AlaFile E-Notice 02-CV-2013-902875.00 Judge: MICHAEL A YOUNGPETER To: DAVID A. MCDONALD dam@krmlaw.com NOTICE OF ELECTRONIC FILING IN THE CIRCUIT COURT OF MOBILE COUNTY, ALABAMA BENNIE J. HOLLINS ETC VS MOBILE INFIRMARY ASSOCATION ETC ET AL 02-CV-2013-902875.00 The following matter was FILED on 4/21/2016 1:16:37 PM C001 HOLLINS BENNIE J AS PERSONAL REP OF TH ESTATE OF MOTION TO STRIKE [Filer: MCDONALD DAVID ALLEN] Notice Date: 4/21/2016 1:16:37 PM JOJO SCHWARZAUER CIRCUIT COURT CLERK MOBILE COUNTY, ALABAMA 205 GOVERNMENT STREET MOBILE, AL 36644 251-574-8420 charles.lewis@alacourt.gov DOCUMENT 1181 STATE OF ALABAMA Revised 3/5/08 Unified Judicial System 02-MOBILE District Court BENNIE J. HOLLINS ETC VS MOBILE INFIRMARY ASSOCATION ETC ET AL ELECTRONICALLY FILED 4/21/2016 1:16 PM 02-CV-2013-902875.00 CIRCUIT COURT OF CV201390287500 MOBILE COUNTY, ALABAMA JOJO SCHWARZAUER, CLERK Case No. Circuit Court CIVIL MOTION COVER SHEET Name of Filing Party: C001 - HOLLINS BENNIE J AS PERSONAL REP OF TH ESTATE OF Oral Arguments Requested Name, Address, and Telephone No. of Attorney or Party. If Not Represented. DAVID A. MCDONALD POST OFFICE BOX 832 MOBILE, AL 36601 Attorney Bar No.: MCD042 TYPE OF MOTION Motions Requiring Fee Motions Not Requiring Fee Default Judgment ($50.00) Add Party Joinder in Other Party's Dispositive Motion (i.e. Summary Judgment, Judgment on the Pleadings, or other Dispositive Motion not pursuant to Rule 12(b)) ($50.00) Amend Change of Venue/Transfer Judgment on the Pleadings ($50.00) Compel Consolidation Continue Deposition Motion to Dismiss, or in the Alternative Summary Judgment($50.00) Designate a Mediator Judgment as a Matter of Law (during Trial) Renewed Dispositive Motion(Summary Judgment, Judgment on the Pleadings, or other Dispositive Motion not pursuant to Rule 12(b)) ($50.00) Disburse Funds Extension of Time Summary Judgment pursuant to Rule 56($50.00) Motion to Intervene ($297.00) In Limine Joinder Other More Definite Statement Motion to Dismiss pursuant to Rule 12(b) ($50.00) pursuant to Rule *Motion fees are enumerated in §12-19-71(a). Fees pursuant to Local Act are not included. Please contact the Clerk of the Court regarding applicable local fees. Local Court Costs $ New Trial Objection of Exemptions Claimed Pendente Lite Plaintiff's Motion to Dismiss Preliminary Injunction Protective Order Quash Release from Stay of Execution 0.00 Sanctions Sever Special Practice in Alabama Stay Strike Supplement to Pending Motion Vacate or Modify Withdraw Other pursuant to Rule Check here if you have filed or are filing contemoraneously with this motion an Affidavit of Substantial Hardship or if you are filing on behalf of an agency or department of the State, county, or municipal government. (Pursuant to §6-5-1 Code of Alabama (1975), governmental entities are exempt from prepayment of filing fees) Date: 4/21/2016 1:13:19 PM (Subject to Filing Fee) Signature of Attorney or Party: /s/ DAVID A. MCDONALD *This Cover Sheet must be completed and submitted to the Clerk of Court upon the filing of any motion. Each motion should contain a separate Cover Sheet. **Motions titled 'Motion to Dismiss' that are not pursuant to Rule 12(b) and are in fact Motions for Summary Judgments are subject to filing fee. DOCUMENT 1182 ELECTRONICALLY FILED 4/21/2016 1:16 PM 02-CV-2013-902875.00 CIRCUIT COURT OF MOBILE COUNTY, ALABAMA JOJO SCHWARZAUER, CLERK IN THE CIRCUIT COURT OF MOBILE COUNTY, ALABAMA * BENNIE J. HOLLINS, as the Personal Representative of the Estate of LeJuan C. Johnson, deceased, * * Plaintiff, * vs. Civil Action No.: 13-902875 * MOBILE INFIRMARY ASSOCIATION d/b/a MOBILE INFIRMARY MEDICAL CENTER; et al. * * Defendants. * PLAINTIFF’S CONSOLIDATED RESPONSE TO MIMC’S MOTION FOR PROTECTIVE ORDER, MOTION TO STRIKE PORTIONS OF AFFIDAVIT OF KELLEY HICKS, AND MOTION TO STRIKE MIMC EXHIBITS B AND C COMES NOW the plaintiff in the above styled cause by and through counsel of record and files this consolidated response to MIMC’s motion for protective order, motion to strike all or a portion of the affidavit of Kelley Hicks, as well as MIMC exhibits B and C and as grounds therefor states as follows: 1. Mobile Infirmary Medical Center (MIMC) is a “Medicare participating hospital.” All “Medicare participating hospitals” must abide by the requirements of the Emergency Medical Treatment and Labor Act (EMTALA), the accompanying regulations found in 42 § 489.24, and the related requirements of 42 CFR 489.20(l), (m), (q), and (r). [Ex. A, “State Operations Manual Appendix V”]. 2. In short, MIMC must provide a medical screening examination to every patient to determine whether an “emergency medical condition” exists, and 1 DOCUMENT 1182 MIMC must treat every “emergency medical condition,” regardless of the patient’s ability to pay. [Ex. A]. 3. In addition to the financial penalties established by EMTALA, any “Medicare participating hospital” that violates EMTALA risks being terminated as a “Medicare participating hospital.” [Ex. A]. 4. The Centers for Medicare and Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services. CMS administers the Medicare and Medicaid Insurance programs, and among other things, coordinates and oversees investigations of EMTALA violations. [Ex. A, B, & C]. 5. CMS is not a healthcare provider and does not conduct “peer reviews.” See Yocabet v. UPMC Presbyterian 119 So. 3d 1012 (Pa. 2015). CMS investigations are “a complaint driven process,” meaning that if CMS receives a complaint regarding a possible EMTALA violation, CMS will conduct an “unannounced” investigation to ascertain: “whether a violation took place, to determine whether the violation constitutes an immediate and serious threat to patient health and safety, to identify any pattern of violations at the facility, and to assess whether the facility has policies and procedures to address the provisions of the EMTALA law.” [Ex. A, p.6]. 6. Between June 24, 2013 and June 26, 2013, CMS, through the Alabama Department of Public Health (ADPH), conducted an unannounced investigation of MIMC to determine whether MIMC had violated EMTALA by 2 DOCUMENT 1182 refusing to treat LeJuan Johnson, by dragging LeJuan Johnson out of MIMC’s emergency room, and by dumping LeJuan Johnson out in the cold in a nearby parking lot. [Ex. B, CMS Report]. 7. After interviewing the MIMC employees involved in this and another incident in which a patient died in MIMC’s parking lot after MIMC refused treatment, CMS concluded that MIMC’s “deficiencies are so serious that they constitute an immediate and serious threat to the health and safety of any individuals who come to the emergency department and request examination or treatment for an emergency medical condition… Consequently, we plan to terminate [MIMC’s] participation in the Medicare program.” [Ex. C, November 1, 2013 termination letter]. 8. After it received this preliminary notice of termination, MIMC managed to avoid CMS’s death sentence by implementing measures mandated by CMS. 9. MIMC wishes to keep the CMS investigation, interviews, and notice of termination out of the public eye. However, nothing within CMS’s investigation of MIMC for MIMC’s violation of federal law is protected by either Ala. Code §22-218 or Ala. Code §6-5-333, (the statues relied upon by MIMC). 10. MIMC tries to make the CMS investigation fit into the above statutes by filing the affidavit of Kelley Hicks, MIMC’s Executive Director of Nursing, and by filing exhibits regarding entities that had nothing to do with CMS’s investigation. 11. Hicks claims that she was “involved in” the CMS investigation. [MIMC’s Ex. A, Hicks aff., ¶3]. Hicks was “involved in” CMS’s investigation of 3 DOCUMENT 1182 MIMC the same way a suspect may be said to be “involved in” the criminal investigation of a murder. The correct term that Hicks is searching for is that she, as a MIMC director, was a “subject” of CMS’s investigation. 12. To the extent that Hicks’s affidavit purports to establish the purpose and scope of CMS’s investigation, Hicks’s affidavit must be stricken for lack of personal knowledge. Hicks was never employed by CMS, Hicks did not participate in the investigation of MIMC on CMS’s behalf, Hicks was not in any way involved in CMS’s conclusion that MIMC posed “an immediate and serious threat to the health and safety of any individual who comes to the emergency department,” and Hicks did not participate in CMS’s decision to terminate MIMC as a Medicare facility. 13. At best, Hicks was interviewed by CMS and Hicks received a copy of CMS’s termination letter. Accordingly, Hicks’s self-serving, conclusory statement that “the materials and reports generated by CMS/AQAF and Mobile Infirmary during the survey were created for quality assurance purposes and to ensure that patient care satisfies the high quality standards established by Medicare” is not based on her personal knowledge, is, in fact, contrary to CMS’s stated purpose for investigating MIMC, and should be stricken from the record. 14. Because CMS is not a healthcare provider and does not conduct “peer reviews” or “accreditation” neither Ala. Code §22-21-8 nor Ala. Code §6-5-333 apply in this case. 4 DOCUMENT 1182 15. In her affidavit, Hicks subtly converts the CMS investigation into what she calls a “CMS/AQAF survey.” MIMC attached as “Exhibit C” to its motion for protective order information about AQAF, an Alabama non-profit which MIMC claims is either a “peer review” organization or an “accrediting agency.” The problem with this is that MIMC has presented no evidence that AQAF had anything to do with the CMS investigation. 16. To the contrary, CMS’s November 1, 2013 termination letter to MIMC [Plaintiff’s Ex. C] makes clear that CMS conducted its investigation through the Alabama Department of Public Health, not AQAF. Because MIMC has offered no evidence that AQAF had anything to do with the CMS investigation, “Exhibit C” to MIMC’s motion for protective order should be stricken. Even if the Court elects not to strike MIMC’s “Exhibit C”, no weight should be given this exhibit because MIMC has failed to establish its relevance. 17. Similarly, “Exhibit B” to MIMC’s motion contains information about a Quality Improvement Organization (QIO), but MIMC has presented no evidence that ties QIO to the CMS investigation that led to the November 1, 2013 termination letter. At best, MIMC can demonstrate that QIO was notified of CMS’s decision to terminate MIMC as a Medicare hospital. This does not convert CMS’s investigation into a “peer review” or review by a “accrediting agency.” Because MIMC has offered no evidence that QIO had anything to do with the CMS 5 DOCUMENT 1182 investigation, “Exhibit C” to MIMC’s motion for protective order should be stricken, or if not stricken, given no weight since MIMC has failed to establish its relevance. WHEREFORE, the premises considered, the plaintiff requests this Court strike the affidavit of Kelley Hicks as well as exhibits B and C attached to MIMC’s motion for protective order, and regardless of the Court’s ruling on plaintiff’s motion to strike, plaintiff requests this Court deny MIMC’s motion for protective order, and for such further, other, and different relief to which plaintiff is entitled. /S/DAVID A. McDONALD DAVID A. McDONALD (MCD042) KILBORN, ROEBUCK & MCDONALD P.O. Box 832 Mobile, Alabama 36601 Telephone: (251) 434-0045 Fax: (251) 434-0047 Attorney for Plaintiff OF COUNSEL: Vincent F. Kilborn, III (KIL004) KILBORN, ROEBUCK & MCDONALD P. O. Box 66710 Mobile, Alabama 36660 Telephone: (251) 479-9010 Facsimile: (251) 479-6747 Andrew T. Citrin (CIT001) CITRIN LAW FIRM, P. C. Post Office Drawer 2187 Daphne, Alabama 36526 Telephone: (251) 621-3000 Facsimile: (251) 626-4943 6 DOCUMENT 1182 S. Russ Copeland (COP018) THE GARDNER FIRM 210 S. Washington Avenue Mobile, AL 36602 Telephone: (251) 433-8100 Facsimile: (251) 433-8181 Barry Johnson Parker (JOH107) 1508 Captain O’Neal Drive Daphne, AL 36526 Telephone: (251) 285-9987 CERTIFICATE OF SERVICE I hereby certify that I have on this the 21st day of April, 2016, served a copy of the foregoing pleading by electronically filing with the Clerk of the Court using the AlaFile system, which will send notification of such filing to the following: Attorneys for Mobile Infirmary Association Tamela E. Esham Norman Waldrop, Jr. S. Gaillard Ladd ARMBRECHT JACKSON LLP Post Office Box 290 Mobile, Alabama 36601 Attorneys for Shawn Poff Michael E. Upchurch, Esq. Ross A. Frazer, Esq. Dorothy A. Barker FRAZER, GREENE, UPCHURCH & BAKER, L.L.C. Post Office Box 1686 Mobile, AL 36633 Attorneys for Jerry Ripple Carroll H. Sullivan SCOTT, SULLIVAN, STREETMAN & FOX, PC 10th Floor Regions Bank Building P. O. Box 1034 Mobile, AL 36633 7 /s/ David A. McDonald EXHIBIT A DOCUMENT 1182 State Operations Manual Appendix V – Interpretive Guidelines – Responsibilities of Medicare Participating Hospitals in Emergency Cases _______________________________________________________________________ (Rev. 60, 07-16-10) Transmittals for Appendix V Part I- Investigative Procedures I. General Information II. Principal Focus of Investigation III. Task 1 - Entrance Conference IV. Task 2 - Case Selection Methodology V. Task 3- Record Review VI. Task 4- Interviews VII. Task 5-Exit Conference VIII. Task 6- Professional Medical Review IX. Task 7- Assessment of Compliance and Completion of the Deficiency Report X. Additional Survey Report Documentation ______________________________________________________________________ Part II - Interpretive Guidelines - Responsibilities of Medicare Participating Hospitals in Emergency Cases §489.20 Basic Section 1866 Commitments Relevant to Section 1867 Responsibilities §489.20(l) §489.20(m) §489.20(q) §489.20(r) §489.24(j) Availability of On-Call physicians §489.24 Special Responsibilities of Medicare Hospitals in Emergency Cases §489.24(a) Applicability of Provisions of this Section §489.24(c) Use of Dedicated Emergency Department for Nonemergency Services §489.24(d) Necessary Stabilizing Treatment for Emergency Medical Conditions §489.24(e) Restricting Transfer Until the Individual Is Stabilized §489.24(f) Recipient Hospital Responsibilities ________________________________________________________________________ DOCUMENT 1182 Part I- Investigative Procedures I. General Information Medicare participating hospitals must meet the Emergency Medical Treatment and Labor Act (EMTALA) statute codified at §1867 of the Social Security Act, (the Act) the accompanying regulations in 42 CFR §489.24 and the related requirements at 42 CFR 489.20(l), (m), (q), and (r). EMTALA requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition (EMC). The term “hospital” includes critical access hospitals. The provisions of EMTALA apply to all individuals (not just Medicare beneficiaries) who attempt to gain access to a hospital for emergency care. The regulations define “hospital with an emergency department” to mean a hospital with a dedicated emergency department (ED). In turn, the regulation defines “dedicated emergency department” as any department or facility of the hospital that either (1) is licensed by the state as an emergency department; (2) held out to the public as providing treatment for emergency medical conditions; or (3) on one-third of the visits to the department in the preceding calendar year actually provided treatment for emergency medical conditions on an urgent basis. These three requirements are discussed in greater detail at Tag A406. The enforcement of EMTALA is a complaint driven process. The investigation of a hospital’s policies/procedures and processes and any subsequent sanctions are initiated by a complaint. If the results of a complaint investigation indicate that a hospital violated one or more of the anti-dumping provisions of §1866 or 1867 (EMTALA), a hospital may be subject to termination of its provider agreement and/or the imposition of civil monetary penalties (CMPs). CMPs may be imposed against hospitals or individual physicians for EMTALA violations. The RO evaluates and authorizes all complaints and refers cases to the SA that warrant investigation. The first step in determining if the hospital has an EMTALA obligation is for the surveyor verify whether the hospital in fact has a dedicated emergency department (ED). To do so, the surveyor must check whether the hospital meets one of the criteria that define whether the hospital has a dedicated emergency department. As discussed above, a dedicated emergency department is defined as meeting one of the following criteria regardless of whether it is located on or off the main hospital campus: The entity: (1) is licensed by the State in which it is located under applicable State law as an emergency room or emergency department; or (2) is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions (EMC) on an urgent basis without requiring a previously scheduled appointment; or (3) during the preceding calendar year, (i.e., the year immediately preceding the calendar year in which a determination under this section is being made), based on a representative sample of patient visits that occurred during the calendar year, it provides at least one-third of all of its visits for the treatment of EMCs on an urgent DOCUMENT 1182 basis without requiring a previously scheduled appointment. This includes individuals who may present as unscheduled ambulatory patients to units (such as labor and delivery or psychiatric units of hospitals) where patients are routinely evaluated and treated for emergency medical conditions. Hospitals with dedicated emergency departments are required to take the following measures: Adopt and enforce policies and procedures to comply with the requirements of 42 CFR §489.24; Post signs in the dedicated ED specifying the rights of individuals with emergency medical conditions and women in labor who come to the dedicated ED for health care services, and indicate on the signs whether the hospital participates in the Medicaid program; Maintain medical and other records related to individuals transferred to and from the hospital for a period of five years from the date of the transfer; Maintain a list of physicians who are on-call to provide further evaluation and or treatment necessary to stabilize an individual with an emergency medical condition; Maintain a central log of individual’s who come to the dedicated ED seeking treatment and indicate whether these individuals: Refused treatment, Were denied treatment, Were treated, admitted, stabilized, and/or transferred or were discharged; Provide for an appropriate medical screening examination; Provide necessary stabilizing treatment for emergency medical conditions and labor within the hospital’s capability and capacity; Provide an appropriate transfer of an unstabilized individual to another medical facility if: The individual (or person acting on his or her behalf) after being informed of the risks and the hospital’s obligations requests a transfer, DOCUMENT 1182 A physician has signed the certification that the benefits of the transfer of the patient to another facility outweigh the risks or A qualified medical person (as determined by the hospital in its by-laws or rules and regulations) has signed the certification after a physician, in consultation with that qualified medical person, has made the determination that the benefits of the transfer outweigh the risks and the physician countersigns in a timely manner the certification. (This last criterion applies if the responsible physician is not physically present in the emergency department at the time the individual is transferred. Provide treatment to minimize the risks of transfer; Send all pertinent records to the receiving hospital; Obtain the consent of the receiving hospital to accept the transfer, Ensure that the transfer of an unstabilized individual is effected through qualified personnel and transportation equipment, including the use of medically appropriate life support measures; Medical screening examination and/or stabilizing treatment is not to be delayed in order to inquire about payment status; Accept appropriate transfer of individuals with an emergency medical condition if the hospital has specialized capabilities or facilities and has the capacity to treat those individuals; and Not penalize or take adverse action against a physician or a qualified medical person because the physician or qualified medical person refuses to authorize the transfer of an individual with an emergency medical condition that has not been stabilized or against any hospital employee who reports a violation of these requirements. If the hospital does not have a dedicated emergency department as defined in 42 CFR §489.24(b), apply 42 CFR §482.12(f) which requires the hospital’s governing body to assure that the medical staff has written policies and procedures for appraisal of emergencies and the provision of initial treatment and referral (Form CMS-1537, “Medicare/Medicaid Hospital Survey Report”). DOCUMENT 1182 Hospitals that violate the provisions in 42 CFR §489.24 or the related requirements in 42 CFR §489.20(l), (m), (q), and (r) are subject to civil monetary penalties or termination. A hospital is required to report to CMS or the State survey agency promptly when it suspects it may have received an improperly transferred individual. Notification should occur within 72 hours of the occurrence. Failure to report improper transfers may subject the receiving hospital to termination of its provider agreement. To assure that CMS is aware of all instances of improper transfer or potential violations of the other anti-dumping requirements, the State survey agencies must promptly report to the RO all complaints related to violations of 42 CFR §489.24 and the related requirements at 42 CFR §489.20(l), (m), (q), and (r). The RO will decide whether a complaint alleges a violation of these requirements and warrants an investigation. Quality of care review performed either by the SA or other physicians must not delay processing of a substantiated EMTALA violation. If during the course of the investigation, you identify possible quality of care issues other than those related to the provisions of this regulation, obtain a copy of the patient’s medical record and send the case to the RO for referral to the appropriate Quality Improvement Organization (QIO). Contact the RO if the hospital refuses to provide a copy of the medical record. If you suspect emergency services are being denied based on diagnosis (e.g., AIDS), financial status, race, color, national origin, or handicap, refer the cases to the RO. The RO will forward the cases to the Office of Civil Rights (OCR) for investigation of discrimination. A hospital must formally determine who is qualified to perform the initial medical screening examinations, i.e., qualified medical person. While it is permissible for a hospital to designate a non-physician practitioner as the qualified medical person, the designated non-physician practitioners must be set forth in a document that is approved by the governing body of the hospital. Those health practitioners designated to perform medical screening examinations are to be identified in the hospital by-laws or in the rules and regulations governing the medical staff following governing body approval. It is not acceptable for the hospital to allow the medical director of the emergency department to make what may be informal personnel appointments that could frequently change. If it appears that a hospital with an dedicated ED does not have adequate staff and equipment to meet the needs of patients, consult the RO to determine whether or not to expand the survey for compliance with the requirements of 42 CFR §482.55 (“Condition of Participation: Emergency Services”). Look for evidence that the procedures and policies for emergency medical services (including triage of patients) are established, evaluated, and updated on an ongoing basis. DOCUMENT 1182 The hospital should have procedures, which assure integration with other hospital services (e.g., including laboratory, radiology, ICU, and operating room services) to ensue continuity of care. II. Principal Focus of Investigation Investigate for compliance with the regulations in 42 CFR §489.24 and the related requirements in 42 CFR §489.20(l), (m), (q), and (r). All investigations are to be unannounced. The investigation is based on an allegation of noncompliance. The purpose of the investigation is to ascertain whether a violation took place, to determine whether the violation constitutes an immediate and serious threat to patient health and safety, to identify any patterns of violations at the facility, and to assess whether the facility has policies and procedures to address the provisions of the EMTALA law. The investigation must be completed within 5 working days of the RO authorization. The focus of the investigation is on the initial allegation of violation and the discovery of additional violations. If the allegation is not confirmed, the surveyors must still be assured that the hospital’s policies and procedures, physician certifications of transfers, etc., are in compliance with the requirements of 42 CFR §489.24 and the related requirements at 42 CFR §489.20(l), (m), (q), and (r). If the allegation(s) is confirmed, the investigation would continue, but with an emphasis on the hospital’s compliance within the last 6 months. Ensure that the case(s), if substantiated, is (are) fully documented on Form CMS-2567, Statement of Deficiencies and Plan of Correction. The investigation paperwork should be completed within ten working days following completion of the onsite survey if it appears there may be a violation of §§1866 and 1867 of the Act (the paperwork is to be in the RO possession by the 20th working day or less following completion of the onsite survey. This includes the 5 days allowed to complete the onsite investigation). If there appears not to be a violation, and the responsibilities of Medicare participating hospitals in emergency cases appear to be met, the time frame to complete the paperwork and return to the RO may be extended to 15 working days (the paperwork is to be in the RO possession by the 25th working day or less following completion of the onsite survey. This includes the 5 days allowed to complete the onsite investigation). Once the investigation is complete the RO is strongly encouraged to share as much information with the hospital as possible in accordance with the Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA) regarding the complaint and investigation. The RO may also include any facts about the violation, a copy of any medical reviews (the identity of the reviewer must be deleted), and the identity of the patient involved (not the identity of the complainant or source of the complaint). CMS will determine if the violation constitutes immediate jeopardy to patient health and safety. The hospital has the opportunity to present evidence to CMS that it believes demonstrates its compliance and the opportunity to comment on evidence CMS believes demonstrates DOCUMENT 1182 the hospital’s noncompliance. CMS’ regional offices retain delegated enforcement authority and final enforcement decisions are made there. III. Task 1 - Entrance Conference A brief entrance conference must be held with the CEO/president of the hospital (or his or her designee) and any other staff the CEO considers appropriate to explain the nature of the allegation, the purpose of the investigation, and the requirements against which the complaint will be investigated. The identity of the complainant and