmed Patient #1’s name is not listed on the ED Central Log. During an interview on 9/30/2025 at 3:45 PM, the ED Medical Director stated the ED physician on duty on 1/13/2024, “...tried to do the patient a favor.” He stated by sending Patient #1 to Facility B the patient would only have one medical bill to pay and could see an Ophthalmologist. He stated Patient #1 did not have an evaluation at Facility A. There is no medical record for Patient #1 on 1/22/2024.”

“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: 51701 Based on review of facility policy, facility documentation, and interviews, the facility failed to provide an appropriate and ongoing Medical Screening Examination (MSE) for one (1) patient (Patient #1) who presented to the Emergency Department (ED) with a Foreign Body in the left eye of 19 ED records reviewed. The findings include: Review of the facility policy, “Emergency Medical Treatment And Labor Act (EMTALA),” reviewed 9/22/2023, revealed “...It is the policy of each [Facility A] hospital to provide an appropriate MSE...All individuals who present to a DED for examination or treatment of ANY medical condition, whether or not emergent...A [Facility A] hospital must not Transfer a patient to another facility, unless the hospital does not have the Capacity or Capability needed to Stabilize the patient or the patient/Authorized Legal Representative requests a Transfer...” Facility documentation revealed Facility A self-reported the incident on 1/22/2024 at 11:33 AM. As a result of this incident, Facility A developed a quality assurance performance improvement action plan with monitoring of the MSE, which included re-education of ED Physicians and ED staff. The education plan focused on EMTALA requirements for a MSE. This process began on 1/29/2024. During an interview on 9/29/2025 at 12:31 PM, with Facility A’s Patient Access Manager, they stated the patient encounter at Facility A was canceled since Patient #1 was not triaged and a MSE was not performed. During an interview on 9/29/2025 at 3:00 PM, with Facility A’s Quality and Risk Manager, she stated she had investigated and self-reported this incident. She stated Patient #1 left Facility A and went to Facility B by private vehicle. Facility A’s ED Physician did not perform a Medical Screening Exam (MSE). During an interview on 9/30/2025 at 3:45, the ED Medical Director stated Patient #1 was not seen or evaluated at Facility A’s ED on 1/13/2024.”