Claiborne 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: 30553 Based on review of facility policy, review of Emergency Department (ED) registration video, review of the ED Central Logs, medical record review, and interview, the facility failed to provide a Medical Screening Examination (MSE) for one (1) patient (#3) who presented to the ED for evaluation of 20 ED records reviewed. The findings include: Patient #3 presented to the facility’s ED on 8/27/2025 at 7:13 PM, after a syncopal (near fainting) episode. The patient stated she was 9.5 weeks pregnant, and had concerns she was having a miscarriage. The patient requested an examination and stated she wanted an ultrasound. Video footage review showed there was a conversation between the patient and the ED registration non-clinical staff and the patient exited the facility’s ED entrance at 7:14 PM. The patient was not registered, she was not listed on the ED Central Logs, and there was no medical record for the patient on 8/27/2025. The patient presented to Facility B where she was evaluated, treated, and discharged. 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: 30553 Based on review of facility policy, review of Emergency Department (ED) registration video, review of the ED Central Logs, and interview, the facility failed to ensure an accurate Emergency Department Central Log for one (1) patient (#3) who presented to the ED for evaluation of 20 ED records reviewed. The findings include: Review of the facility policy, “Emergency Medical Treatment & Active Labor Act (EMTALA) Guidelines,” revised 5/2024, showed “...Central Logs. All patients presenting to the Emergency Department requesting evaluation and treatment will be logged in the ED Log...the log will include the disposition of the patient and will indicate whether these individuals were...refused... treatment...denied...treatment...treated...admitted...condition...transferred... discharged...” Review of ED video footage dated 8/27/2025, showed the following: 7:13 PM (46 seconds) - a female and male entered the ED and went to the registration desk. The registration staff spoke with the female and male. 7:14 PM (28 seconds) - the female and male exited out of the ED entrance doors. Review of the ED Central Logs for 8/27/2025 showed the patient was not listed on the logs. During an interview on 9/2/2025 at 3:45 PM, Registration Clerk #1, confirmed the patient was not registered or placed on the ED Central Logs. During an interview and review of video footage in the ED Registration area on 9/2/2025 at 4:00 PM, the Chief Nursing Officer (CNO) and Director of Quality Management confirmed the patient arrived at the facility’s ED Registration area on 8/27/2025. They confirmed the patient was on the facility’s property and the patient was not listed on the facility’s ED Central Log. During an interview on 9/2/2025 at 4:15 PM, the ED Nurse Manager confirmed Patient #3 presented to the ED for evaluation and was not listed on the ED Central Log. Cross Refer to 2406.”

“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: 30553 Based on review of facility policy, review of Emergency Department (ED) registration video, medical record review, and interview, the facility failed to provide a Medical Screening Examination (MSE) for one (1) patient (#3) who presented to the ED for evaluation of 20 ED records reviewed. The findings include: Review of the facility policy, “Emergency Medical Treatment & Active Labor Act (EMTALA) Guidelines,” revised 5/2024, showed “...Medical Screening Examination: Medical screening examinations will be conducted by a Qualified Medical Professional (QMP) who is determined by the governing body of the hospital...EMTALA refers to the Federal Emergency Medical Treatment and Active Labor Act that required hospitals to provide emergency screening medical examinations, stabilization to all patients presenting to the hospital requesting such services and in certain circumstances or per patient request, appropriate transfer of the patient to another facility...” Review of ED video footage dated 8/27/2025 showed the following: 7:13 PM (46 seconds) - a female (identified as Patient #3) and male entered the ED and went to the registration desk. The registration staff spoke with the female and male. 7:14 PM (28 seconds) - the female and male exited out of the ED entrance doors. Medical record review showed there was no nursing triage or MSE provided for the patient on 8/27/2025. Medical record review of an ED record from Facility B dated 8/27/2025 at 7:45 PM, showed the patient presented with a syncopal episode and increased urinary frequency throughout the day. She was 9 weeks pregnant with her second child. During an interview on 9/2/2025 at 3:45 PM, Registration Clerk #1 stated she remembered the patient presenting to the ED on 8/27/2025. The patient stated she wanted an ultrasound related to being 9 weeks pregnant, she had almost passed out, and she was afraid she was having a miscarriage. Registration Clerk #1 informed the patient the facility did not offer Obstetric (OB) services and there was no obstetrician on staff. She informed the patient the closest facility would be [Facility B] and they would be able to provide an ultrasound. The patient left the facility. She confirmed the patient was not registered and she was not triaged. During an interview and video footage of the ED Registration area on 9/2/2025 at 4:00 PM, the Chief Nursing Officer and the Director of Quality Management confirmed the patient arrived at the facility’s ED Registration area on 8/27/2025. They confirmed the patient was on the facility’s property, she was not on the facility’s ED Central Log, there was no medical record for the patient and a nursing triage or MSE was not provided for the patient. During an interview on 9/2/2025 at 4:15 PM, the ED Nurse Manager confirmed all patients who come to the ED for evaluation should be registered, they should receive a nursing triage and a medical screening examination. The ED Nurse Manager confirmed the patient was not listed on the ED Central Log and the patient did not receive medical screening examination. During an interview on 9/3/2025 at 8:45 AM, ED Physician #1 confirmed all patients who presented to the ED seeking care should be registered, triaged, and receive a Medical Screening Examination. During an interview on 9/3/2025 at 9:50 AM, the Director of Registration and Chief Financial Officer stated if there were any questions related to a patient, the registration staff should notify the ED staff and/or ED Provider. They stated registration staff were non-clinical and were not clinically trained to evaluate patients. They confirmed the patient was not listed on the ED Central Logs and a medical record was not generated for Patient #3, who presented to the ED for evaluation.”