patient must always be kept confidential unless written consent is obtained. Ask the CEO to have the staff provide you with the following information (as appropriate): Dedicated ED logs for the past 6-12 months; The dedicated ED policy/procedures manual (review triage and assessment of patients presenting to the ED with emergency medical conditions, assessment of labor, transfers of individuals with emergency medical conditions, etc.); Consent forms for transfers of unstable individuals; Dedicated ED committee meeting minutes for the past 12 months; Dedicated ED staffing schedule (physicians for the past 3 months and nurses for the last 4 weeks) or as appropriate; Bylaws/rules and regulations of the medical staff; Minutes from medical staff meetings for the past 6-12 months; Current medical staff roster; Physician on-call lists for the past 6 months; Credential files (to be selected by you) include the director of the emergency department and emergency department physicians. Review of credentials files is optional. However, if there has been a turnover in significant personnel (e.g., the ED director) or an unusual turnover of ED physicians, or a problem is identified during record review of a particular physician’s screening or treatment in the ER, credentials files should be obtained and reviewed; Quality Assessment and Performance Improvement (QAPI) Plan (formally known as Quality Assurance); QAPI minutes (request the portion of the quality improvement minutes and plan, which specifically relates to EMTALA regulations. If a problem is identified that DOCUMENT 1182 would require a more thorough review, additional portions of the quality improvement plan and minutes may be requested for review); List of contracted services (request this list if a potential violation of §1866 and 1867 of the Act is noted during the investigation and the use of contracted services is questioned); Dedicated ED personnel records (optional); In-service training program records, schedules, reports, etc. (optional review if questions arise through interview and record review regarding the staff’s knowledge of 42 CFR §489.24); Ambulance trip reports and memoranda of transfer, if available (to be selected by you if the cases you are reviewing concern transfers); and Ambulance ownership information and applicable State/regional/community EMS protocols. In addition, if the case you are investigating occurred prior to the time frames mentioned, examine the above records for a three-month period surrounding the date of the alleged violation. Inform the CEO that you will be selecting a sample of cases (medical records) for review from the ED log and that you will require those records in a timely fashion. IV. Task 2 - Case Selection Methodology Even though a single occurrence is considered a violation a sample is done to identify additional violations and/or patterns of violations. A. Sample Size. Select 20-50 records to review in depth, using the selection criteria described below. The sample is not intended to be a statistically valid sample and the sample selection should be focused on potential problem areas. The sample size should be expanded as necessary in order to adequately investigate possible violations or patterns of violations. B. Sample Selection. The type of records sampled will vary based on the nature of the complaint and the types of patients requesting emergency services. Do not allow the facility staff to select the sample. Use the emergency department log and other appropriate information, such as patient charts, to identify: Individuals transferred to other facilities; Gaps, return cases, or nonsequential entries in the log; DOCUMENT 1182 Refusals of examination, treatment, or transfer; Patients leaving against medical advice or left without being seen (LWBS); and Patients returning to the emergency department within 48 hours. Sample selection requires that: 1. You identify the number of emergency cases seen per month for each of the 6 months preceding the survey. Place this information on Form CMS-1541B, “Responsibilities of Medicare Participating Hospitals in Emergency Cases Investigation Report,” (Exhibit 137). 2. You identify the number of transfers of emergency patients to other acute care hospitals per month for each of the preceding 6 months. Review in-depth, transfers of patients where it appears that the transferring hospital could have provided continuing medical care. Place this information on Form CMS-1541B. 3. You include the complaint case (s) in the sample, regardless of how long ago it occurred. Select other cases at the time of the complaint in order to identify patterns of hospital behavior and to help protect the identity of the patient. 4. If the complaint case did not involve an inappropriate transfer (e.g., the complaint was for failure to provide an adequate screening examination, or a hospital with specialized capabilities refused an appropriate transfer), identify similar cases and review them. 5. If you identify additional violations, determine, if possible, whether there is a pattern related to: Diagnosis (e.g., labor, AIDS, psych); Race; Color; Type of health insurance (Medicaid, uninsured, under-insured, or managed care); Nationality; or Disability. DOCUMENT 1182 Representative Sample Size for the dedicated emergency department if applicable: The SA surveyor should consult with the RO prior to conducting the representative sample of patient visits for a hospital department to determine whether the department meets the criteria of being a dedicated emergency department. To determine if a hospital department is a dedicated emergency department because it meets the “one-third requirement” described above (i.e., the hospital, in the preceding year, had at least one-third of all of its visits for the treatment of EMCs on an urgent basis without requiring a previously scheduled appointment) the surveyor is to select a representative sample of patient visits that occurred the previous calendar year in the area of the hospital to be evaluated for status as a dedicated emergency department. This includes individuals who may present as unscheduled ambulatory patients to units (such as labor and delivery or psychiatric units of hospitals) where patients are routinely admitted for evaluation and treatment. The surveyors will review the facility log, appointment roster and other appropriate information to identify patients seen in the area or facility in question. Surveyors are to review 20 - 50 records of patients with diagnoses or presenting complaints, which may be associated with an emergency medical condition (e.g., cardiac, respiratory, pediatric patients (high fever, lethargic), loss of consciousness, etc.). Surveyors have the discretion (in consultation with the regional office) to expand the sample size as necessary in order to adequately investigate possible violations or patterns of violations. Do not allow the facility staff to select the sample. Review the selected cases to determine if patients had an emergency medical condition and received stabilizing treatment. If at least one-third of the sample cases reviewed were for the treatment of EMCs on an urgent basis without requiring a previously scheduled appointment, the area being evaluated is a dedicated emergency department, and therefore, the hospital has an EMTALA obligation. Hospitals that may meet this one-third criterion may be specialty hospitals (such as psychiatric hospitals), hospitals without “traditional” emergency departments, and urgent care centers. In addition, it is not relevant if the entity that meets the definition of a dedicated ED is not located on the campus of the main hospital. DOCUMENT 1182 Guidelines to determine if a department of a hospital meets the one-third criteria of being a dedicated emergency department: For each case, the surveyors should answer three questions. 1. Was the individual an outpatient? Y 2. Was the individual a walk-in (unscheduled appointment)? Y 3. N If not, what was his or her status (e.g., inpatient, visitor or other)? N Did the individual have an EMC, and received stabilizing treatment? Y N (NOTE- an affirmative yes must be present for both parts of this question for the case to be counted toward the one-third criterion to be met. If no is answered for any part of this question, the criterion was not met, and select no for the overall answer). All questions must have an answer of yes to confirm that the case is included as part of the percentage (one-third) to determine if the hospital has a dedicated emergency department. If one-third of the total cases being reviewed receive answers of “yes” to the three questions above, then the hospital has an EMTALA obligation. Document information concerning your sample selection on a blank sheet of paper or SA worksheet and label it “Summary Listing of Sampled Cases.” Include the dates the individuals requested services, any identifier codes used to protect the individual’s confidentiality, and the reasons for your decision to include these individuals in your sample. V. Task 3- Record Review While surveyors may make preliminary findings during the course of the investigation, a physician must usually determine the appropriateness of the MSE, stabilizing treatment, and transfer. Because expert medical review is usually necessary, obtain copies of the medical and other record(s) of the alleged violation case (both hospitals if an individual sought care at two hospitals or were transferred) and any other violation cases identified in the course of the investigation. Also, review documents pertaining to QAPI activities in the emergency department and remedial actions taken in response to a violation of these regulations. Document hospital corrective actions taken prior to the survey and take such corrective action into account when developing your recommendation to the RO. DOCUMENT 1182 In an accredited hospital, if it appears that CoPs are not met, contact the RO for authorization to extend the investigation. If you are conducting the investigation in a non-accredited hospital, you may expand the investigation to include other conditions without contacting the RO first. When there is insufficient information documented on the emergency record regarding a request for emergency care, it may be helpful to interview hospital staff, physicians, witnesses, ambulance personnel, the individual, or the individual’s family. Ask for RO guidance if you are still unable to obtain a consistent and reliable account of what happened. Any time delivery of a baby occurs during transfer, obtain a copy of all available records and refer the case for review to the QIO physician reviewer. If you are unsure whether qualified personnel and or transportation equipment were used to effectuate a transfer, review the hospital’s transfer policies, and obtain a copy of the medical record and transfer records. In cases where treatment is rendered to stabilize an EMC, the medical records should reflect the medically indicated treatment necessary to stabilize it, the medications, treatments, surgeries and services rendered, and the effect of treatment on the individual’s emergency condition or on the woman’s labor and the unborn child. The medical records should contain documentation such as: medically indicated screenings, tests, mental status evaluation, impressions, and diagnoses (supported by a history and physical examination, laboratory, and other test results) as appropriate. For pregnant women, the medical records should show evidence that the screening examination included ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of the membranes, i.e., ruptured, leaking, intact. For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. In cases where an individual (or person acting in the individual’s behalf) withdrew the initial request for a medical screening examination (MSE) and/or treatment for an EMC and demanded his or her transfer, or demanded to leave the hospital, look for a signed informed refusal of examination and treatment form by either the individual or a person acting on the individual’s behalf. Hospital personnel must inform the individual (or person acting on his or her behalf) of the risks and benefits associated with the transfer or the patient’s refusal to seek further care. If the individual (or person acting in the individual’s behalf) refused to sign the consent form, look for documentation by the hospital personnel that states that the individual refused to sign the form. The fact that an individual has not signed the form is not, however, automatically a violation of the DOCUMENT 1182 screening requirement. Hospitals must, under the regulations, use their best efforts to obtain a signature from an individual refusing further care. Examine the ambulance trip reports in questionable transfer cases (if available). These records can answer questions concerning the appropriateness of a transfer and the stability of the individual during the transfer. Appropriate record review should also be conducted at the receiving (or recipient) hospital if the alleged case and any other suspicious transfer cases involve the transfer or movement of the individual to another hospital. Document all significant record review findings in the complaint investigation narrative. VI. Task 4- Interviews To obtain a clear picture of the circumstances surrounding a suspected violation of the special responsibilities of Medicare hospitals in emergency cases, it is necessary to interview facility staff. For example, you may be able to gather a great deal of information from the admitting clerk in the emergency department, the nurses on shift at the time the individual sought treatment, and the Director of Quality Improvement in the hospital to name a few. You may also need to interview witnesses, the patient, and/or the patient’s family. The physician(s) involved in the incident should be interviewed. Document each interview you conduct on a blank sheet of paper or SA worksheet and label it “Summary of Interviews.” Include the following information, as appropriate, in your notes for each interview: The individual’s job title and assignment at the time of the incident; Relationship to the patient and/or reason for the interview; and Summary of the information obtained. Appropriate interviews should also be conducted at the receiving hospital in cases of transfer or movement of the individual to another hospital. VII. Task 5-Exit Conference The purpose of the exit conference is to inform the hospital of the scope of the investigation, including the nature of the complaint, investigation tasks, and requirements investigated, and any hospital CoPs surveyed. Explain to the hospital staff the consequences of a violation of the requirements in 42 CFR §489.24 or the related requirements in 42 CFR §489.20(l), (m), (q), and (r) and the time frames that will be followed if a violation is found. Do not tell the hospital whether or not a violation was identified since it is the responsibility of the RO to make that determination. Inform the CEO (or his or her designee) that the RO will make the determination of compliance DOCUMENT 1182 based on the information collected during this investigation and any additional information acquired from physician review of the case. Do not leave a draft of the deficiencies of Form CMS-2567 with the hospital. Inform the hospital that the RO will send that information to the hospital once it is complete. VIII. Task 6- Professional Medical Review The purpose of a professional medical review (physician review) is to provide peer review using information available to the hospital at the time the alleged violation took place. Physician review is required prior to the imposition of CMPs or the termination of a hospital’s provider agreement to determine if: The screening examination was appropriate. Under EMTALA, the term “appropriate” does not mean “correct”, in the sense that the treating emergency physician is not required to correctly diagnose the individual’s medical condition. The fact that a physician may have been negligent in his screening of an individual is not necessarily an EMTALA violation. When used in the context of EMTALA, “appropriate” means that the screening examination was suitable for the symptoms presented and conducted in a nondisparate fashion. Physician review is not necessary when the hospital did not screen the individual; The individual had an emergency medical condition. The physician should identify what the condition was and why it was an emergency (e.g., what could have happened to the patient if the treatment was delayed); In the case of a pregnant woman, there was inadequate time to affect a safe transfer to another hospital before delivery, or the transfer posed a threat to the health and safety of the woman or the unborn child; The stabilizing treatment was appropriate within a hospital’s capability (NOTE that the clinical outcome of an individual’s medical condition is not the basis for determining whether an appropriate screening was provided or whether the person transferred was stabilized); The transfer was effected through qualified personnel and transportation equipment, including the use of medically appropriate life support measures; If applicable, the on-call physician’s response time was reasonable; and DOCUMENT 1182 The transfer was appropriate for the individual because the individual; requested the transfer or because the medical benefits of the transfer outweighed the risk. If you recommend a medical review of the case, indicate on Form CMS-1541B that you recommend such a review. IX. Task 7- Assessment of Compliance and Completion of the Deficiency Report A. Analysis. Analyze your findings relative to each provision of the regulations for the frequency of occurrence, dates of occurrence, and patterns in terms of race, color, diagnosis, nationality, handicap, and financial status. A single occurrence constitutes a violation and is sufficient for an adverse recommendation. Older cases where the hospital implemented corrective actions with no repeat violations may require consultation with the RO concerning appropriate recommendations. If a team conducted the investigation, the team should meet to discuss the findings. Consider information provided by the hospital. Ask the hospital for additional information or clarification about particular findings, if necessary. Review each regulation tag number sequentially in this Appendix, and come to a consensus as to whether or not the hospital complies with each stated requirement. The following outline may be helpful in this review. For each requirement recommended as not met, record all salient findings on the Form CMS-2567. Outline of Data Tags Used for Citing Violations of Responsibilities of Medicare Participating Hospitals in Emergency Cases Deficiency Tags A400 Requirements (§489.20) Policies and Procedures Which Address AntiDumping Provisions A401 (§489.20(m)) Receiving Hospitals Must Report Suspected Incidences of IndividualsWith An Emergency Medical Condition Transferred in Violation of §489.24(e) A402 (§489.20(q)) Sign Posting A403 (§489.24(r)) Maintain Transfer Records for Five Years A404 (§489.20(r)(2); §489.24(j)) On-Call Physicians A405 (§489.20(r)(3)) Logs DOCUMENT 1182 Deficiency Tags A406 Requirements (§489.24(a); §489.24(c)) Appropriate Medical Screening Examination A407 (§489.24(d)(3)) Stabilizing Treatment (§489.24(d)(4)) A408 (§489.24(d)(4) and (5)) No Delay in Examination or Treatment in Order to Inquire About Payment Status A409 (§489.24 (e)(1) and (2)) Appropriate Transfer A410 (§489.24(e)(3)) Whistleblower Protections A411 (§489.24(f)) Recipient Hospital Responsibilities (Nondiscrimination) B. Composing the Statement of Deficiencies (Form CMS-2567). Support all deficiency citations by documenting evidence obtained from your interviews and record reviews on Form CMS-2567, “Statement of Deficiencies and Plan of Correction.” Deficiencies related to the Conditions of Participation should also be documented on Form CMS-2567. Indicate whether your findings show that the deficiency constitutes an immediate jeopardy to patient health and safety (e.g., a situation that prevents individuals from getting medical screening examinations and/or a lack of treatment reflecting both the capacity and capability of the hospital’s full resources, as guaranteed under §1867 of the Act). Some examples include stabilizing treatment not provided when required; failure of an on-call physician to respond appropriately, improper transfer; or evidence that there was a denial of medical screening examinations and/or treatment to persons with emergency medical conditions as a direct result of requesting payment information before assessment of the individual’s medical condition. Examples of noncompliance, which usually does not pose an immediate jeopardy, include the following scenarios: 1. A transfer which was appropriate, but the physician certification was not signed or dated by the physician; 2. An appropriate, functioning central log that on one particular day in not fully completed; and 3. A written hospital policy that is missing, but nonetheless being implemented. Do not make a medical judgment, but focus on the processes of the facility “beyond the paper.” Identify whether single incidents of patient dumping, which do not represent a hospital’s customary practice, are nonetheless serious and capable of being repeated. DOCUMENT 1182 Immediate jeopardy violations require a 23-day termination track. Non-immediate jeopardy violations require a 90-day termination track. Write the deficiency statement in terms specific enough to allow a reasonably knowledgeable person to understand the aspect(s) of the requirement(s) that is (are) not met. Do not prescribe an acceptable remedy. Indicate the data prefix tag and regulatory citation, followed by a summary of the deficiency and supporting findings. When it is necessary to use specific examples, use individual identifier codes, not individual names. The emergency services condition, or any other condition, is not automatically found out of compliance based on a violation of 42 CFR §489.20 and/or 42 CFR §489.24. A determination of noncompliance must be based on the regulatory requirements for the individual condition. X. Additional Survey Report Documentation Upon completion of each investigation, the team leader assures that the following additional documentation has been prepared for submission, along with Forms CMS-1541B, CMS-562, CMS-2567, and a copy of the medical record(s) to the RO: A. Summary Listing of Sample Cases and Description of Sample Selection (See Task 2). At a minimum, identify: The name of each individual chosen to be a part of the sample and the date of their request for emergency services; Any individual identifier codes used as a reference to protect the individual’s confidentiality; The reason for including the individual in the sample (e.g., unstabilized transfer, lack of screening, lack of treatment, failure to stabilize, diagnosis, race, color, financial status, handicap, nationality); and Include a copy of the medical record(s) for all individuals where the hospital violated the provisions in 42 CFR §489.24. Also identify: How the sample was selected; The number of individuals in the sample; and Any overall characteristics of the individuals in the sample, such as race, color, nationality, handicap, financial status, and diagnosis. DOCUMENT 1182 B. Summary of Interviews (See Task 4). Document interviews conducted with patients, families, staff, physicians, administrators, managers, and others. At a minimum, include the individual’s job title and/or assignment at the time of the incident, the relationship to the patient and/or reason for the interview, and a summary of the information obtained in each interview. C. Complaint Investigation Narrative (See Task 3). Summarize significant findings in the medical records, meeting minutes, hospital policies and procedures, staffing schedules, quality assurance plans, hospital by-laws, rules and regulations, training programs, credential files, personnel files, and contracted services reviewed in the course of the investigation. Briefly summarize your findings in the investigation and the rationale used for the course of action recommended to the RO. DOCUMENT 1182 ______________________________________________________________________ Part II - Interpretive Guidelines - Responsibilities of Medicare Participating Hospitals in Emergency Cases The Interpretive Guidelines is a tool for surveyors where the regulation is broken into regulatory citations (tag numbers), followed by the regulation language and provides detailed interpretation of the regulation(s) to surveyors. ______________________________________________________________________ Basic Section 1866 Commitments Relevant to Section 1867 Responsibilities – Tags A-2400/C2400 – A2405/C2405 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) Tag A-2400/C-2400 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.20(l) [The provider agrees to the following:] (l) In the case of a hospital as defined in §489.24 (b) to comply with §489.24 . Interpretive Guidelines: §489.20(l) The term “hospital” is defined in §489.24(b) as including critical access hospitals as defined in §1861(mm)(1) of the Act. Therefore, a critical access hospital that operates a dedicated emergency department (as that term is defined below) is subject to the requirements of EMTALA. Section 42 CFR 489.20(l) of the provider’s agreement requires that hospitals comply with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. Under the provisions of §489.24, hospitals with an emergency department that participate in Medicare are required under EMTALA to do the following: Provide an appropriate MSE to any individual who comes to the emergency department; Provide necessary stabilizing treatment to an individual with an EMC or an individual in labor; Provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capability or capacity to DOCUMENT 1182 provide the treatment necessary to stabilize the EMC (or the capability or capacity to admit the individual); Not delay examination and/or treatment in order to inquire about the individual’s insurance or payment status; Obtain or attempt to obtain written and informed refusal of examination, treatment or an appropriate transfer in the case of an individual who refuses examination, treatment or transfer; and Not take adverse action against a physician or qualified medical personnel who refuses to transfer an individual with an emergency medical condition, or against an employee who reports a violation of these requirements. Further, any participating Medicare hospital is required to accept appropriate transfers of individuals with emergency medical conditions if the hospital has the specialized capabilities not available at the transferring hospital, and has the capacity to treat those individuals. Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of §489.24. Noncompliance with EMTALA requirements will lead CMS to initiate procedures for termination from the Medicare program. Noncompliance may also trigger the imposition of civil monetary penalties by the Office of the Inspector General. Surveyors review the following documents to help determine if the hospital is in compliance with the requirement(s): Review the bylaws, rules, and regulations of the medical staff to determine if they reflect the requirements of §489.24 and the related requirements at §489.20. Review the emergency department policies and procedure manuals for procedures related to the requirements of §489.24 and the related requirements at §489.20. If a hospital violates §489.24, surveyors are to cite a corresponding violation of §489.20(l), Tag A-2400/C-2400. DOCUMENT 1182 _____________________________________________________________________ Tag A-2401/C-2401 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.20(m) [The provider agrees to the following:] In the case of a hospital as defined in §489.24(b), to report to CMS or the State survey agency any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition from another hospital in violation of the requirements of §489.24(e). Interpretive Guidelines: §489.20 (m) A hospital (recipient) that suspects it may have received an improperly transferred (transfer of an unstable individual with an emergency medical condition who was not provided an appropriate transfer according to §489.24(e)(2)), individual is required to promptly report the incident to CMS or the State Agency (SA) within 72 hours of the occurrence. If a recipient hospital fails to report an improper transfer, the hospital may be subject to termination of it’s provider agreement according to 42 CFR489.53(a). Surveyors are to look for evidence that the recipient hospital knew, or suspected the individual had been to a hospital prior to the recipient hospital, and had not been transferred in accordance with §489.24(e). Evidence may be obtained in the medical record or through interviews with the individual, family members or staff. Review the emergency department log and medical records of patients received as transfers. Look for evidence that: The hospital had agreed in advance to accept the transfers; The hospital had received appropriate medical records; All transfers had been effected through qualified personnel, transportation equipment and medically appropriate life support measures; and The hospital had available space and qualified personnel to treat the patients. DOCUMENT 1182 ________________________________________________________________________ Tag A-2402/C-2402 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.20(q) [The provider agrees to the following:] In the case of a hospital as defined in §489.24 (b)— (1) To post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency department (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor; and (2) To post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX; Interpretive Guidelines: §489.20(q)(1) and (2) Section 1866(a)(1)(N)(iii) of the Act requires the posting of signs which specify the rights of individuals with EMCs and women in labor. To comply with the requirements hospital signage must at a minimum: Specify the rights of individuals with EMCs and women in labor who come to the emergency department for health care services; Indicate whether the facility participates in the Medicaid program; The wording of the sign(s) must be clear and in simple terms and language(s) that are understandable by the population served by the hospital; and The sign(s) must be posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment (e.g., entrance, admitting area, waiting room, treatment area). DOCUMENT 1182 ________________________________________________________________________ Tag A-2403/C-2403 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.20(r) [The provider agrees to the following:] In the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain— (1) Medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of transfer; Interpretive Guidelines: §489.20(r)(1) The medical records of individuals transferred to or from the hospital must be retained in their original or legally reproduced form in hard copy, microfilm, microfiche, optical disks, computer disks, or computer memory for a period of 5 years from the date of transfer. ________________________________________________________________________ Tag A-2404/C-2404 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.20(r)(2) [The provider agrees to the following: In the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain--] (2) An on-call list of physicians who are on the hospital’s medical staff or who have privileges at the hospital, or who are on staff or have privileges at another hospital participating in a formal community call plan, in accordance with §489.24(j)(2)(iii), available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions who are receiving services under §489.24 in accordance with the resources available to the hospital; §489.24(j) - Availability of On-call Physicians In accordance with the on-call requirements specified in §489.20(r)(2), a hospital must have written policies and procedures in place-- DOCUMENT 1182 (1) (2) To respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control; To provide that emergency services are available to meet the needs of individuals with emergency medical conditions if a hospital elects to— (i) Permit on-call physicians to schedule elective surgery during the time they are on call (ii) Permit on-call physicians to have simultaneous on-call duties; (iii) Participate in a formal community call plan. Notwithstanding participation in a community call plan, hospitals are still required to perform medical screening examinations on individuals who present seeking treatment and to conduct appropriate transfers. The formal community call plan must include the following elements: (A) A clear delineation of on-call coverage responsibilities; that is, when each hospital participating in the plan is responsible for on-call coverage. (B) A description of the specific geographic area to which the plan applies. (C) A signature by an appropriate representative of each hospital participating in the plan. (D) Assurances that any local and regional EMS system protocol formally includes information on community-call arrangements. (E) A statement specifying that even if an individual arrives at a hospital that is not designated as the on-call hospital, that hospital still has an obligation under §489.24 to provide a medical screening examination and stabilizing treatment within its capability, and that hospitals participating in the community call plan must abide by the regulations under §489.24 governing appropriate transfers. (F) An annual assessment of the community call plan by the participating hospitals. Interpretive Guidelines §489.20(r)(2) and §489.24(j) DOCUMENT 1182 On-Call List Requirements and Options Section 1866(a)(1)(I)(iii)of the Act states, as a requirement for participation in the Medicare program, that hospitals must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition. This on-call list requirement is a general provider agreement requirement for all hospitals and is thus technically an “EMTALA-related” requirement rather than a specific requirement of the EMTALA portion of the Act. When determining compliance with the on-call list requirement as part of an EMTALA survey it must be remembered that the on-call list requirement applies not only to hospitals with dedicated emergency departments, but also to hospitals subject to EMTALA requirements to accept appropriate transfers. (See discussion of §489.24(f).) The on-call list clearly identifies and ensures that the hospital’s personnel is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide stabilizing treatment for individuals with emergency medical conditions. The list of on-call physicians must be composed of physicians who are current members of the medical staff or who have hospital privileges. If the hospital participates in a community call plan then the list must also include the names of physicians at other hospitals who are on-call pursuant to the plan. The list must be up-to-date, and accurately reflect the current privileges of the physicians on-call. Physician group names are not acceptable for identifying the on-call physician. Individual physician names are to be identified on the list with their accurate contact information. Hospital administrators and the physicians who provide the on-call services have flexibility regarding how to configure an on-call coverage system. Several options to enhance this flexibility are permitted under the regulations. It is crucial, however, that hospitals are aware of their responsibility to ensure that they are providing sufficient oncall services to the meet the needs of their community in accordance with the resources they have available. CMS expects a hospital to strive to provide adequate specialty oncall coverage consistent with the services provided at the hospital and the resources the hospital has available. (73 FR 48662). Permitted On-Call Options Community Call Plan CMS permits hospitals to satisfy their on-call obligations through participation in a community call plan (CCP). It is strictly voluntary. Under such a community on-call plan, a hospital may augment its on-call list by adding to it physicians at another hospital. There are different ways a CCP could be organized. For example, if there are two hospitals that choose to participate in community call, Hospital A could be designated as the on-call facility for the first 15 days of the month and Hospital B could be designated as the on-call facility for the remaining days of the month. Alternatively, Hospital A DOCUMENT 1182 could be designated as on-call for cases requiring specialized interventional cardiac care, while Hospital B could be designated as on-call for neurosurgical cases. Ideally, a CCP could allow various physicians in a certain specialty in the aggregate to be on continuous call (24 hours a day, 7 days a week) without putting a continuous call obligation at the participating hospitals on any one physician. Even if this ideal cannot be achieved, given the resources of the participating hospitals, at a minimum, hospitals choosing to participate in a CCP should to be able to provide more on-call specialty coverage than they would on their own. The plan must clearly articulate which on-call services will be provided on which dates/times by each hospital participating in the plan. Furthermore, the DED in each hospital must have specific information based on the allocation of on-call responsibilities in the plan readily available as part of the on-call list, so that personnel who are providing required services to individuals protected under EMTALA know which specialists based in which hospital(s) are available on-call to provide the necessary specialist services. Participation in a community call plan does not mean that on-call physicians must travel from the hospital where they practice to the hospital needing their on-call services. Instead, this arrangement facilitates appropriate transfers to the hospital providing the specialty on-call services pursuant to the plan. The hospital where the individual initially presents still has an EMTALA obligation to conduct a medical screening examination, and, for individuals found to have an emergency medical condition, to provide stabilizing treatment within its capability and capacity. However, when the individual is appropriately transferred pursuant to a CCP for further stabilizing treatment, it can generally be assumed that the transferring hospital has provided treatment within its capability and capacity and that its on-call list is adequate for that specialty. For example, if an individual requires the services of a neurologist on a date when the neurologist on-call pursuant to the CCP is based at hospital B, and that neurologist is part of hospital A’s on-call list, then a transfer to hospital B to obtain the services of the neurologist on-call would be in order, assuming all other transfer requirements have been met. In those cases where, for example, hospitals A and B participate in a CCP and a physician who is a member of the medical staff or has privileges at both hospitals is on-call directly at hospital B, but only indirectly through the CCP to hospital A, there is no regulatory prohibition against the on-call physician going to hospital A to provide the stabilizing treatment, rather than transferring the individual to hospital B. The treating and on-call physician might consider which approach is in the best interests of the patient and also maintains the availability of the on-call specialist pursuant to the CCP. The regulations establish a number of specific requirements for community call plans: The plan must include the geographic parameters of the on-call coverage, indicating what patient origin areas the plan expects to service (e.g., certain communities, counties, regions, municipalities). CMS does not stipulate geographic criteria that a community call plan must meet, since the intent of the plan is to promote flexibility amongst the participating hospitals in DOCUMENT 1182 developing a call plan that best meets the needs of their communities and utilizes the resources within the region. Similarly, there is no requirement that all hospitals within a defined geographic area must participate in the community call plan. Regardless of the geographic specifications of the community call plan, the existence of a CCP in a specific area does not eliminate the EMTALA obligations of hospitals with respect to making appropriate transfers. Among other things this means that: - hospitals participating in the community call plan are not relieved of their recipient hospital obligations to accept appropriate transfers from hospitals not participating in the plan. - non-participating hospitals must accept appropriate transfers, regardless of whether the transferring hospital participates in a CCP with the recipient hospital or any other hospital. - non-participating hospitals must provide stabilizing treatment within their capability and capacity before seeking to transfer an individual to another hospital, regardless of whether the recipient hospital is providing on-call services to other hospitals pursuant to a CCP. In other words, all Medicare-participating hospitals must fulfill their transfer responsibilities under EMTALA, notwithstanding the presence or absence of a transfer agreement and regardless of whether the transferring or recipient hospital is participating in a formal community call plan (73 FR 48667). The community call plan for each participating hospital must show evidence that the duly authorized representative of each hospital has officially signed the plan. The regulations do not require that the plan be signed by an appropriate representative as part of the annual assessment but it is expected that updated signatures would be included in any subsequent revision of the CCP. The delivery of pre-hospital medical services is quite varied throughout the country and there are no specific EMTALA requirements that pertain to the development of EMS protocols. However, if there are EMS protocols in effect in part or all of the areas served by the CCP, then there must be an attestation by the CCP-participating hospitals that the CCP arrangement information has been communicated to the EMS providers and will be updated as needed so that EMS providers have the opportunity to consider this information when developing protocols. In addition, hospitals which are in the process of developing and refining their own CCPs may want to consider including input from the EMS providers that serve their DEDs so DOCUMENT 1182 as to facilitate the efficient implementation of the CCP. For communities that do not have formalized EMS protocols, hospitals participating in a CCP would still be well-advised to inform individual EMS providers of the CCP arrangements amongst the hospitals in the geographic area specified in the plan. The formal language of the CCP must contain a statement that each hospital participating in the CCP will continue to follow the regulations requiring the provision of MSEs, and stabilizing treatment for individuals determined to have EMCs. Hospitals must conduct an annual reassessment of their CCP, including an analysis of the specialty on-call needs of the communities for which the CCP is effective (73 FR 48665). It is expected that the CCP would expand specialty coverage to the communities served by the plan and improve, within the hospitals’ capabilities and capacities, the adequacy of the on-call list for the hospitals participating in the plan. CMS expects the annual assessment to support a Quality Assurance/Performance Improvement approach to the functioning of the CCP, and that hospitals would, as necessary and feasible, adjust the CCP based on the annual reassessment. Hospitals participating in the CCP have flexibility to determine how to design and implement the assessment. Simultaneous Call Hospitals are permitted to allow physicians to be on-call simultaneously at two or more facilities. Hospitals are also permitted to adopt a policy that does not allow physicians to take simultaneous call at more than one hospital. If a hospital permits simultaneous call, then it must have written policies and procedures to follow when the on-call physician is not available to respond because he/she has been called to another hospital. All hospitals where the physician is on-call need to be aware of the details of the simultaneous call arrangements for the physician and have back-up plans established. Scheduled Elective Surgery Hospitals are permitted to allow physicians to perform elective surgery or other procedures while they are on-call. Hospitals are also permitted to adopt a policy that does not allow physicians to perform elective surgery or other procedures while they are on-call. (Critical Access Hospitals (CAHs) should be aware that if they reimburse physicians for being on-call, there are Medicare payment policy regulations, outside the scope of EMTALA requirements, that the CAH might want to consider before making a decision to permit on-call physicians to schedule elective procedures.) When a physician has agreed to be on-call at a particular hospital during a particular period of time, but also has scheduled elective surgery or an elective diagnostic or therapeutic procedure during that time as permitted by hospital policy, that physician and DOCUMENT 1182 the hospital must have planned back-up in the event the physician is called while performing elective surgery and is unable to respond to an on-call request in a reasonable time. Medical Staff Exemptions There is no EMTALA or Medicare provider agreement requirement for all physicians on the medical staff and/or having hospital privileges to take call. A hospital policy allowing exemptions to medical staff members (e.g., senior physicians) would not in of itself violate EMTALA-related Medicare provider agreement requirements. However, if a hospital permits physicians to selectively take call only for their own established patients who present to the ED for evaluation, then the hospital must be careful to assure that it maintains adequate on-call services, and that the selective call policy is not a substitute for the on-call services required by the Medicare provider agreement. Other On-call List Regulatory Requirements A hospital must have written on-call policies and procedures and must clearly define the responsibilities of the on-call physician to respond, examine and treat patients with an EMC. Among other things, the policies and procedures must address the steps to be taken if a particular specialty is not available or the on-call physician cannot respond due to circumstances beyond his/her control (e.g., transportation failures, personal illness, etc.). The policies and procedures must also ensure that the hospital provides emergency services that meet the needs of an individual with an EMC if the hospital chooses to employ any of the on-call options permitted under the regulations, i.e., community call, simultaneous call, or elective procedures while on-call. In other words, there must be a back-up plan to these optional arrangements. For instance, some hospitals may employ the use of “jeopardy” or back-up call schedules to be used only under extreme circumstances. The hospital must be able to demonstrate that hospital staff is aware of and able to execute the back-up procedures. Assessment of On-call List Adequacy by Surveyors CMS expects that a hospital should strive to provide adequate on-call coverage consistent with the services provided at the hospital and the resources the hospital has available, including the availability of specialists. (42 FR 48662). CMS does not have specified requirements regarding how frequently on-call physicians are expected to be available to provide on-call coverage. However, CMS recognizes that in order to supply safe and effective care it would not be prudent for a hospital to expect one physician to be on-call every day of the week, every week of the year. There is also no pre-determined ratio CMS uses to identify how many days a hospital must provide medical staff on-call coverage for a particular specialty based on the number of physicians on staff for that particular specialty. In particular, CMS has no rule stating that whenever there are at least three physicians in a specialty, the hospital must provide 24-hour/7-day coverage in that specialty. DOCUMENT 1182 If a hospital participates in a community call plan, its on-call list must reflect this. The plan does not have to be pre-approved or require formal authorization by CMS or any local, State or Federal agency, in order to be instituted. However, during a complaint investigation, the design and implementation of the CCP will come under review. Generally, in determining a hospital’s on-call list compliance, CMS will consider all relevant factors in a case-specific manner, including the number of physicians on the medical staff/holding hospital privileges, other demands on these physicians, the frequency with which individuals with EMCs typically require the stabilizing services of the hospital’s on-call physicians, and the provisions the hospital has made for situations in which a physician on-call is not available or is unable to respond due to circumstances beyond his/her control. For instance, if the hospital under investigation performs a significant amount of interventional cardiac catheterizations and holds itself out to the public through various advertising methods as a center of excellence in providing this specialized procedure to the community, it would be reasonable to expect that there would be adequate on-call coverage by a physician who is able to perform an emergent interventional cardiac procedure on individuals who present to that hospital’s DED in need of such an intervention or who are appropriately transferred to that hospital for such an intervention. On the other hand, it may not be reasonable to expect a CAH to have an interventional radiologist on call if that service is not routinely provided at the CAH or in the local vicinity of the CAH, unless the CAH participates in a community call plan that provides for this service. On-call Physician Appearance Requirements Although the on-call list requirement is found in Section 1866, which is the provider agreement section of the Act, Section 1867, the EMTALA section of the Act, provides for enforcement actions against both a physician and a hospital when a physician who is on the hospital’s on-call list fails or refuses to appear within a reasonable period of time after being notified to appear. Hospitals would be well-advised to make physicians who are on-call aware of the hospital’s on-call policies and the physician’s EMTALA obligations when on call. If a physician is listed as on-call and requested to make an in-person appearance to evaluate and treat an individual, that physician must respond in person in a reasonable amount of time. If an individual presents to Hospital A with an EMC that requires the specialty services provided by Hospital B pursuant to the CCP, then the physician who is based at Hospital B is required to report to Hospital B to provide the stabilizing treatment for the individual who presented to Hospital A and was subsequently transferred to Hospital B. When a physician is on-call for the hospital and seeing patients with scheduled appointments in his/her private office, it is generally not acceptable to refer emergency cases to his or her office for examination and treatment of an EMC. The physician must DOCUMENT 1182 come to the hospital to examine the individual if requested to do so by the treating physician. If, however, it is medically indicated, the treating physician may send an individual needing the specialized services of the on-call physician to the physician’s office if it is a provider-based part of the hospital (i.e., department of the hospital sharing the same CMS certification number as the hospital) It must be clear that this transport is not done for the convenience of the specialist but that there is a genuine medical reason to move the individual, that all individuals with the same medical condition, regardless of their ability to pay, are similarly moved to the specialist’s office, and that the appropriate medical personnel accompany the individual to the office. If it is permitted under the hospital’s policies, an on-call physician has the option of sending a representative, i.e., directing a licensed non-physician practitioner as his or her representative to appear at the hospital and provide further assessment or stabilizing treatment to an individual. This determination should be based on the individual’s medical need and the capabilities of the hospital and the applicable State scope of practice laws, hospital by-laws and rules and regulations. There are some circumstances in which the non-physician practitioner can provide the specialty treatment more expeditiously than the physician on-call. It is important to note, however, that the designated on-call physician is ultimately responsible for providing the necessary services to the individual in the DED, regardless of who makes the in-person appearance. Furthermore, in the event that the treating physician disagrees with the on-call physician’s decision to send a representative and requests the actual appearance of the on-call physician, then the on-call physician is required under EMTALA to appear in person. Both the hospital and the on-call physician who fails or refuses to appear in a reasonable period of time may be subject to sanctions for violation of the EMTALA statutory requirements. There is no EMTALA prohibition against the treating physician consulting on a case with another physician, who may or may not be on the hospital’s on-call list, by telephone, video conferencing, transmission of test results, or any other means of communication. CMS is aware that it is increasingly common for hospitals to use telecommunications to exchange imaging studies, laboratory results, EKGs, real-time audio and video images of patients and/or other clinical information with a consulting physician not on the hospital’s premises. Such practices may contribute to improved patient safety and efficiency of care. In some cases it may be understood by the hospitals and physicians who establish such remote consulting arrangements that the physician consultant is not available for an in-person assessment of the individual at the treating physician’s hospital. However, if a physician: is on a hospital's on-call list; has been requested by the treating physician to appear at the hospital; and fails or refuses to appear within a reasonable period of time; DOCUMENT 1182 then the hospital and the on-call physician may be subject to sanctions for violation of the EMTALA statutory requirements. It is an entirely separate issue, outside the scope of EMTALA enforcement, whether or not insurers or other third party payers, including Medicare, will provide reimbursement to physicians who provide remote consultation services. Hospitals and/or physicians interested in Medicare reimbursement policy for telemedicine or telehealth services should consult Medicare Benefit Policy Manual, Pub. 100-02, Chapter 18, §270. If a physician who is on-call, either directly, or indirectly pursuant to a CCP, refuses or fails to appear at the hospital where he/she is directly on call in a reasonable period of time, then that physician as well as the hospital may be found to be in violation of EMTALA. Likewise, if a physician who is on-call typically directs the individual to be transferred to another hospital instead of making an appearance as requested, then that physician as well as the hospital may be found to be in violation of EMTALA. While CMS’ enforcement of the EMTALA section of the Act and regulations and the EMTALA-related provisions of the provider agreement section of the Act and regulations are directed solely against hospitals, it is important to note that Section 1867 of the Act also provides for the Office of the Inspector General (OIG) to levy civil monetary penalties or take other actions against hospitals or physicians for EMTALA violations. CMS refers cases it has investigated to the OIG when CMS finds violations that appear to fall within the OIG’s EMTALA jurisdiction. Section 1867(d)(1)(C) of the Act specifically provides for penalties against both a hospital and the physician when a physician who is on-call either fails to appear or refuses to appear within a reasonable period of time. Thus, a hospital would be well-advised to establish in its on-call policies and procedures specific guidelines-- e.g., the maximum number of minutes that may elapse between receipt of a request and the physician’s appearance for what constitutes a reasonable response time, and to make sure that its on-call physicians and other staff are aware of these time-sensitive requirements. If a physician on-call does not fulfill his/her on-call obligation, but the hospital arranges in a timely manner for another of its physicians in that specialty to assess/stabilize an individual as requested by the treating physician in the DED, then the hospital would not be in violation of CMS’ on-call requirements. However, if a physician on-call does not fulfill his/her on-call obligation and the individual is, as a result, transferred to another hospital, then the hospital may be in violation of CMS’s requirements and both the hospital and the on-call physician may be subject to enforcement action by the OIG under the Act. DOCUMENT 1182 ________________________________________________________________________ Tag A-2405/C-2405 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) Section 489.20(r)(3) - 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. Interpretive Guidelines: §489.20(r)(3) The purpose of the central log is to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition. Each hospital has the discretion to maintain the log in a form that best meets the needs of the hospital. The central log includes, directly or by reference, patient logs from other areas of the hospital that may be considered dedicated emergency departments, such as pediatrics and labor and delivery where a patient might present for emergency services or receive a medical screening examination instead of in the “traditional” emergency department. These additional logs must be available in a timely manner for surveyor review. The hospital may also keep its central log in an electronic format. Review the emergency department log covering at least a 6-month period that contains information on all individuals coming to the emergency department and check for completeness, gaps in entries or missing information. ________________________________________________________________________ Section 489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases (Section 1867 EMTALA Requirements – Tags A2406/C2406 – A2411/C2411) Tag A-2406/C-2406 (Rev. 60, Issued: 07-16-10, Effective: 07-16-10, Implementation: 07-16-10) §489.24(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 DOCUMENT 1182 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 Interpretive Guidelines §489.24(a)(1)(i) A “hospital with an emergency department” is defined in §489.24(b) as a hospital with a dedicated emergency department. An EMTALA obligation is triggered for such a hospital when an individual comes by him or herself, with another person, to a hospital’s dedicated emergency department (as that term is defined above) and a request is made by the individual or on the individual’s behalf, or a prudent layperson observer would conclude from the individual’s appearance or behavior a need, for examination or treatment of a medical condition. In such a case, the hospital has incurred an obligation to provide an appropriate medical screening examination (MSE) for the individual and stabilizing treatment or an appropriate transfer. The purpose of the MSE is to determine whether or not an emergency medical condition exits. If an individual who is not a hospital patient comes elsewhere on hospital property (that is, the individual comes to the hospital but not to the dedicated emergency department), an EMTALA obligation on the part of the hospital may be triggered if either the individual requests examination or treatment for an emergency medical condition or if a prudent layperson observer would believe that the individual is suffering from an emergency medical condition. The term “hospital property” means the entire main hospital campus as defined in §413.65(a), including the parking lot, sidewalk and driveway or hospital departments, including any building owned by the hospital that are within 250 yards of the hospital). If an individual is registered as an outpatient of the hospital and they present on hospital property but not to a dedicated emergency department, the hospital does not incur an obligation to provide a medical screening examination for that individual if they have begun to receive a scheduled course of outpatient care. Such an individual is protected by the hospital Conditions of Participation (CoPs) that protect patient’s health and safety and to ensure that quality care is furnished to all patients in Medicare-participating hospital. If such an individual experiences an EMC while receiving outpatient care, the hospital does not have an obligation to conduct an MSE for that patient. As discussed in greater detail below, such a patient has adequate protections under the Medicare CoPs and state law. If an individual is initially screened in a department or facility on-campus outside of the ED, the individual could be moved to another hospital department or facility on-campus to receive further screening or stabilizing treatment without such movement being regarded as a transfer, as long as: (1) all persons with the same medical condition are DOCUMENT 1182 moved in such circumstances, regardless of their ability to pay for treatment; (2) there is bona fide medical reason to move the individual; and (3) appropriate medical personnel accompany the individual. The same is also true for an individual who presents to the dedicated emergency department (e.g., patient with an eye injury in need of stationary ophthalmology equipment located in the eye clinic) and must be moved to another hospital-owned facility or department on-campus for further screening or stabilizing treatment. The movement of the individual between hospital departments is not considered an EMTALA transfer under this section, since the individual is simply being moved from one department of a hospital to another department or facility of the same hospital. Hospitals should not move individuals to off-campus facilities or departments (such as an urgent care center or satellite clinic) for a MSE. If an individual comes to a hospitalowned facility or department, which is off-campus and operates under the hospital’s Medicare provider number, §1867 (42 CFR 489.24) will not apply to that facility and/or department unless it meets the definition of a dedicated emergency department. If, however, such a facility does not meet the definition of a dedicated ED, it must screen and stabilize the patient to the best of its ability or execute an appropriate transfer if necessary to another hospital or to the hospital on whose Medicare provider number it is operated. Hospital resources and staff available at the main campus are likewise available to individuals seeking care at the off campus facilities or departments within the capability of the hospital. Movement of the individual to the main campus of the hospital is not considered a transfer since the individual is simply being moved from one department of a hospital to another department or facility of the same hospital. In addition, a transfer from such an entity (i.e., an off-campus facility that meets the definition of a dedicated ED) to a nonaffiliated hospital (i.e., a hospital that does not own the off-campus facility) is allowed where the facility at which the individual presented cannot stabilize the individual and the benefits of transfer exceed the risks of transfer. In other words, there is no requirement under EMTALA that the individual be always transferred back to the hospital that owns and operates the off-campus dedicated ED. Rather, the requirement of EMTALA is that the individual be transferred to an appropriate facility for treatment. If a request were made for emergency care in a hospital department off the hospital’s main campus that does not meet the definition of a dedicated emergency department, EMTALA would not apply. However, such an off-campus facility must have policies and procedures in place as how to handle patients in need of immediate care. For example, the off-campus facility policy may direct the staff to contact the emergency medical services/911 (EMS) to take the patient to an emergency department (not necessarily the emergency department of the hospital that operates the off-campus department, but rather the closest emergency department) or provide the necessary care if it is within the hospital’s capability. Therefore, a hospital off-campus facility that does not meet the definition of a dedicated emergency department does not have an EMTALA obligation and not required to be staffed to handle potential EMC. DOCUMENT 1182 Medicare hospitals that do not provide emergency services must meet the standard of §482.12 (f) , which requires hospitals to have written policies and procedures for the appraisal of emergencies, initial treatment within its capability and capacity, and makes an appropriate referral to a hospital that is capable of providing the necessary emergency services. If a hospital has an EMTALA obligation, it must screen individuals to determine if an EMC exists. It is not appropriate to merely “log in” an individual and not provide a MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. An MSE is not an isolated event. It is an ongoing process that begins, but typically does not end, with triage. Triage entails the clinical assessment of the individual’s presenting signs and symptoms at the time of arrival at the hospital, in order to prioritize when the individual will be seen by a physician or other qualified medical personnel (QMP). Individuals coming to the emergency department must be provided an MSE appropriate to the individuals’ presenting signs and symptoms, as well as the capability and capacity of the hospital. Depending on the individual’s presenting signs and symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures, such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans, and/or other diagnostic tests and procedures. The medical record must reflect continued monitoring according to the individual’s needs until it is determined whether or not the individual has an EMC and, if he/she does, until he/she is stabilized or appropriately transferred. There should be evidence of this ongoing monitoring prior to discharge or transfer. The MSE must be the same MSE that the hospital would perform on any individual coming to the hospital’s dedicated emergency department with those signs and symptoms, regardless of the individual’s ability to pay for medical care. If a hospital applies in a nondiscriminatory manner (i.e., a different level of care must not exist based on payment status, race, national origin, etc.) a screening process that is reasonably calculated to determine whether an EMC exists, it has met its obligations under EMTALA. If the MSE is appropriate and does not reveal an EMC, the hospital has no further obligation under 42 CFR 489.24. Regardless of a positive or negative individual outcome, a hospital would be in violation of the anti-dumping statute if it fails to meet any of the medical screening requirements under 42 CFR 489.24. The clinical outcome of an individual’s condition is not a proper basis for determining whether an appropriate screening was provided or whether a person transferred was stable. However, the outcome may be a “red flag” indicating that a more thorough investigation is needed. Do not make decisions base on clinical information that was not available at the time of stabilizing or transfer. If an individual was DOCUMENT 1182 misdiagnosed, but the hospital utilized all of its resources, a violation of the screening requirement did not occur. It is not impermissible under EMTALA for a hospital to follow normal registration procedures for individuals who come to the emergency department. For example, a hospital may ask the individual for an insurance card, so long as doing so does not delay the medical screening examination. In addition, the hospital may seek other information (not payment) from the individual’s health plan about the individual such as medical history. And, in the case of an individual with an emergency medical condition, once the hospital has conducted the medical screening examination and has initiated stabilizing treatment, it may seek authorization for all services from the plan, again, as long as doing so does not delay the implementation of the required MSE and stabilizing treatment. A hospital that is not a managed care plan’s network of designated providers cannot refuse to screen and treat (or appropriately transfer, if the medical benefits of the transfer outweigh the risks or if the individual requests the transfer) individuals who are enrolled in the plan who come to the hospital if that hospital participates in the Medicare program. Once an individual has presented to the hospital seeking emergency care, the determination of whether an EMC exists is made by the examining physician(s) or other qualified medical personnel of the hospital. Medicare participating hospitals that provide emergency services must provide a medical screening examination to any individual regardless of diagnosis (e.g., labor, AIDS), financial status (e.g., uninsured, Medicaid), race, and color, national origin (e.g. Hispanic or Native American surnames), and/or disability, etc. A hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with emergency medical conditions who come to the hospital for examination and treatment. “Labor” is defined to mean the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor, unless a physician, certified nurse-midwife, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and State law, certifies that, after a reasonable time of observation, the woman is in false labor. An infant that is born alive is a "person" and an "individual" under 1 U.S.C. 8(a) and the screening requirement of EMTALA applies to "any individual" who comes to the emergency department. If an infant was born alive in a dedicated emergency department, and a request was made on that infant's behalf for screening for a medical condition (or if a prudent layperson would conclude, based on the infant's appearance or behavior, that the infant needed examination or treatment for a medical condition), the hospital and physician could be liable for violating EMTALA for failure to provide such a medical screening examination. DOCUMENT 1182 If an infant is born alive elsewhere on the hospital's campus (i.e., not in the hospital's dedicated emergency department) and a prudent layperson observer would conclude, based on the born-alive infant's appearance or behavior, that the infant was suffering from an emergency medical condition, the hospital and its medical staff are required to perform a medical screening examination on the infant to determine whether or not an emergency medical condition exists. Whether in the DED or elsewhere on the hospital’s campus, if the physician or other authorized qualified medical personnel performing the medical screening examination determines that the infant is suffering from an emergency medical condition, the hospital has an obligation under EMTALA to provide stabilizing treatment or an appropriate transfer. If the hospital admits the infant, its obligation under EMTALA ends. A minor (child) can request an examination or treatment for an EMC. The hospital is required by law to conduct the examination if requested by an individual or on the individual’s behalf to determine if an EMC exists. Hospital personnel should not delay the MSE by waiting for parental consent. If after screening the minor, it is determined than no EMC is present, the staff can wait for parental consent before proceeding with further examination and treatment. On-campus provider-based entities (such as rural health clinics or physician offices) are not subject to EMTALA, therefore it would be inappropriate to move individuals to these facilities for a MSE or stabilizing treatment under this Act. If an individual is not on hospital property (which includes a hospital owned and operated ambulance), this regulation is not applicable. Hospital property includes ambulances owned and operated by the hospital, even if the ambulance is not on the hospital campus. An individual in a non-hospital owned ambulance, which is on hospital property is considered to have come to the hospital’s emergency department. An individual in a non- hospital owned ambulance not on the hospital’s property is not considered to have come to the hospital’s emergency department when the ambulance personnel contact “Hospital A” by telephone or telemetry communications. If an individual is in an ambulance, regardless of whether the ambulance is owned by the hospital, a hospital may divert individuals when it is in “diversionary” status because it does not have the staff or facilities to accept any additional emergency patients at that time. However, if the ambulance is owned by the hospital, the diversion of the ambulance is only appropriate if the hospital is being diverted pursuant to community-wide EMS protocols. Moreover, if any ambulance (regardless of whether or not owned by the hospital) disregards the hospital’s instructions and brings the individual on to hospital campus, the individual has come to the hospital and the hospital has incurred an obligation to conduct a medical screening examination for the individual. Hospitals that deliberately delay moving an individual from an EMS stretcher to an emergency department bed do not thereby delay the point in time at which their EMTALA obligation begins. Furthermore, such a practice of “parking” patients arriving via EMS, refusing to release EMS equipment or personnel, jeopardizes patient health and DOCUMENT 1182 adversely impacts the ability of the EMS personnel to provide emergency response services to the rest of the community. Hospitals that “park” patients may also find themselves in violation of 42 CFR 482.55, the Hospital Condition of Participation for Emergency Services, which requires that hospitals meet the emergency needs of patients in accordance with acceptable standards of practice. On the other hand, this does not mean that a hospital will necessarily have violated EMTALA and/or the hospital CoPs if it does not, in every instance, immediately assume from the EMS provider all responsibility for the individual, regardless of any other circumstances in the ED. For example, there may be situations when a hospital does not have the capacity or capability at the time of the individual's presentation to provide an immediate medical screening examination (MSE) and, if needed, stabilizing treatment or an appropriate transfer. So, if the EMS provider brought an individual to the dedicated ED at a time when ED staff was occupied dealing with multiple major trauma cases, it could under those circumstances be reasonable for the hospital to ask the EMS provider to stay with the individual until such time as there were ED staff available to provide care to that individual. However, even if a hospital cannot immediately complete an appropriate MSE, it must still assess the individual’s condition upon arrival to ensure that the individual is appropriately prioritized, based on his/her presenting signs and symptoms, to be seen by a physician or other QMP for completion of the MSE. The hospital should also assess whether the EMS provider can appropriately monitor the individual's condition. Should a hospital, which is not in diversionary status, fail to accept a telephone or radio request for transfer or admission, the refusal could represent a violation of other Federal or State requirements (e.g., Hill-Burton). If you suspect a violation of related laws, refer the case to the responsible agency for investigation. The following two circumstances will not trigger EMTALA: The use of a hospital’s helipad by local ambulance services or other hospitals for the transport of individuals to tertiary hospitals located throughout the State does not trigger an EMTALA obligation for the hospital that has the helipad on its property when the helipad is being used for the purpose of transit as long as the sending hospital conducted the MSE prior to transporting the individual to the helipad for medical helicopter transport to a designated recipient hospital. The sending hospital is responsible for conducting the MSE prior to transfer to determine if an EMC exists and implementing stabilizing treatment or conducting an appropriate transfer. Therefore, if the helipad serves simply as a point of transit for individuals who have received a MSE performed prior to transfer to the helipad, the hospital with the helipad is not obligated to perform another MSE prior to the individual’s continued travel to the recipient hospital. If, however, while at the helipad, the individual’s condition deteriorates, the hospital at which the helipad is located must provide another MSE and stabilizing treatment within its capacity if requested by medical personnel accompanying the individual. DOCUMENT 1182 If as part of the EMS protocol, EMS activates helicopter evacuation of an individual with a potential EMC, the hospital that has the helipad does not have an EMTALA obligation if they are not the recipient hospital, unless a request is made by EMS personnel, the individual or a legally responsible person acting on the individual’s behalf for the examination or treatment of an EMC. Hospitals are not relieved of their EMTALA obligation to screen, provide stabilizing treatment and/or an appropriate transfer to individuals because of prearranged community or State plans that have designated specific hospitals to care for selected individuals (e.g., Medicaid patients, psychiatric patients, pregnant women). Hospitals located in those States which have State/local laws that require particular individuals, such as psychiatric or indigent individuals, to be evaluated and treated at designated facilities/hospitals may violate EMTALA if the hospital disregards the EMTALA requirements and does not conduct an MSE and provide stabilizing treatment or conduct an appropriate transfer prior to referring the individual to the State/local facility. If, after conducting the MSE and ruling out an EMC (or after stabilizing the EMC) the sending hospital needs to transfer an individual to another hospital for treatment, it may elect to transfer the individual to the hospital so designated by these State or local laws. Hospitals are also prohibited from discharging individuals who have not been screened or who have an emergency medical condition to non-hospital facilities for purposes of compliance with State law. The existence of a State law requiring transfer of certain individuals to certain facilities is not a defense to an EMTALA violation for failure to provide an MSE or failure to stabilize an EMC therefore hospitals must meet the federal EMTALA requirements or risk violating EMTALA. If a screening examination reveals an EMC and the individual is told to wait for treatment, but the individual leaves the hospital, the hospital did not “dump” the individual unless: The individual left the emergency department based on a “suggestion” by the hospital; The individual’s condition was an emergency, but the hospital was operating beyond its capacity and did not attempt to transfer the individual to another facility, or If an individual leaves a hospital Against Medical Advice (AMA) or LWBS, on his or her own free will (no coercion or suggestion) the hospital is not in violation of EMTALA. Hospital resources and staff available to inpatients at the hospital for emergency services must likewise be available to individuals coming to the hospital for examination and treatment of an EMC because these resources are within the capability of the hospital. For example, a woman in labor who presents at a hospital providing obstetrical services must be treated with the resources available whether or not the hospital normally provides unassigned emergency obstetrical services. DOCUMENT 1182 The MSE must be conducted by an individual(s) who is determined qualified by hospital by-laws or rules and regulations and who meets the requirements of §482.55 concerning emergency services personnel and direction. The designation of the qualified medical personnel (QMP) should be set forth in a document approved by the governing body of the hospital. If the rules and regulations of the hospital are approved by the board of trustees or other governing body, those personnel qualified to perform the medical screening examinations may be set forth in the rules and regulations, or the hospital bylaws. It is not acceptable for the hospital to allow informal personnel appointments that could frequently change. (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. Interpretive Guidelines §489.24(a)(1)(ii) Refer to Tag A-2407/C-2407 for stabilizing treatment and inpatients, and Tag A-2409/C2409 for an appropriate transfer for EMTALA. EMTALA does not apply to hospital inpatients. The existing hospital CoPs protect individuals who are already patients of a hospital and who experience an EMC. Hospitals that fail to provide treatment to these patients may be subject to further enforcement actions. If the surveyor discovers during the investigation that a hospital did not admit an individual in good faith with the intention of providing treatment (i.e., the hospital used the inpatient admission as a means to avoid EMTALA requirements), then the hospital is considered liable under EMTALA and actions may be pursued. §489.24(a)(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. DOCUMENT 1182 (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. Interpretive Guidelines: §489.24(a)(2) What can be Waived Under Section 1135? In accordance with Section 1135(b)(3) of the Act, hospitals and CAHs operating under an EMTALA waiver will not be sanctioned for: Redirecting an individual who “comes to the emergency department,” as that term is defined at §489.24(b), to an alternate location for an MSE, pursuant to a State emergency preparedness plan or, as applicable, a State pandemic preparedness plan. Even when a waiver is in effect there is still the expectation that everyone who comes to the ED will receive an appropriate MSE, if not in the ED, then at the alternate care site to which they are redirected or relocated. Inappropriately transferring an individual protected under EMTALA, when the transfer is necessitated by the circumstances of the declared emergencies. Transfers may be inappropriate under EMTALA for a number of reasons. However, even if a hospital/CAH is operating under an EMTALA waiver, the hospital/CAH would not be exempt from sanctions if it discriminates among individuals based on their ability to pay for services, or the source of their payment for services when redirecting or relocating them for the MSE or when making inappropriate transfers. DOCUMENT 1182 All other EMTALA-related requirements at 42 CFR 489.20 and EMTALA requirements at 42 CFR 489.24 continue to apply, even when a hospital is operating under an EMTALA waiver. For example, the statute does not provide for a waiver of a recipient hospital’s obligation to accept an appropriate transfer of an individual protected under EMTALA. (As a reminder, even without a waiver, a hospital is obligated to accept an appropriate EMTALA transfer only when that recipient hospital has specialized capabilities required by the individual and the requisite capacity at the time of the transfer request.) Waiver of EMTALA requirements in accordance with a Section 1135 waiver does not affect a hospital’s or CAH’s obligation to comply with State law or regulation that may separately impose requirements similar to those under EMTALA law and regulations. Facilities are encouraged to communicate with their State licensure authorities as to the availability of waivers under State law. When Can a Waiver Be Issued? In accordance with Section 1135 of the Act, an EMTALA waiver may be issued only when: The President has declared an emergency or disaster pursuant to the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act; and The Secretary has declared a public health emergency (PHE) pursuant to Section 319 of the Public Health Service Act; and The Secretary has exercised his/her waiver authority pursuant to Section 1135 of the Act and notified Congress at least 48 hours in advance of exercising his/her waiver authority. In exercising his/her waiver authority, the Secretary may choose to delegate to the Centers for Medicare & Medicaid Services (CMS) the decision as to which Medicare, Medicaid, or CHIP requirements specified in Section 1135 should be temporarily waived or modified, and for which health care providers or groups of providers such waivers are necessary. Specifically, the Secretary may delegate to CMS decision-making about whether and for which hospitals/CAHs to waive EMTALA sanctions as specified in Section 1135(b)(3). In addition, in order for an EMTALA waiver to apply to a specific hospital or CAH: The hospital or CAH must activate its disaster protocol; and The State must have activated an emergency preparedness plan or pandemic preparedness plan in the emergency area, and any redirection of individuals for an MSE must be consistent with such plan. It is not necessary for the State to activate its plan statewide, so long as it is activated in the area where the hospital DOCUMENT 1182 is located. It is also not necessary for the State plan to identify the specific location of the alternate screening sites to which individuals will be directed, although some may do so. How Long Does an EMTALA Waiver Last? Except in the case of waivers related to pandemic infectious disease, an EMTALA waiver is limited in duration to 72 hours beginning upon activation of the hospital’s/CAH’s disaster protocol. In the case of a public health emergency (PHE) involving pandemic infectious disease, the general EMTALA waiver authority will continue in effect until the termination of the declaration of the PHE. However, application of this general authority to a specific hospital/CAH or groups of hospitals and CAHs may limit the waiver’s application to a date prior to the termination of the PHE declaration, since case-specific applications of the waiver authority are issued only to the extent they are necessary, as determined by CMS. Furthermore, if a State emergency/pandemic preparedness plan is deactivated in the area where the hospital or CAH is located prior to the termination of the public health emergency, the hospital or CAH no longer meets the conditions for an EMTALA waiver and that hospital/CAH waiver would cease to be in effect as of the deactivation date. Likewise, if a hospital or CAH deactivates its disaster protocol prior to the termination of the public health emergency, the hospital or CAH no longer meets the conditions for an EMTALA waiver and that hospital/CAH waiver would cease to be in effect as of the deactivation date. What is the Process for Seeking an EMTALA Waiver? Section 1135 provides for waivers of certain Medicare, Medicaid, or CHIP requirements, including waivers of EMTALA sanctions, but only to the extent necessary, to ensure sufficient health care items and services are available to meet the needs of Medicare, Medicaid, and CHIP beneficiaries. The waivers also ensure that health care providers who provide such services in good faith but are unable to comply with one or more of the specified requirements may be reimbursed for such items and services and exempted from sanctions for noncompliance, absent any fraud or abuse. When the Secretary has exercised his/her waiver authority and delegated to CMS decision-making about specific EMTALA waivers, CMS policy in exercising its authority for granting EMTALA waivers is as follows: Localized Emergency Area: In the case of localized disasters, such as those related to floods or hurricanes, CMS may exercise its discretion to advise hospitals/CAHs in the affected areas that they are covered by the EMTALA waiver, without requiring individual applications for each waiver. However, hospitals or CAHs that activate their disaster protocol and expect to take advantage of the area-wide waiver must notify their State Survey Agency (SA) at the time they activate their disaster protocol. DOCUMENT 1182 Nationwide Emergency Area: In the case of a nationwide emergency area, CMS may also exercise its discretion to advise hospitals/CAHs in a specific geographical area(s) that they are covered by the EMTALA waiver for a timelimited period. CMS expects to do this only if the State has activated its emergency or pandemic preparedness plan in the affected area(s), and if there is other evidence of need for the waiver for a broad group of hospitals or CAHs. CMS will rely upon SAs to advise their CMS Regional Office (RO) whether and where a State’s preparedness plan has been activated, as well as when the plan has been deactivated. In the absence of CMS notification of area-wide applications of the waiver, hospitals/CAHs must contact CMS and request that the waiver provisions be applied to their facility. In all cases, the Act envisions that individuals protected under EMTALA will still receive appropriate MSEs somewhere (even if the MSE is not conducted not at the hospital or CAH where they present), and that individuals who are transferred for stabilization of their emergency medical condition will be sent to a facility capable of providing stabilizing services, regardless of whether a waiver is in effect. Unless CMS advises otherwise, in cases of a public health emergency involving pandemic infectious disease, hospitals/CAHs in areas covered by time-limited, area-wide applications of the EMTALA waiver that seek to extend the waiver’s application to a later date within the waiver period (that is, within the period of the PHE declaration) must submit individual requests for extension. The requests must demonstrate their need for continued application of the waiver. Such requests must be received at least three calendar days prior to expiration of the time-limited waiver. Extensions of an EMTALA waiver in emergencies that do not involve pandemic infectious disease are not available. Waiver Request Process Hospitals or CAHs seeking an EMTALA waiver must demonstrate to CMS that application of the waiver to their facility is necessary, and that they have activated their disaster protocol. CMS will confirm with the SA whether the State’s preparedness plan has been activated in the area where the hospital or CAH is located. CMS will also seek to confirm when the hospital activated its disaster protocol, whether other measures may address the situation in a manner that does not require a waiver, and other factors important to the ability of the hospital to demonstrate that a waiver is needed. What will CMS do in response to EMTALA complaints concerning events occurring during the waiver period? EMTALA enforcement is a complaint-driven process. CMS will assess any complaints/allegations related to alleged EMTALA violations concerning the MSE or transfer during the waiver period to determine whether the hospital or CAH in question was operating under an EMTALA waiver at the time of the complaint, and, if so, whether DOCUMENT 1182 the nature of the complaint involves actions or requirements not covered by the EMTALA waiver and warrants further on-site investigation by the SA. §489.24(c) Use of Dedicated Emergency Department for Non-emergency 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. Interpretive Guidelines §489.24(c) Any individual with a medical condition that presents to a hospital’s ED must receive an MSE that is appropriate for their medical condition. The objective of the MSE is to determine whether or not an emergency medical condition exists. This does not mean that all EMTALA screenings must be equally extensive. If the nature of the individual’s request makes clear that the medical condition is not of an emergency nature, the MSE is reflective of the individual presenting complaints or symptoms. A hospital may, if it chooses, have protocols that permit a QMP (e.g., registered nurse) to conduct specific MSE(s) if the nature of the individual’s request for examination and treatment is within the scope of practice of the QMP (e.g., a request for a blood pressure check and that check reveals that the patient’s blood pressure is within normal range). Once the individual is screened and it is determined the individual has only presented to the ED for a nonemergency purpose, the hospital’s EMTALA obligation ends for that individual at the completion of the MSE. Hospitals are not obligated under EMTALA to provide screening services beyond those needed to determine that there is no EMC. For a hospital to be exempted from its EMTALA obligations to screen individuals presenting at its emergency department for nonemergency tests (e.g., individual has consulted with physician by telephone and the physician refers the individual to a hospital emergency department for a nonemergency test) the hospital must be able to document that it is only being asked to collect evidence, not analyze the test results, or to otherwise examine or treat the individual. Furthermore, a hospital may be exempted from its EMTALA obligations to screen individuals presenting to its dedicated emergency department if the individual had a previously scheduled appointment. If an individual presents to an ED and requests pharmaceutical services (medication) for a medical condition, the hospital generally would have an EMTALA obligation. Surveyors are encouraged to ask probing questions of the hospital staff to determine if the hospital in fact had an EMTALA obligation in this situation (e.g., did the individual present to the ED with an EMC and informed staff they had not taken their medication? Was it obvious from the nature of the medication requested that it was likely that the patient had an EMC?). The circumstances surrounding why the request is being made DOCUMENT 1182 would confirm if the hospital in fact has an EMTALA obligation. If the individual requires the medication to resolve or provide stabilizing treatment of an EMC, then the hospital has an EMTALA obligation. Hospitals are not required by EMTALA to provide medication to individuals who do not have an EMC simply because the individual is unable to pay or does not wish to purchase the medication from a retail pharmacy or did not plan appropriately to secure prescription refills. If an individual presents to a dedicated emergency department and requests services that are not for a medical condition, such as preventive care services (immunizations, allergy shots, flu shots) or the gathering of evidence for criminal law cases (e.g., sexual assault, blood alcohol test), the hospital is not obligated to provide a MSE under EMTALA to this individual. Attention to detail concerning blood alcohol testing (BAT) in the ED is instrumental when determining if a MSE is to be conducted. If an individual is brought to the ED and law enforcement personnel request that emergency department personnel draw blood for a BAT only and does not request examination or treatment for a medical condition, such as intoxication and a prudent lay person observer would not believe that the individual needed such examination or treatment, then the EMTALA’s screening requirement is not applicable to this situation because the only request made on behalf of the individual was for evidence. However, if for example, the individual in police custody was involved in a motor vehicle accident or may have sustained injury to him or herself and presents to the ED a MSE would be warranted to determine if an EMC exists. When law enforcement officials request hospital emergency personnel to provide clearance for incarceration, the hospital has an EMTALA obligation to provide a MSE to determine if an EMC exists. If no EMC is present, the hospital has met its EMTALA obligation and no further actions are necessary for EMTALA compliance. Surveyors will evaluate each case on its own merit when determining a hospital’s EMTALA obligation when law enforcement officials request screening or BAT for use as evidence in criminal proceedings. This principle also applies to sexual assault cases. DOCUMENT 1182 ________________________________________________________________________ Tag A-2407/C-2407 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.24(d) Necessary Stabilizing Treatment for Emergency Medical Conditions (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. Interpretive Guidelines §489.24(d)(1)(i) A hospital is obligated to provide the services specified in the statute and this regulation regardless of whether a hospital will be paid. After the medical screening has been implemented and the hospital has determined that an emergency medical condition exists, the hospital must provide stabilizing treatment within its capability and capacity. Capabilities of a medical facility mean that there is physical space, equipment, supplies, and specialized services that the hospital provides (e.g., surgery, psychiatry, obstetrics, intensive care, pediatrics, trauma care). Capabilities of the staff of a facility means the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses. This includes coverage available through the hospitals on-call roster. The capacity to render care is not reflected simply by the number of persons occupying a specialized unit, the number of staff on duty, or the amount of equipment on the hospital’s premises. Capacity includes whatever a hospital customarily does to accommodate patients in excess of its occupancy limits §489.24 (b). If a hospital has customarily accommodated patients in excess of its occupancy limits by whatever mean (e.g., moving patients to other units, calling in additional staff, borrowing equipment from other facilities) it has, in fact, demonstrated the ability to provide services to patients in excess of its occupancy limits. A hospital may appropriately transfer (see Tag A-2409/C-2409) an individual before the sending hospital has used and exhausted all of its resources available if the individual requests the transfer to another hospital for his or her treatment and refuses treatment at the sending hospital. DOCUMENT 1182 To comply with the MSE and stabilization requirements of §1867 all individuals with similar medical conditions are to be treated consistently. Compliance with local, State, or regionally approved EMS transport of individuals with an emergency is usually deemed to indicate compliance with §1867; however a copy of the protocol should be obtained and reviewed at the time of the survey. If community wide plans exist for specific hospitals to treat certain EMCs (e.g., psychiatric, trauma, physical or sexual abuse), the hospital must meet its EMTALA obligations (screen, stabilize, and or appropriately transfer) prior to transferring the individual to the community plan hospital. An example of a community wide plan would be a trauma system hospital. A trauma system is a comprehensive system providing injury prevention services and timely and appropriate delivery of emergency medical treatment for people with acute illness and traumatic injury. These systems are designed so that patients with catastrophic injuries will have the quickest possible access to an established trauma center or a hospital that has the capabilities to provide comprehensive emergency medical care. These systems ensure that the severely injured patient can be rapidly cared for in the facility that is most appropriately prepared to treat the severity of injury. Community plans (not a formal community call plan provided for under §489.24(j)(iii)) are designed to provide an organized, pre-planned response to patient needs to assure the best patient care and efficient use of limited health care resources. Community plans are designed to augment physician’s care if the necessary services are not within the capability of the hospital but does not mandate patient care nor transfer patterns. Patient health status frequently depends on the appropriate use of the community plans. The matching of the appropriate facility with the needs of the patient is the focal point of this plan and assures every patient receives the best care possible. Therefore, a sending hospital’s appropriate transfer of an individual in accordance with community wide protocols in instances where it cannot provide stabilizing treatment would be deemed to indicate compliance with §1867. If an individual seeking care is a member of a managed health care plan (e.g., HMO, PPO or CMP), the hospital is obligated to comply with the requirements of §489.24 regardless of the individual’s payor source or financial status. The hospitals is obligated to provide the services necessary to determine if an EMC is present and provide stabilizing treatment if indicated. This is true regardless if the individual is enrolled in a managed care plan that restricts its enrollees’ choice of health care provider. EMTALA is a requirement imposed on hospitals, and the fact that an individual who comes to the hospital is enrolled in a managed care plan that does not contract with that hospital has no bearing on the obligation of the hospital to conduct an MSE and to at lease initiate stabilizing treatment. A managed health care plan may only state the services for which it will pay or decline payment, but that does not excuse the hospital from compliance with EMTALA. DOCUMENT 1182 Section 42 CFR 489.24(b) defines stabilized to mean: “… that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an “emergency medical condition” as defined in this section under paragraph (2) of that definition, that a woman has delivered the child and the placenta.” The regulation sets the standard determining when a patient is stabilized. If a hospital is unable to stabilize an individual within its capability, an appropriate transfer should be implemented. To be considered stable the emergency medical condition that caused the individual to seek care in the dedicated ED must be resolved, although the underlying medical condition may persist. For example, an individual presents to a hospital complaining of chest tightness, wheezing, and shortness of breath and has a medical history of asthma. The physician completes a medical screening examination and diagnoses the individual as having an asthma attack that is an emergency medical condition. Stabilizing treatment is provided (medication and oxygen) to alleviate the acute respiratory symptoms. In this scenario the EMC was resolved and the hospital’s EMTALA obligation is therefore ended, but the underlying medical condition of asthma still exists. After stabilizing the individual, the hospital no longer has an EMTALA obligation. The physician may discharge the individual home, admit him/her to the hospital, or transfer (the “appropriate transfer” requirement under EMTALA does not apply to this situation since the individual has been stabilized) the individual to another hospital depending on his/her needs. The preceding example does not reflect a change in policy, rather it is a clarification as to when an appropriate transfer is to be implemented to decrease hospitals risk of being in violation of EMTALA due to inappropriate transfers An individual will be deemed stabilized if the treating physician or QMP attending to the individual in the emergency department/hospital has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved. For those individuals whose EMCs have been resolved the physician or QMP has several options: Discharge home with follow-up instructions. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care as part of the discharge instructions. The EMC that caused the individual to present to the dedicated ED must be resolved, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure the DOCUMENT 1182 necessary follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital; or Inpatient admission for continued care. Hospitals are responsible for treating and stabilizing, within their capacity and capability, any individual who presents him/herself to a hospital with an EMC. The hospital must provide care until the condition ceases to be an emergency or until the individual is properly transferred to another facility. An inappropriate transfer or discharge of an individual with an EMC would be a violation of EMTALA. If a hospital is alleged to have violated EMTALA by transferring an unstable individual without implementing an appropriate transfer according to §489.24(e), and the hospital believes that the individual was stable (EMC resolved) the burden of proof is the responsibility of the transferring hospital. When interpreting the facts the surveyor should assess whether or not the individual was stable. Was it reasonable to believe that the transferring hospital should have been knowledgeable of the potential complications during transport? To determine whether the individual was stable and treated appropriately surveyors will request that the QIO physician review the case. If the treating physician is in doubt that an individual’s EMC is stabilized the physician should implement an appropriate transfer (see Tag A-2409/C-2409) to prevent a potential violation of EMTALA, if his/her hospital cannot provide further stabilizing treatment. If a physician is not physically present at the time of transfer, then the qualified medical personnel (as determined by hospital bylaws or other board-approved documents) must consult with a physician to determine if an individual with an EMC is to be transferred to another facility for further stabilizing treatment. The failure of a receiving facility to provide the care it maintained it could provide to the individual when the transfer was arranged should not be construed to mean that the individual’s condition worsened as a result of the transfer. In the case of psychiatric emergencies, if an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others, would be considered to have an EMC. Psychiatric patients are considered stable when they are protected and prevented from injuring or harming him/herself or others. The administration of chemical or physical restraints for purposes of transferring an individual from one facility to another may stabilize a psychiatric patient for a period of time and remove the immediate EMC but the underlying medical condition may persist and if not treated for longevity the patient may experience exacerbation of the EMC. Therefore, practitioners should use great care when determining if the medical condition is in fact stable after administering chemical or physical restraints. DOCUMENT 1182 A hospital’s EMTALA obligation ends when a physician or qualified medical person has made a decision: That no emergency medical condition exists (even though the underlying medical condition may persist); That an emergency medical condition exists and the individual is appropriately transferred to another facility; or That an emergency medical condition exists and the individual is admitted to the hospital for further stabilizing treatment. (ii) For transfer of the individual to another medical facility in accordance with paragraph (e) of this section. Interpretive Guidelines: §489.24(d)(1)(ii) When a hospital has exhausted all of its capabilities in attempting to resolve the EMC, it must effect an appropriate transfer of the individual (see Tag A-2409/C-2409). Section 42 CFR 489.24(b) defines transfer to mean: “… the movement (including the discharge) of an individual outside a hospital’s facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who (i) has been declared dead, or (ii) leaves the facility without the permission of any such person.” If an individual is admitted as an inpatient, EMCs must be stabilized either by the hospital to which an individual presents or the hospital to which the individual is transferred. If a woman is in labor, the hospital must deliver the baby and the placenta or transfer appropriately. She may not be transferred unless she, or a legally responsible person acting on her behalf, requests a transfer and a physician or other qualified medical personnel, in consultation with a physician, certifies that the benefits to the woman and/or the unborn child outweigh the risks associated with the transfer. If the individual’s condition requires immediate medical stabilizing treatment and the hospital is not able to attend to that individual because the emergency department is operating beyond its capacity, then the hospital should transfer the individual to a hospital that has the capability and capacity to treat the individual’s EMC. DOCUMENT 1182 (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 Interpretive Guidelines: §489.24(d)(2)(i) A hospital’s EMTALA obligation ends when the individual has been admitted in good faith for inpatient hospital services whether or not the individual has been stabilized. An individual is considered to be “admitted” when the decision is made to admit the individual to receive inpatient hospital services with the expectation that the patient will remain in the hospital at least overnight. Typically, we would expect that this would be documented in the patient’s chart and medical record at the time that a physician signed and dated the admission order. Hospital policies should clearly delineate, which practitioners are responsible for writing admission orders. A hospital continues to have a responsibility to meet the patient emergency needs in accordance with hospital CoPs at 42 CFR Part 482. The hospital CoPs protect individuals who are admitted, and they do not permit the hospital to inappropriately discharge or transfer any patient to another facility. The hospital CoPs that are most relevant in this case are as follows: emergency services, governing body, discharge planning, quality assurance and medical staff. Hospitals are responsible for assuring that inpatients receive acceptable medical care upon admission. Hospital services for inpatients should include diagnostic services and therapeutic services for medical diagnosis, treatment, and care of the injured, disabled or sick persons with the intention of treating patients. If during an EMTALA investigation there is a question as to whether an individual was admitted so that a hospital could avoid its EMTALA obligation, the SA surveyor is to consult with RO personnel to determine if the survey should be expanded to a survey of the hospital CoPs. After completion of the survey, the case is to be forwarded to the RO for violation determination. If it is determined that the hospital admitted the individual solely for the purpose of avoiding its EMTALA obligation, then the hospital is liable under EMTALA and may be subject to further enforcement action. (ii) This section is not applicable to an inpatient who was admitted for elective (non-emergency) diagnosis or treatment. Interpretive Guidelines: §489.24(d)(2)(ii) Individuals admitted to the hospital for elective medical services are not protected by EMTALA. The hospital CoPs protect all classifications of inpatients, elective and emergent. DOCUMENT 1182 (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. Interpretive Guidelines: §489.24(d)(2)(iii) If an inpatient develops an EMC, the hospital is required to meet the patient’s emergency needs in accordance with acceptable standards of practice. The hospital CoPs protects patients who are admitted, and the hospital may not discharge or transfer any patient to another facility inappropriately. The protective CoPs are found at 42 CFR Part 482. The five CoPs that are most relevant in affording patients protection in cases when patients with an EMC is admitted are as follows: Emergency services (§482.55) Governing body (§482.12) Discharge planning (§482.43) Quality assessment and performance improvement (§482.21) Medical staff (§482.22) If a hospital is noncompliant with any of the above COPs, the hospital will be subject to enforcement action. (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. DOCUMENT 1182 Interpretive Guidelines: §489.24(d)(3) The medical record should reflect that screening, further examination, and or treatment were offered by the hospital prior to the individual’s refusal. In the event an individual refuses to consent to further examination or treatment, the hospital must indicate in writing the risks/benefits of the examination and/or treatment; the reasons for refusal; a description of the examination or treatment that was refused; and the steps taken to try to secure the written, informed refusal if it was not secured. Hospitals may not attempt to coerce individuals into making judgments against their interest by informing them that they will have to pay for their care if they remain but that their care will be free or at a lower cost if they transfer to another hospital. An individual may only refuse examination, treatment, or transfer on behalf of a patient if the patient is incapable of making an informed choice for him/herself. ________________________________________________________________________ Tag A-2408/C-2408 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.24(d)(4) and (5) (4) Delay in Examination or Treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii) A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or non-physician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. DOCUMENT 1182 (iv) Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. Interpretive Guidelines §489.24(d)(4)(i),(ii),(iii) and (iv) Hospitals should not delay providing a medical screening examination or necessary stabilizing treatment by inquiring about an individual’s ability to pay for care. All individuals who present to a hospital and request an MSE for a medical condition (or have a request for an MSE made on their behalf) must receive that screening examination, regardless of the answers the individual may give to the insurance questions asked during the registration process. In addition, a hospital may not delay screening or treatment to any individual while it verifies the information provided. Hospitals may follow reasonable registration processes for individuals presenting with an EMC. Reasonable registration processes may include asking whether an individual is insured and, if so, what the insurance is, as long as this inquiry do not delay screening, treatment or unduly discourage individuals from remaining for further evaluation. The registration process permitted in the dedicated ED typically consists of collecting demographic information, insurance information, whom to contact in an emergency and other relevant information. If a managed care member comes to a hospital that offers emergency services, the hospital must provide the services required under the EMTALA statute without regard for the individual’s insurance status or any prior authorization requirement of such insurance. This requirement applies equally to both the referring and the receiving (recipient) hospital. Therefore, it may be a violation if the receiving hospital delays acceptance of the transfer of an individual with an unstabilized EMC pending receipt or verification of financial information. It would not be a violation if the receiving hospital delayed acceptance of the transfer of an individual with a stabilized EMC pending receipt or verification of financial information because EMTALA protections no longer apply once a patient is stabilized. If a delay in screening was due to an unusual internal crisis whereby it was simply not within the capability of the hospital to provide an appropriate screening examination at the time the individual came to the hospital (e.g., mass casualty occupying all the hospital’s resources for a time period), surveyors are to interview hospital staff members to elicit the facts surrounding the circumstances to help determine if there was a violation of EMTALA. DOCUMENT 1182 (5) Refusal to Consent to Transfer. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual's behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual's written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual's refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. Interpretive Guidelines: §489.24 (d)(5) For individuals who refuse to consent to a transfer, the hospital staff must inform the individual of the risks and benefits and document the refusal and, if possible, place a signed informed consent to refusal of the transfer in the individual’s medical record. If an individual or the individual’s representative refuses to be transferred and also refuses to sign a statement to that effect, the hospital may document such refusals as they see fit. ________________________________________________________________________ Tag A-2409/C-2409 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.24(e) Restricting Transfer Until the Individual Is Stabilized (1) General. If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless— (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii) (A) The individual (or a legally responsible person acting on the individual's behalf) requests the transfer, after being informed of the hospital's obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer; DOCUMENT 1182 (B) A physician (within the meaning of Section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in Section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which(i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility-(A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment; (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any oncall physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet DOCUMENT 1182 available or historical records not readily available from the hospital's files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. Interpretive Guidelines: §489.24(e) The EMTALA regulations at 42 CFR 489.24(b) define ―transfer‖ as ― …the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who (i) has been declared dead, or (ii) leaves the facility without the permission of any such person.‖ The requirements in 42 CFR 489.24(e) apply to transfers to another hospital. Transfer of Individuals with Unstabilized EMCs In the case of individuals found to have an EMC a hospital is required under EMTALA rules at 42 CFR 489.24(d) to provide stabilizing treatment within the capabilities of the staff and facilities available in the hospital, or to provide a transfer to another hospital as required by 42 CFR 489.24(e). Transfer of the individual to another hospital may be reasonable and permissible, but the regulations establish a number of requirements that each transfer must meet in order to comply with EMTALA. If an individual’s EMC has not been stabilized, prior to transferring the individual to another hospital, the sending hospital is required under EMTALA to pursue a transfer because either: the individual requests the transfer; or the expected benefits of the transfer outweigh the increased risks of the transfer. In either case, the transfer must also always meet the four requirements of an “appropriate” transfer. If an individual is moved to a diagnostic facility located at another hospital for diagnostic procedures not available at the transferring hospital, and the hospitals arrange to return the individual to the transferring hospital, the transfer requirements must still be met by the sending hospital. The recipient hospital is not obligated to meet the EMTALA transfer requirements when implementing an appropriate transfer back to the transferring hospital. However, it is reasonable to expect the recipient hospital with the diagnostic capability to communicate (e.g., telephonic report or documentation within the medical record) with the transferring hospital its findings of the medical condition and a status report of the individual during and after the procedure. DOCUMENT 1182 The transfer requirements apply only to individuals who have been determined to have an EMC that has not been stabilized. The hospital has no further EMTALA obligation to an individual who has been determined not to have an EMC or whose EMC has been stabilized, or who has been admitted as an inpatient (See discussion related to the requirements of 42 CFR 489.24(d), concerning stabilizing treatment.) However, the hospital has other obligations to the individual under the Hospital Conditions of Participation. These transfer requirements do not apply to an individual who is moved to another part of the hospital, because technically the patient has not been transferred. This is also the case when an individual who presents to an off-campus dedicated emergency department is found to have an EMC and is moved to the hospital’s main campus for stabilizing treatment that cannot be provided at the off-campus site. Transfer at the Request of the Individual A transfer may be made at the request of the individual with an EMC or of a person legally responsible for that individual. The hospital must assure that the individual or legally responsible person is first informed of the hospital’s obligations under EMTALA, e.g., its obligation to provide stabilizing treatment within its capability and capacity, regardless of the individual’s ability to pay. The hospital must also assure that the individual has been advised of the medical risks associated with transfer. After the hospital has communicated this information, the individual’s request for a transfer must be in writing. The request must include the reason(s) why the transfer is being requested and a statement that the individual is aware of the risks and benefits associated with the transfer. The individual or individual’s representative must sign the written request. Transfer with a Physician Certification Alternatively, a transfer may be made when a physician certifies that the expected benefits of the transfer outweigh the risks. Specifically, a physician must certify that the medical benefits to the individual with the EMC that could reasonably be expected from provision of appropriate treatment at another hospital outweigh the increased risks that result from being transferred. In the case of a pregnant woman in labor, the physician must certify that the expected benefits outweigh the risk to both the pregnant woman and the unborn child. Under certain circumstances qualified medical personnel other than a physician may sign the certification. A qualified medical person (QMP) may sign the certification of benefits versus risks of a transfer only after consultation with a physician who agrees with the transfer. The physician must subsequently countersign the certification. The physician’s countersignature must be obtained within the established timeframe according to hospital policies and procedures. Hospital by-laws or rules or regulations must specify the criteria and process for granting medical staff privileges to QMPs, and, in accordance with the hospital or CAH Conditions of Participation, each individual QMP must be appropriately privileged. The date and time of the physician (or the QMP) certification should closely match the date and time of the transfer. DOCUMENT 1182 Section 1861(r)(i) of the Act defines physicians as: A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action. (This provision is not to be construed to limit the authority of a doctor or medicine or osteopathy to delegate tasks to other qualified health care personnel to the extent recognized under State law or a State’s regulatory mechanism). The regulation at §489.24 (e)(1) requires an express written certification. Physician certification cannot simply be implied from the findings in the medical record and the fact that the patient was transferred. The certification must state the reason(s) for transfer. The narrative rationale need not be a lengthy discussion of the individual’s medical condition reiterating facts already contained in the medical record, but it should give a complete picture of the benefits to be expected from appropriate care at the receiving (recipient) facility and the risks associated with the transfer, including the time away from an acute care setting necessary to effect the transfer. The risks and benefits certification should be specific to the condition of the patient upon transfer. This rationale may be included on the certification form or in the medical record. In cases where the individual’s medical record does not include a certification, the hospital may be given the opportunity to retrieve the certification. Certifications may not be backdated. Women in Labor Regardless of practices within a State, a woman in labor may be transferred only if she or her representative requests the transfer or if a physician or other qualified medical personnel signs a certification that the benefits outweigh the risks. If the hospital does not provide obstetrical services, the benefits of a transfer may outweigh the risks. A hospital cannot cite State law or practice as the basis for transfer. Hospitals that are not capable of handling high-risk deliveries or high-risk infants often have written transfer agreements with facilities capable of handling highrisk cases. The hospital must still meet the screening, treatment, and transfer requirements. DOCUMENT 1182 Four Requirements for an Appropriate Transfer 1. §489.24 (e)(2)(i) - The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child; Before implementing a transfer of an individual with an unstablized EMC, a hospital is required to provide stabilizing treatment within its capability and capacity. See discussion of stabilizing treatment, 42 CFR 489.24(d). This includes treatment to minimize the transfer risk to the health of the individual and, in the case of a pregnant woman in labor, the health of the unborn child. If Hospital A participates in a community call plan with Hospital B and an individual with an EMC requires the services of an on-call specialist who, pursuant to the community call plan, is on-call at Hospital B to respond to the specialty needs of individuals at Hospital A, then generally a transfer of the individual to Hospital B is warranted. However, Hospital A is still required to provide treatment within its on-site capability and capacity to minimize the risks of transfer, and all other transfer requirements must also be met, notwithstanding the participation in the community call plan. 2. §489.24(e)(2)(ii) - The receiving facility-(A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment; The transferring hospital must obtain permission from the receiving (recipient) hospital to transfer an individual. The transferring hospital should document its communication with the receiving (recipient) hospital, including the date and time of the transfer request and the name and title of the person accepting the transfer. DOCUMENT 1182 3. §489.24 (e)(2)(iii) - The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital's files) must be sent as soon as practicable after transfer; Necessary medical records must accompany individuals being transferred to another hospital. If a transfer is in an individual’s best interest, it should not be delayed until records are retrieved or test results come back from the laboratory. Whatever medical records are available at the time the individual is transferred should be sent to the receiving (recipient) hospital with the patient. Test results that become available after the individual is transferred should be telephoned to the receiving (recipient) hospital, and then mailed or sent via electronic transmission consistent with HIPAA provisions on the transmission of electronic data. 4. §489.24 (e)(2)(iv) - The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. Emergency medical technicians may not always be “qualified personnel” for purposes of transferring an individual under these regulations. Depending on the individual’s condition, there may be situations in which a physician’s presence or some other specialist’s presence might be necessary. The physician at the sending hospital (not at the receiving hospital) has the responsibility to determine the appropriate mode, equipment, and attendants for transfer. While the sending hospital is ultimately responsible for ensuring that the transfer is affected appropriately, the hospital may meet its obligations as it sees fit. These regulations do not require that a hospital operate an emergency medical transportation service. DOCUMENT 1182 _____________________________________________________________ Tag A-2410/C-2410 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.24(e)(3) (3) A participating hospital may not penalize or take adverse action against a physician or a qualified medical person described in paragraph (e)(1)(ii)(C) of this section because the physician or qualified medical person refuses to authorize the transfer of an individual with an emergency medical condition that has not been stabilized, or against any hospital employee because the employee reports a violation of a requirement of this section. Interpretive Guidelines: §489.24 (e)(3) A “participating hospital” means a hospital that has entered into a provider agreement under §1866 of the Act. Hospital employees reporting alleged EMTALA violations are also protected by this regulation. ________________________________________________________________________ Tag A-2411/C-2411 (Rev. 46, Issued: 05-29-09, Effective/Implementation: 05-29-09) §489.24(f) Recipient Hospital Responsibilities A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or, with respect to rural areas, regional referral centers (which, for purposes of this subpart, mean hospitals meeting the requirements of referral centers found at §412.96 of this chapter)) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. (1) The provisions of this paragraph (f) apply to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. (2) The provisions of this paragraph (f) do not apply to an individual who has been admitted to a referring hospital under the provisions of paragraph (d)(2)(i) of this section. Interpretive Guidelines: §489.24(f) DOCUMENT 1182 A Medicare-participating hospital that has specialized capabilities or facilities may not refuse to accept an appropriate transfer from another hospital of an individual with an unstabilized emergency medical condition who is protected under EMTALA and requires such specialized capabilities or facilities. This assumes that, in addition to its specialized capabilities, the recipient hospital has the capacity to treat the individual, and that the transferring, i.e. referring, hospital lacks that capability or capacity. Hospitals with specialized capabilities or facilities may include, but are not limited to, hospitals with burn units, shock trauma units, neonatal intensive care units or hospitals that are regional referral centers that serve rural areas as defined by the requirements at 42 CFR 412.96. This requirement to accept an appropriate transfer applies to any Medicare-participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. In other words, while some obligations under EMTALA apply only to hospitals that have a dedicated emergency department, e.g., requirements related to providing a medical screening examination, the EMTALA recipient hospital obligation can also apply to hospitals that do not have a dedicated emergency department. For example, if an individual is found to have an emergency medical condition that requires specialized psychiatric capabilities, a psychiatric hospital that participates in Medicare and has capacity is obligated to accept an appropriate transfer of that individual. It does not matter if the psychiatric hospital does not have a dedicated emergency department. The regulation states that a recipient hospital’s EMTALA obligations do not extend to individuals who are inpatients of another hospital. Thus, a hospital may not be cited for violating EMTALA if it refuses to accept the transfer of an inpatient from the referring hospital. Section 489.24(b) defines inpatient: “Inpatient means an individual who is admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services as described in §409.10(a) of this chapter with the expectation that he or she will remain at least overnight and occupy a bed even though the situation later develops that the individual can be discharged or transferred to another hospital and does not actually use a hospital bed overnight.” Individuals who are placed in observation status are not inpatients, even if they occupy a bed overnight. Therefore, placement in an observation status of an individual who came to the hospital’s DED does not terminate the EMTALA obligations of that hospital or a recipient hospital toward the individual. There is no EMTALA obligation for a Medicare-participating hospital with specialized capabilities to accept transfers from hospitals located outside the boundaries of the United States. In accordance with Section 210(i) of the Social Security Act, the term “United States,” when used in a geographical sense, means the States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, and American Samoa. Hospitals that request transfers must recognize that the appropriate transfer of individuals with unstabilized emergency medical conditions that require specialized services should DOCUMENT 1182 not routinely be made over great distances, bypassing closer hospitals with the needed capability and capacity. A hospital with specialized capabilities or facilities that has the necessary capacity to treat an individual with an emergency medical condition may not condition or attempt to condition its acceptance of an appropriate transfer of an individual protected under EMTALA on the use of a particular mode of transport or transport service. It is the treating physician at the transferring hospital who decides how the individual is transported to the recipient hospital and what transport service will be used, since this physician has assessed the individual personally. The transferring hospital is required to arrange transport that minimizes the risk to the individual who is being transferred, in accordance with the requirements of §489.24(e)(2)(B)(iv). A hospital with specialized capabilities that delays the treatment of an individual with an emergency medical condition who arrives as a transfer from another facility could be in violation of EMTALA, depending on the circumstances of that delay. For instance, if there is evidence that the recipient hospital unreasonably delayed the treatment of certain individuals and expedited the treatment of other individuals, based on their ability to pay for the services or some other form of discrimination, then the recipient hospital may be in violation of EMTALA. Hospitals that deliberately delay moving an individual from an EMS stretcher do not thereby delay the point in time at which their EMTALA obligation begins. Furthermore, such a practice of “parking” individuals arriving via EMS, refusing to release EMS personnel or equipment, can potentially jeopardize the health and safety of the transferred individual and other individuals in the community who may need EMS services at that time. On the other hand, this does not mean that a hospital will necessarily have violated EMTALA and/or the hospital CoPs if it does not, in every instance, immediately assume from the EMS provider all responsibility for the individual, regardless of any other circumstances in the hospital. Lateral transfers, that is, transfers between facilities of comparable resources and capabilities, are not required by §489.24(f), because the benefits of such a transfer would not be likely to outweigh the risks of the transfer, except when the transferring hospital has a serious capacity problem, a mechanical failure of equipment, or similar situations, such as loss of power or significant flooding. Assessment of whether the transferring hospital with the requisite capabilities lacked the capacity to provide stabilizing treatment, or of whether the recipient hospital lacked the capacity to accept an appropriate transfer requires a review of the hospital’s general practices in adjusting its capacity. If a hospital generally has a record of accommodating additional patients by various means, such as moving patients from one unit to another, calling in additional staff, and temporarily borrowing additional equipment from other facilities, then that hospital would be expected under EMTALA to take reasonable steps to respond to the treatment needs of an individual requiring stabilizing treatment for an emergency medical condition. The determination of a hospital’s capacity would depend on the case-specific circumstances and the hospital’s previous implementation of capacity management actions. DOCUMENT 1182 The criteria for classifying hospitals as rural regional referral centers are defined in 42 CFR 412.96. A designated rural regional referral center is obligated to accept appropriate transfers of individuals who require the hospital’s specialized capabilities if the hospital has the capacity to treat the individual. DOCUMENT 1182 Transmittals Issued for this Appendix Rev # Issue Date Subject Impl Date CR# R60SOM 07/16/2010 Revisions to Appendix V,-Interpretive Guidelines-Responsibilities of Medicare Participating Hospitals in Emergency Cases 07/16/2010 N/A R46SOM 05/29/2009 Revisions to Appendix V,-“Emergency Medical Treatment and Labor Act (EMTALA) Interpretive Guidelines 05/29/2009 N/A R01SOM 05/21/2004 Initial Release of Pub 100-07 N/A N/A EXHIBIT DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 000 INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 000 An EMTALA (Emergency Medical Treatment and Labor Act) complaint survey was conducted on 6/24/2013 through 6/26/2013 for the investigation of Complaint Number AL00029174. The hospital's Chief Nursing Officer was notified on November 1, 2013 at 1222 p.m., that Immediate Jeopardy (IJ) existed related to two incidents that occurred at Mobile Infirmary. The determination of the IJ was based on review of records, review of security video and interviews that revealed Patient Identifier (PI)# 2 presented to the Emergency Department on 3/5/2013 displaying inappropriate behavior and Mobile Infirmary staff failed to manage the behavior and provide a medical screening examination to determine whether or not Patient # 2 had an emergency medical condition. The failure of Mobile Infirmary to provide a medical screening examination resulted in PI#2 patient identifier did not receive an appropriate medical screening examination nor stabilizing treatment as required, prior to discharge. According to a security video tape, a security officer picked up the patient and put him/her in a wheelchair. The security officer transported Patient # 2 off of hospital property and dumped him/her out of the wheelchair. Hours later, the patient was picked up via Emergency Medical Services, transported to another acute care hospital and was admitted to the intensive care unit. Patient # 2 died on 3/18/2013. Additionally, Mobile Infirmary failed to provide a medical screening examination and stabilizing treatment for Patient # 1's return visit to the Emergency Department on 5/27/2013. Patient # 1's representative, acting in Patient # 1's behalf, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE TITLE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 1 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 000 Continued From page 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 000 requested medical assistance. The representative requested medical assistance with getting the patient out of the privately owned vehicle because he/she thought the patient was having a seizure. Patient # 1's representative was allegedly told by the security officer to leave the hospital. The patient's representative left the hospital premises and transported Patient # 1 immediately to another acute care hospital on 5/27/2013. Upon arrival Patient # 1 was pulseless and not breathing. The patient expired shortly thereafter. The hospital's failure to provide a medical screening examination and stabilizing treatment posed an immediate threat to Patient #1 and Patient # 2's health and safety and inappropriately delayed treatment for their emergency medical conditions. Hospital 2 was not in compliance with the Federal Requirements at 42 CFR 489.24 and related provisions of CFR 42 489.20 Responsibilities of Medicare Participating Hospitals in Emergency Cases on 6/26/2013. Please refer to Findings at A2400, A2405, A2406, A2407 and A2409. A2400 489.20(l) COMPLIANCE WITH 489.24 A2400 [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: Based on interviews, review of EMS (Emergency Medical Services) reports and EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures, Hospital 2 failed to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 2 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2400 Continued From page 2 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2400 1. Provide a Medical Screening Examination (MSE) for two of 29 sampled patients: Patient Identifier # 1, a patient who returned to the ED on 5/27/13, minutes after leaving Against Medical Advise (AMA) and PI # 2, a patient who presented to the Emergency Department (ED) via ambulance on 3/5/13 with a chief complaint of weakness. Refer to findings at tag A2406. 2. Provide Stabilizing Treatment for PI #1 and PI # 2, two of 29 sampled patients. Refer to findings at tag A2407. 3. Arrange, implement and document an appropriate transfer for PI # 1 and PI # 2. Refer to findings at tag A2409. Hospital 2's deficient practice effected PI # 1 and PI # 2, two of 29 sampled patients who presented to Hospital 2's Emergency Department and has the potential to negatively effect all patients who present to Hospital 2's ED for a Medical Screening Examination to determine if an Emergency Medical Condition exists, require stabilizing treatment, and / or require or request transfer from Hospital 2 to another hospital. These citations were written as a result of the investigation of Complaint Number AL00029174. Please refer to findings at: A- 2405 / 489.20 (r)(3) - Emergency Room Log FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 3 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG A2400 Continued From page 3 A2400 A - 2406 / 489.24(r) and 489.24(c) - Medical Screening Examination; A - 2407 / 489.24(d)(1-3) - Stabilizing Treatment and A - 2409 / 489.24(e)(1-2) - Appropriate Transfer. A2405 489.20(r)(3) EMERGENCY ROOM LOG A2405 (X5) COMPLETION DATE [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: .0Based on interviews and review of EMTALA policies and procedures, Hospital 2 failed to document any information in the Emergency Department (ED) Central Log concerning Patient Identifier (PI) # 1's return to the ED on 5/27/13 when PI # 1's representative returned to the ED and notified staff that something was wrong with PI # 1. This deficient practice effected 1 of 29 sampled patients presenting to Hospital 2's ED and had the potential to negatively effect all patients who present to Hospital # 2's ED. Findings Include: Review of PI # 1's medical record from Hospital 2 revealed the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 4 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2405 Continued From page 4 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2405 Patient arrived in ED at 04:20 AM. Triage began at 04:30 AM and includes the following documentation: 04:34:12 - Pt c/o (complained of) SOB (shortness of breath) with occas. (occasional) CP (Chest pain) on & off for the last month. Worse tonight, " I feel like I can' t catch my breath." Some n/v (nausea/vomiting) when pain is worst. 0435: Temp: 96.9, Pulse 84, Blood Pressure: 135/89, Blood Glucose 256. 4:38:33: Patient was taken to ED room 24. 04:54:24: "Awaiting MD (Medical Doctor) eval (evaluation)." 06:34 AM - The ED Physician (EI # 5) documented, "This case is a certified medical emergency..." 06:46:22 - EI # 8 documented, "... RN (Registered Nurse) went to pts (patient's) room. Pt asked to see (doctor) - RN asked what this was concerning and pt became belligerent. Pt was not in stretcher, did not have O2 on, and began cursing @ RN. RN explained to pt that need to be in bed with O2 on. Security called. Pt wants to leave ama (against medical advice). MD (Medical Doctor) (EI # 5) informed. Pt informed of risks of leaving ama. Pt refused to sign AMA form. Pt removed own IV would not allow (nurse) to apply gauze. Pt states, "You can't keep me here, I am not under arrest." Pt walked to truck by own power with security. Threatening security along the way..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 5 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2405 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2405 06:48:58 - ED disposition set to eloped per ED Physician (EI #5). 06:49 - ED Physician (EI # 5) documented, ED Course/Plan, "... Chest pain: SOB (Shortness of breath) Diagnosis management comments: The patient became hostile and belligerent and had to be removed from the emergency department prior to my evaluation. I did not lay eyes on this patient ... Patient Progress: stable..." Interview with Employee Identifier (EI) # 8, Staff RN ED at Hospital 2, 0630 - 1830 shift, on 6/26/13 at 10:50 AM: EI # 8 verified he was the RN assigned to PI # 1 when the patient left the ED Against Medical Advice (AMA) on 5/27/13 and returned several minutes later. Sometime around 0630 on 5/27/2013, EI # 8 reported PI # 1 said he was leaving and PI # 1 abruptly left the ED AMA before he was seen by a physician. Minutes later, the ED Liaison (EI # 9) informed the charge nurse that a female representative for PI # 1 entered the ED waiting area and reported something was wrong with PI # 1. The representative said PI # 1 was in the truck parked in the ambulance bay and was possibly having a seizure. . According to the EI # 8, as he and the ED Charge Nurse (EI # 4) arrived at the ambulance bay doors, a truck allegedly containing PI # 1, was driving off. Interview with EI # 9, ED Liaison / Hospital 2, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 6 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2405 Continued From page 6 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2405 6/26/2013 at 3:30 PM: EI # 9 stated the first time PI # 1 left the ED on 5/27/13 she observed PI # 1 and staff walking outside in the ambulance bay. PI # 1 got in a truck and left the ED. A few minutes later a female driving a truck pulled into the ambulance bay, got out of the truck and walked into the ED waiting area. The female reported (PI # 1), who is reportedly in the truck, was having a seizure or "something." "They (Hospital 2 staff ) just made us leave." EI # 9 said she initially advised a staff RN about the complaint. EI # 9 said she then saw the ED Charge Nurse (EI # 4) and advised her of the situation. According to EI # 9, the Charge Nurse (EI # 4) told the staff RN (EI # 8) to accompany her to the ambulance bay to check on the patient (PI # 1). EI # 9 stated she saw a security officer standing by the truck in the ambulance bay talking with the female who reported the concern about PI # 1. Reportedly the officer told the female the police are called when a person who has been asked to leave the hospital does not leave. Allegedly the female said, "Well I'm not going to jail on Memorial Day." She got into the truck and drove away. EI # 9 stated she saw the Charge Nurse (EI # 4) and another staff member (unsure of identity) in the ambulance bay as the truck drove away. Interview with EI # 4, RN, Day shift ED Charge Nurse at Hospital 2, on 6/25/13 at 4:57 PM: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 7 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2405 Continued From page 7 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2405 Shortly after PI # 1 left the ED, the ED Liaison (EI # 9) came to me and said PI # 1 is back. According to EI # 4, she and a staff RN (EI # 8) went to the ambulance bay just as the female was driving the truck away from the bay area. "I never saw the patient (PI #1) after he walked out with the security guard." Interview with EI # 6, Protective Services Officer at Hospital 2, 0630 to 1830 Shift, on 6/26/13 at 1:08 PM: Relationship to PI # 1: Conversation with female (driver) who accompanied PI # 1 to Hospital 2's ED on 5/27/13. EI # 6 said at the beginning of the day shift, he was informed by the Protective Services night shift Team Leader that PI # 1 had been removed from the ED due to aggressive behavior and cursing staff. He reported he was advised PI # 1 and the person accompanying PI # 1 had been asked to leave the hospital. The Team Leader pointed to a truck parked in a space near Circle One (Hospital 2 Property) and said, "That's the truck." EI # 6 said the truck pulled away as he walked toward the vehicle. According to EI # 6, before he could walk back to the ambulance bay at the ED, the truck pulled in and parked in the bay. A female was standing outside of the truck when EI # 6 arrived. EI # 6 said he asked the female if the truck was her vehicle and she said yes. The officer said to the female, "Ya'll have been asked to leave the property." The female reportedly said, "I don't know what to do." According to EI # 6, the female FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 8 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2405 Continued From page 8 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2405 did not say anything about PI # 1. The officer stated he said, "I don't know, but you were asked to leave here." The female returned to the truck and pulled away. EI # 6 was asked if he/she saw Patient #1. EI # 6 said no. All he/she could see was a leg. A review of Hospital 2's ED Log on 6/24/13 revealed there was no documentation in the log regarding PI #1's return to the ED on 5/27/13. . Hospital # 2's Policy & Procedure review revealed the following: Policy Title: Medical Screening Examination Policy revealed in part, ..."Additionally, an ambulance or private vehicle transporting a patient to the hospital which arrives anywhere on hospital property is considered having come to the hospital and the patient must be offered a medical screening exam... 3) In the event the patient has not been registered, document the patient's visit and disposition on the centralized log in the emergency department..." The hospital failed to ensure their policy was followed as evidenced by PI # 1's return visit to Hospital 2's ED was not documented in the ED Log. Additionally, the policy was not followed as evidenced by the ED staff failing to consider that on 5/27/2013 when Patient # 1 arrived on hospital property (ambulance bay area) for the second visit, as stated in the hospital's policy was "considered having come to the hospital." A2406 489.24(r) and 489.24(c) MEDICAL SCREENING EXAM A2406 Applicability of provisions of this section. (1) In the case of a hospital that has an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 9 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 9 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 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 (b) 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) Nonapplicability of provisions of this section. Sanctions under this section for inappropriate transfer during a national emergency 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 located in an emergency area, as specified in section 1135(g)(1) of the Act. 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 10 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 10 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 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 for by 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: Based on medical record reviews, review of Emergency Medical Services (EMS) reports, Hospital EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures (P & P), Hospital 2's Action Plan and Medical Staff Rules and Regulations, Hospital 2 failed to provide a medical screening examination for two of 29 sampled patients presenting to Hospital 2's Emergency Department (ED) to determine whether or not an emergency medical condition existed. This deficient practice effected Patient Identifier (PI) # 1, a patient who returned to the Emergency Department after leaving Against Medical Advice on 5/27/13, and PI # 2, a patient who presented to the ED on 3/5/13 via ambulance with an arrival complaint of weakness and nausea. This deficient practice has the potential to negatively affect all patients who FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 11 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 present to Hospital 2's Emergency Department (ED). Findings Include: 1. Review of PI # 1's medical record dated 5/27/2013 from Hospital 2 revealed the following: Patient arrived in ED at 04:20 AM. Triage began at 04:30 AM. The following documentation was included in the Triage notes: 04:34:12 - Pt. c/o (complained of) SOB (shortness of breath) with occas. (occasional) CP (Chest pain) on & off for the last month. Worse tonight, "I feel like I can't catch my breath." Some n/v (nausea/vomiting) when pain is worst. 04:35 - Vital signs - Temperature 96.9 orally, Pulse 84, Blood pressure 135/89 sitting, Oxygen Saturation 100% on room air, Blood Glucose 256 (normal range 70 -99), Pain 9 (0-10 scale with 0 being no pain and 10 being worst pain), location chest. 04:38:33 Patient was taken to ED room 24. 04:39:21 Orders for Cardiac monitoring, Oxygen set-up, Pulse ox (Oxygen monitoring) CBC (Complete blood count) with differential, Comprehensive metabolic panel, PTT (Partial Thromboplastin Time), INR (International normalized ratio), Cardiac enzymes, BNP (Brain Natriuretic Peptide), Urinalysis w/o (without) microscopic, ECG (Electrocardiogram), Chest x-ray. 04:53: The RN documented the placement of an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 12 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 18 G (gauge) peripheral IV (intravenous) to the left antecubital area. 04:54: The RN documented, "Awaiting MD (Medical Doctor) eval (evaluation)." Lab results were documented as follows: 05:09 - CBC (complete blood count) with differential with abnormal results included the following: WBC (White blood count) = 17.7 (normal range 5.0 - 10.0) RBC (Red blood count) = 5.43 (normal range 4.20 - 5.40) Hematocrit = 49 (normal range 36 - 48 % proportion of total blood volume that is composed of red blood cells) MCH (Mean corpuscular hemoglobin) = 32 (normal range 26 - 31) 05:28 - BNP = 51.87 (normal range <50 years old 450 pg/mil - picograms/milli-liter) 05:30 - Comprehensive metabolic panel Glucose = 287 (normal range 70 - 99) 06:18 - Employee Identifier (EI # 8), Registered Nurse (RN) was assigned to the patient. EI # 8 documented the patient's assessment as follows: Neurological - within defined limits, pulmonary assessment: dry cough, skin assessment: within defined limits, cardiac assessment: within defined limits, normal sinus rhythm 06:19 - Pulse 87, Blood pressure 139/92, respirations 20, O2 (Oxygen) saturation 97%. 06:28: 12 Lead EKG (electrocardiogram) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 13 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 13 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 interpretation by ED Physician: Sinus Rhythm, rate 70, normal PR interval, normal ST segment... 06:34 AM - EI # 5, Emergency Department (ED) physician, documented, "This case is a certified medical emergency ..." 06:46: EI # 8 documented, "... RN went to pts (patient's) room. Pt asked to see (doctor) - RN asked what this was concerning and pt became belligerent. Pt was not in stretcher, did not have O2 on, and began cursing @ RN. RN explained to pt that need to be in bed with O2 on. Security called. Pt wants to leave ama (against medical advice). Name of ED Physician (EI # 4) informed. Pt informed of risks of leaving ama. Pt refused to sign AMA form. Pt removed own IV would not allow (nurse) to apply gauze. Pt states, "You can't keep me here, I am not under arrest". Pt walked to truck by own power with security. Threatening security along the way ..." 06:48: ED disposition set to eloped as documented by EI # 5. 06:49 - EI # 5 (ED Physician) documented, ED Course/Plan, "... Chest pain: SOB (Shortness of breath) Diagnosis management comments: The patient became hostile and belligerent and had to be removed from the emergency department prior to my evaluation. I did not lay eyes on this patient...Patient Progress: stable..." Review of Patient Identifier (PI) # 1's medical records from Hospital # 1(Hospital where Patient # 1 was taken by his/her representative after leaving Mobile Infirmary) revealed PI # 1 returned to Hospital # 1's ED at 07:03 AM on 5/27/2013 by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 14 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 14 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 private vehicle. Review of the Medical Screening/Nursing Assessment revealed the patient's chief complaint was Cardiac Arrest ... possible seizure (sudden disruption of the brain's normal electrical activity as evidenced by altered consciousness and/or other neurological manifestations), CPR (cardiopulmonary resuscitation). PI# 1's primary assessment revealed the patient was unresponsive... skin was warm and dry with no movement. Further documentation revealed, "... 35 yom (year old male) presents to ED, POV (privately owned vehicle) for possible seizure ... pt was found to be pulseless (having no pulse, lifeless) and apneic (temporary absence or cessation of breathing). CPR initiated. Pt taken to TR (Trauma Room) with CPR cont. (continued) 7.0 ETT (endotracheal tube) placed & confirmed with ... BBS (bilateral breath sounds) (no) epigastric gurgling ... ACLS (Advanced Cardiac Life Support) ... Pt defibrillated ... firing for VF (ventricular fibrillation: rapid erratic heartbeat medical emergency) with no response except asystole (absence of a heartbeat). Heroic measures performed. CPR and defib ... No signs of life... Asystole... pt had been at (Hospital # 2) PTA (prior to arrival) ..." PI # 1's time of death was documented as 07:22 AM. Interview with Employee Identifier (EI) # 8, Staff RN - ED at Hospital 2, 0630 - 1830 shift, on 6/26/13 at 10:50 AM. Relationship to PI #1: RN assigned to PI # 1 when the patient left Against Medical Advice. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 15 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 15 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 Sometime around 0630 on 5/27/2013, EI # 8 said he was notified that PI # 1 wanted to see the doctor. EI # 8 went into PI # 1's room. According to EI # 8, PI # 1 was cursing, yelling and hostile. PI # 1 stated he was hurting, had completed multiple tests and wanted to leave. The RN (EI # 8) said he explained to PI #1, the "MD (Medical Doctor) has to see you." Security was called. PI # 1 said, "You can't keep me here." The RN said he reviewed the AMA form with PI #1, but the patient refused to sign the form. PI # 1 pulled out his IV and was bleeding on the floor. As PI # 1 was leaving the ED, the RN said he was advising the patient of the risks of leaving without being seen by a physician including endangerment of his life. According to EI # 8, the physician was notified, "As a courtesy that PI # 1 wanted to leave AMA." EI # 8 indicated there was not enough time for the physician to see PI #1, once PI # 1 decided to leave AMA. EI # 8 said PI # 1's departure was, "Not really an AMA," but staff still attempts to get the AMA form signed by the patient. According to EI # 8, Hospital 2 does not have an elopement form. The ED Physician reportedly said, "O.K. I haven't even seen him." According to EI # 8, PI # 1's request to leave was abrupt. While walking to his truck, PI # 1 was "loud and belligerent." PI # 1 said, "You can't keep me here." The RN (EI # 8) said PI # 1 was not short of breath and was able to yell without difficulty. EI # 8 described PI # 1 as "verbally combative." EI # 8 denied that PI #1 threatened him. According to EI # 8, he reviewed PI # 1's vital signs and lab results with the ED Physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 16 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 16 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 Minutes later, the ED Liaison (admitting clerk), informed the charge nurse that PI # 1 was reportedly seizing in the ambulance bay. According to EI # 8 (Staff RN), as he and the ED Charge Nurse arrived at the ambulance bay doors, a truck allegedly containing PI # 1, was driving off. The RN could not see the driver or the patient. Later, (time unknown) Hospital 2's ED received a call from Hospital 1's ED asking for PI # 1's history. Hospital 1 reported staff had, "Just pulled PI # 1 out of the truck." The RN said he was informed that PI # 1 died. EI # 8 said he and the ED Physician discussed the case to determine if anything was missed during PI # 1's visit. We determined we did not miss anything. Interview with EI # 5, MD, ED Physician at Hospital 2, 0600 - 1830 Shift, on 6/25/13 at 8:14 PM: Relationship to PI # 1: ER Physician on 5/27/13 when PI # 1 left AMA. EI # 5 was asked if he recalled PI # 1 and he responded, "No, I never laid eyes on him... the shift changes at 0600. I picked up 3 to four charts and clicked on. I was just starting my day. The patient (PI # 1) had already gone when I got ready to see him." When asked if anyone told him about PI # 1, EI # 5 said, "They told me generically that the patient (PI #1) was in the room. I said...I'll get around to him." EI # 5 verified he documented PI # 1's visit on 5/27/2013 was a certified medical emergency in PI # 1's medical record. According to EI # 5, he based this decision on a lay person's definition of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 17 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 17 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 an emergency. "If a patient shows up. A lay person would consider the patient's presentation to the Emergency Room an emergency." EI # 5 said he documents every patient who presents to the ED is a certified medical emergency. EI # 5 was advised his documentation in the medical record revealed PI # 1 was stable at discharge. The physician was asked to explain how he determined the patient was stable, if he did not assess PI # 1. EI # 5 said, "I assume if the patient (PI # 1) left on his own power the patient was stable." Interview with EI # 6, Protective Services Officer at Hospital 2, 0630 to 1830 Shift, on 6/26/13 at 1:08 PM: Relationship to PI # 1: Conversation with PI # 1's representative (driver) who accompanied PI # 1 to Hospital 2's ED on 5/27/13. EI # 6 said when he began the day shift, he was informed by the Protective Services night shift Team Leader that PI # 1 had been removed from the ED due to aggressive behavior and cursing staff. PI # 6 said he was advised PI # 1 and the person accompanying PI # 1, had been asked to leave the hospital. The Team Leader pointed to a truck parked in a space near Circle One (Hospital 2 Property) and said, "That's the truck." EI # 6 said the truck pulled away as he walked toward the vehicle. According to EI # 6, before he could walk back to the ambulance bay, the truck pulled in and parked in the bay. A female was standing outside of the truck when EI # 6 arrived. EI # 6 said he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 18 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 18 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 asked the female if the truck was her vehicle and she said yes. The officer said to the female, "Ya'll have been asked to leave the property." The female reportedly said, "I don't know what to do." EI # 6 reported the female did not say anything about PI # 1. According to EI # 6 (security officer) he said, " I don't know, but you were asked to leave here." The female returned to the truck and pulled away. EI # 6 was asked if he saw PI #1 and he said no. EI # 6 said he could only see a leg. EI # 6 was asked if ED staff were present in the ambulance bay. EI # 6 said, "No. They (staff) came out as the truck was pulling away." EI # 6 was asked if the hospital has a policy and procedure regarding management of aggressive behavior and he said no. "We've been taught it's hands off." Interview with EI # 4, RN, Day shift ED Charge Nurse at Hospital 2, on 6/25/13 at 4:57 PM: Relationship to PI # 1: Charge Nurse when PI # 1 arrived at Hospital 2's ED on on 5/27/13: According to EI # 4, she went to Room 24/25 (room assigned to PI # 1) to check the emergency cart and saw a male sitting in a chair. EI # 4 said she noted a female lying in the bed. EI # 4 stated she left the room never realizing (at the time) the female was not the patient. "Twenty minutes later, the RN assigned to PI #1 came out of the room (room 24/25) and asked me to get security. The patient (PI # 1) is irate, belligerent and wants to leave." EI # 4 (Charge Nurse) reports she told the RN assigned to PI # 1 to talk with the ED Physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 19 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 19 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 about PI #1. EI # 4 said when a patient wants to leave we get the MD involved - make MD aware. The Charge Nurse reported she went to notify security and saw security walk in PI # 1's room. Several minutes later, EI # 4 said she saw a security guard and PI # 1 walking out of the ED. PI # 1 was not wearing a shirt. Shortly after PI # 1 left the ED, the ED Liaison came to the treatment area and said PI # 1 is back. EI # 4 said she and a staff RN went to the ambulance bay just as the female was driving the truck away from the bay area. "I never saw the patient (PI #1) after he walked out with the security guard." ED staff from Hospital 1 called to,"Let us know the patient (PI # 1) was there." EI # 4 was asked if PI # 1 was seen/evaluated by the ED physician at Hospital 2 and she said, No." According to EI # 4, she informed the ED Physician that a female returned to the ED and reported PI # 1 was having seizures. ED staff went to the ambulance bay to check PI #1, but the female drove away before staff reached the vehicle. EI # 4 said she was asked by the physician to find out what happened to PI # 1. EI # 4 said she contacted ED staff at Hospital 1 and was advised PI # 1 coded and expired. EI # 4 was asked to describe the ED Physician's response and she stated the physician advised her to inform the House Supervisor at Hospital 2 about the incident. The ED Director and the ED Manager were in the ED and they were advised about the incident. Interview with EI # 7, ED RN at Hospital 2, 1830 0630 shift, on 6/26/13 at 8:49 AM: Relationship to PI # 1: Triage of PI # 1 on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 20 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 20 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 5/27/13. EI # 7 was asked if she remembered PI # 1 and she said yes. "He (PI # 1) cursed us out the entire time he was in triage." EI # 7 accompanied PI # 1 to room 24 and reports she never saw PI # 1 after this encounter. Interview with EI # 1, ED RN at Hospital 2, 1830 -0600 Shift on 6/25/13 at 4:07 PM: Relationship to PI # 1: RN assigned to PI # 1 at 0452 on 5/27/13: EI #1 described PI # 1 as "abrasive and very demanding." PI # 1 wanted his girlfriend in the room (Room 24) with him and became very angry when EI #1 was unable to find her. Interview with EI # 2, RN/Day Shift House Supervisor at Hospital 2, on 6/25/13 at 4:40 PM: EI # 2 stated he was informed by an ED staff RN that PI # 1 left AMA (Against Medical Advice) on 5/27/2013. Per the RN's report, the patient was not in the ED bed, but had been sitting in a chair and refused oxygen. PI # 1's female friend had been laying in PI # 1's bed. Interview with EI # 9, ED Liaison Hospital 2, on 6/26/2013 at 3:30 PM: EI # 9 stated the ED Charge Nurse came to the waiting area on 5/27/13 to obtain assistance from the security officer to, "Make this patient (PI # 1) leave because he was cursing all of the nurses." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 21 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 21 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 From a monitor at the registration desk in the waiting area, EI # 9 said she could see PI # 1 and staff walking outside in the ambulance bay. Although there is no audio monitoring, EI # 9 said she could hear PI # 1 and staff when they were in the ambulance bay when the automatic doors opened (doors in close proximity to EI # 9's desk). According to EI # 9, she heard PI # 1 say, "This is not right. Why are ya'll making me leave. I'm sick." PI # 1 got in a truck and left the ED. "A few minutes later a female driver pulls into the ambulance bay, walks into Hospital 2's ED waiting area and says her boyfriend (PI # 1) is having a seizure or something. They (staff) just made us leave." EI # 9 said she went to the ED (patient area) and advised a staff RN about the female's complaint. EI #9 alleged the staff RN said, "We're not going to get him (PI # 1) out of the truck. We don't do that." EI # 9 said she then advised the ED Charge Nurse of the situation. According to EI # 9, the Charge Nurse told the staff RN to accompany her to the ambulance bay to check on the patient (PI # 1). EI # 9, ED Liaison, stated she continued to watch the video camera and saw a security officer standing by the truck in the ambulance bay talking with the female who reported the concern about PI # 1. Reportedly the officer told the female the police are called when a person has been asked to leave and does not leave. The female said, "Well I'm not going to jail on Memorial Day." She got into the truck and drove away. EI # 9 stated she saw the Charge Nurse and another staff member (unsure of identity) in the ambulance bay. EI # 9 said the female, "Did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 22 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 22 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 not seem terrified, she was not crying and did not seem to be in a panic." The hospital failed to ensure their policies were followed as evidenced by failing to ensure that on 5/27/2013 when Patient # 1 was transported to the hospital via private vehicle and arrived at the at the hospital's ambulance bay, "the patient must be offered a medical screening examination." On 5/27/2013 after a request was made by the representative on Patient # 1's behalf for medical assistance, the hospital failed to provide a medical screening examination to determine whether or not an emergency medical condition existed. 2. PI # 2: Review of the EMS Patient Care report dated 3/5/13 revealed PI # 2 was transported from a residence to Hospital 2: Review of the EMS Patient Care report dated 3/5/13 revealed PI # 2's chief complaint was weakness and AMS (altered mental status). Pt's friend called 911 today at 1930 due to the patient presenting with weakness unknown onset. (Patient) is responsive to verbal stimuli, not alert and O (oriented) times 2 only. Pt has not been seen "for a few days" and pt's friend reports pt has not been compliant in taking retroviral (for HIV) (Human Immunodeficiency virus) meds as directed. (A) (Assessment) Pt responsive to verbal stimuli, lethargic, O x 2 (oriented times 2) ... speech (?) Pt denies HA (headache), No trauma, PERRL (pupils equal, round reactive to light). BBS ... without SOB (shortness of breath), no CP (chest pain) (pt denies pain anywhere except LLQ (left lower quadrant) on palp. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 23 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 23 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 (palpation) ... skin dry, warm (normal) color but a few lesions (closed) are noted (2 on abd (abdomen) a few on arms..." Arrived at destination (Hospital 2) at 20:45. Review of the electronic copy of the EMS (Emergency Medical Services) report revealed the patient was conscious, but not alert. Responded to verbal stimuli only and responded to most questions only after question is asked multiple times; does not answer all questions. PI # 2 had a blunted affect, exhibited some lethargy in route and upon arrival at Hospital 2's ED. ECG (Electrocardiogram) showed sinus tachycardia at 128 -140 BPM (beats per minute). PI # 2's blood pressure was 155/108. PI # 2 confirmed nausea but, no vomiting. PI # 2's temperature was 98.5. PI # 2's abdomen was soft with tenderness to palpation of LLQ (left lower quadrant). PI # 2 was transported to (Hospital 2) to the (ED) waiting room with the following incident: "... After obtaining wheelchair and attempting to assist pt from stretcher to the wheelchair (via stand & pivot) Pt repeatedly refused attempts to get off of the stretcher. Pt pushed attendant 1 away twice, and the second time, Pt picked his legs back up on the stretcher, curling his legs up, lying back and appearing to take a nap. At this point, ER (Emergency Room) Charge RN (Registered Nurse) attempted to verbally motivate pt to get off the stretcher without success. Ultimately, (Hospital # 2) ... Security Officer (an off duty Police Officer) had to physically remove pt from the stretcher, Though pt did not suffer any apparent injuries in this process. Pt was wheeled to waiting rm and checked in (with admissions) with transfer of care, written & verbal report to ER FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 24 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 24 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 triage RN. Treatment, transport & transfer of care without additional incident except as noted in this section..." Review of Patient Identifier (PI) # 2's medical record from Hospital 2 revealed the patient presented to Hospital 2's ED on 3/5/13 at 9:00 PM by ambulance with weakness and nausea. EI # 15, Registered Nurse (RN) Triage Nurse, documented PI # 2's disposition at 22:12 was AMA/LWBS (Against medical advice/Left without being seen) before triage. There was no other documentation in PI # 2's medical record to indicate that a medical screening examination was completed to determine whether or not an emergency medical condition existed. During a review of the hospital's security tape, (dated 3/15/2013), the patient was seen lying on the floor between the ED and the ambulance bay. A security officer picked up the patient and placed him in a wheelchair. Next, the officer was seen pushing the wheelchair in the driveway of the ambulance bay away from the Emergency Department. During an interview with EI # 4 on 6/25/13 at 2:36 PM, the Director Protective Services, said the officer transported the patient (PI # 2) off hospital property. Review of the Fire-Rescue Field Triage Sheet dated 3/6/13 (time not documented) revealed the incident location was "Dead end Center St at (Hospital # 2) ..." The Fire-Rescue staff member documented, "... Pt was kicked out of (Hospital 2) at 2200 per (Hospital 2) staff. Vitals taken ... (Ambulance company name) ..." (See EMS Report # 2 below) Review of EMS Report # 2 revealed a call was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 25 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 25 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 received at 02:07 AM on 3/6/13 for "One Down" (person down on the ground). EMS arrived at the location and found PI # 2 on the ground for "4 hours" after security told to leave (Hospital 2) ... Pt has weakness and AMS (altered mental status). Pt would not speak. Pt skin very cold...given supportive care ...moved to stretcher...transported to (Hospital 3- another acute care hospital)." Interview with EI # 11, RN ED Charge Nurse at Hospital 2, on 6/26/13 at 10:00 AM. EI # 11 stated PI # 2 arrived via EMS at Hospital 2 on 3/5/13. EI # 11 directed EMS staff to take PI # to triage to be signed in as a "regular patient." EI # 11 was asked to identify the criteria used to determine PI #2's appropriateness for triage versus direct placement in an ED bed. EI # 11 verified the criteria as PI # 2's complaint of weakness, noncompliance with medications per EMS staff, PI # 2's age and vital signs. EI # 11 said PI # 2 did not want to get off of the stretcher and into a wheelchair, but was eventually compliant without assistance. EI # 11 said she was advised PI #2 did not want to be treated and "walked off." EI # 11 stated she was informed PI # 2 told the triage nurse, "Get your "f....g hands off me." The only information documented in PI # 2's medical record on 3/5/13 includes, "2100: Arrived ED. 22:12: AMA/LWBS - LWBS (Left Without Being Seen) before triage. 22:13: Pt. (patient) dismissed." Interview with EI # 12, ED Staff RN Hospital 2, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 26 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 26 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 6/26/13 at 9:25 AM: According to EI # 12, the Charge Nurse directed PI # 2 to triage after PI # 2 arrived in the ED via ambulance. EI #12 reported seeing EMS staff and hospital security attempting to move PI # 2 from a stretcher to a wheelchair. EI # 12 described the patient as "kind of combative." "He (PI # 2) was sitting up and all of a sudden refused to do anything." According to EI # 12, the ED was very busy and she took report from EMS staff for the triage nurse. After giving report to the triage nurse, EI # 12 said she had no further contact with PI # 2. Interview with ED Admission Assistant at Hospital 2, EI # 13, on 6/26/13 at 2:20 PM: EI # 13 stated she was asked by a paramedic on 3/5/13 to notify security assistance was needed because PI # 2 was refusing to get off a stretcher and into a wheelchair. EI # 13 said she notified the officer, identified as an off duty policeman, as requested. PI # 2 was assisted to a wheelchair and brought to the ED waiting area. EI # 13 did not interact with PI # 2, but registered PI # 2 via computer with information provided by the paramedic. After PI # 2 was in the triage room, EI # 13 reports she heard screaming. PI # 2 was out of the wheelchair and saying he did not want to be seen. EI # 13 reports security escorted PI # 2 out of the triage room. Interview on 6/25/13 at 2:36 PM with EI # 14, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 27 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 27 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 Director Protective Services at Hospital 2: According to EI # 14, PI # 2 had been disruptive and non-compliant in the triage area. PI # 2, "Went to the ground" at the ambulance bay doors when exiting the ED on 3/5/13. PI # 2 was put in a wheelchair and escorted off hospital property by a security officer who is no longer employed by Hospital 2. The triage nurse (EI # 15) and security officer (EI # 16) associated with PI # 2's visit to the ED at Hospital 2 on 3/5/13 are no longer employed by the hospital. Hospital # 2's Policies & Procedures reviews revealed the following: 1. Medical Screening Examination Policy For individuals seeking treatment on hospital property, the facility will provide a medical screening examination conducted by a qualified medical person to determine if an emergency medical condition exists. Additionally, an ambulance or private vehicle transporting a patient to the hospital which arrives anywhere on hospital property is considered having come to the hospital and the patient must be offered a medical screening exam ... A registered nurse may perform the medical screening examinations to ascertain emergency medical conditions. Questionable determinations if an emergency medical condition shall require a focused physical exam and physician review. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 28 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 28 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 If an emergency medical condition exists, a chart documenting findings shall be initiated. Anyone presenting for examination will be recorded on a centralized log. Patient priorities shall be established according to triage guidelines with the most critically ill patients being given first priority. Medical Screening Examination Procedure A. A qualified medical person, either a registered nurse or physician shall: 1) Conduct medical screening examination upon arrival. 2) Screen as follows: a. Assessment of chief complaint; b. Assessment of general appearance; c. Attainment of vital signs; d. Evaluation of mental status; e. Performance of an applicable Focused Physical Exam as indicated by clinical finding during Medical Screening Examination. 3) Document assessment of clinical findings from the medical screening exam on the emergency department triage record or the medical record or on the Transfer to Acute Care/Speciality Facility Summary form. 4) Establish priority of care by acuity and assign to appropriate area of care. Consider the Emergency Medical Condition Policy, if indicated ... 6) Document triage priority category. 7) Document ongoing monitoring and disposition of patient... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 29 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 29 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 B. Consent for screening and/or treatment may be implied if the patient is incapable of giving consent and no representative is available or any delay to obtain consent would jeopardize the patient's safety. If a patient or a person acting on the individual's behalf refuses to consent to the medical screening exam or treatment: 1) Inform the patient or person acting on the individual's behalf of risks of refusal of the proposed examination or treatment and of the potential benefits. 2) Document steps taken to secure written refusal in the medical record or on the Against Medical Advice (AMA) form or on the Transfer to Acute Care/Speciality Facility Summary form. Obtain signature of patient or representative, if applicable. If patient or person acting on behalf of the individual refuses to sign, document refusal in the medical record. 3) In the event the patient has not been registered, document the patient's visit and disposition on the centralized log in the emergency department. 4) A patient who has refused the screening or treatment may be released. 2. Emergency Medical Condition Assessment Policy: Emergency medical conditions are those manifesting themselves by acute symptoms of sufficient severity including severe pain, psychiatric disturbances, symptoms of substance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 30 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 30 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 abuse, and/or women in labor such that the absence of immediate medical attention could reasonable be expected to result in: 1) Placing the health of the individual in serious jeopardy ... Procedure if an emergency medical condition exists: 1) Personnel should immediately begin stabilizing measures. 2) Emergency medical conditions must be stabilized within the capabilities of the hospital ... 5) Consent for screening and/or treatment may be implied if the patient is incapable of giving consent and no representative is available or any delay to obtain consent would jeopardize the patient's safety. 6) If a patient or person acting on the individual's behalf refuses to consent to the medical screening exam or treatment: a. Inform the patient or person acting on the individual's behalf of the risks of refusal of the proposed examination or treatment and of the potential benefits. b. If the patient is unstable, attempt to have the physician complete the Informed Consent for Transfer to Acute/Care Speciality form ... 3. Against Medical Advice (AMA) Discharge Purpose: To establish a process for documentation of patients leaving against medical advice. Policy: The appropriate "Release from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 31 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 31 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 Responsibility for Leaving Against Medical Advice" form shall be completed when a patient insists upon leaving the hospital against medical advice (AMA). The form should be signed by the patient or the patient's representative if the patient is a minor or otherwise legally incapacitated and witnessed by two staff members. This form shall remain in the medical records. Refer to the hospital policy on consent to determine who is an appropriate patient representative for a minor or otherwise legally incapacitated patient. Procedure: 1. Assess the patient's current condition and the rationale for wanting to leave AMA. Notify the Manage, Director or House Supervisor to assess the patient and situation. 2. Attempts should be made to intervene as appropriate to prevent the patient from leaving AMA (such as having the attending physician talk with the patient, or the patient's representative, via phone or in person). 3. Notify the attending physician if the patient insists upon leaving the hospital AMA ... 4. Document in the focus notes the patient interactions, interventions by staff, and the attending physician's response to the patient's request to leave the hospital AMA and discussions with the patient. Hospital # 2's Medical Staff Rules and Regulations adopted by the Medical Executive Committee on November 12, 2012 and approved by the Mobile Infirmary Association Board on December 13, 2010 revealed the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 32 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2406 Continued From page 32 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2406 Article X Emergency Services 10.2 Medical Screening Examinations: (a) Medical screening examinations, within the capability of the Medical Center, will be performed on all individuals who come to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations within applicable Medical Center policies and procedures are defined as: (1) Emergency Department: (i) members of the Medical Staff with clinical privileges in Emergency Medicine; (ii) other Medical Staff members; and (iii) appropriately credentialed allied health professionals ... Hospital 2's Action Plan: (Received via email on 6/27/13) A. In April 2013 a Performance Improvement project to decrease Left Without Being Seen (LWBS) rates, decrease door to physician time and decrease Length of Stay (LOS) for patients discharged from the Emergency Department (ED) was initiated. These actions included: 1. Placing an RN in the waiting room to assign an initial triage level for patients arriving between 10:00 AM and 10:00 PM. 2. Assign a Nurse Practitioner to the Triage area to perform Medical Screening Exams (MSE), treat and discharge lower acuity patients... 3. In July and August, Security, ED staff and physicians will be re-educated regarding EMTALA law and care of LWBS and disruptive patients, Communication, Chain of Command and Core values of Mobile Infirmary. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 33 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG A2406 Continued From page 33 A2406 4. An intense Analysis was completed regarding both incidents. A2407 489.24(d)(1-3) STABILIZING TREATMENT A2407 (X5) COMPLETION DATE (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 34 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 34 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 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: Based on interviews, review of medical records, Emergency Medical Services (EMS) reports and Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, it was determined Hospital 2 failed to provide stabilizing treatment for Patient Identifier (PI) # 1 and PI # 2, two of 29 sampled patients who presented to Hospital 2's Emergency Department (ED). This deficient practice negatively effected Patient Identifier (PI) # 1, a patient who was returned to Hospital 2's ED on 5/27/13 by a responsible representative who notified ED staff that something was wrong with PI #1. The deficient practice also negatively effected PI # 2, a patient who presented to the ED via ambulance on 3/5/13 with a chief complaint of weakness and altered mental status. PI # 2 reportedly acted aggressively, refused triage and laid down on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 35 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 35 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 floor. ED Clinical staff failed to evaluate PI # 2's behavior to determine if the behavior was related to a emergency medical condition. Clinical staff reportedly observed PI # 2's behavior and observed the placement of PI # 2 in a wheelchair by security staff. PI # 2 was then transported off Hospital 2's property. This deficient practice had the potential to negatively effect all patients who present to Hospital # 2's ED with a emergency medical condition and require stabilizing treatment. Findings include: Review of PI # 1's medical record dated 5/27/2013 from Hospital 2 revealed the following: Patient arrived in ED at 04:20 AM. Triage began at 04:30 AM. The following documentation was included in the Triage notes: 04:34:12 - Pt c/o (complained of) SOB (shortness of breath) with occas. (occasional) CP (Chest pain) on & off for the last month. Worse tonight, "I feel like I can't catch my breath." Some n/v (nausea/vomiting) when pain is worst. 04:38:33 Patient was taken to ED room 24. 04:54:24 the nurse documented, "Awaiting MD (Medical Doctor) eval (evaluation)." 06:34 AM - EI # 5, ED physician documented, "This case is a certified medical emergency ..." 06:46:22 EI # 8, RN documented, "... RN went to pts (patient's) room. Pt asked to see (doctor) RN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 36 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 36 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 asked what this was concerning and pt became belligerent. Pt was not in stretcher, did not have O2 on, and began cursing @ RN. RN explained to pt that need to be in bed with O2 on. Security called. Pt wants to leave ama (against medical advice). EI # 8, ED physician informed. Pt informed of risks of leaving ama. Pt refused to sign AMA form. Pt removed own IV would not allow (nurse) to apply gauze. Pt states, "You can't keep me here, I am not under arrest". Pt walked to truck by own power with security. Threatening security along the way ..." 06:48:58 - ED disposition set to eloped as documented by EI # 5, ED physician. 06:49 - EI # 5, ED physician documented, ED Course/Plan, "... Chest pain: SOB (Shortness of breath) Diagnosis management comments: The patient became hostile and belligerent and had to be removed from the emergency department prior to my evaluation. I did not lay eyes on this patient ... Patient Progress: stable ..." Interview with Employee Identifier (EI) # 8, Staff RN ED at Hospital 2, 0630 - 1830 shift, on 6/26/13 at 10:50 AM: Relationship to PI #1: RN assigned to PI # 1 when patient left Against Medical Advice (AMA). Sometime around 0630 on 5/27/2013, EI # 8 said he was notified that PI # 1 wanted to see the doctor. EI # 8 went into PI # 1's room. According to EI # 8, PI # 1 was cursing, yelling and hostile. PI # 1 stated he was hurting, had completed multiple tests and wanted to leave. The RN (EI # FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 37 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 37 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 8) said he explained to PI #1, the "MD (Medical Doctor) has to see you." Security was called. PI # 1 said, "You can't keep me here." The RN said he reviewed the AMA form with PI #1, but the patient refused to sign the form. PI # 1 pulled out his IV and was bleeding on the floor. According to EI # 8, the RN notified the physician "as a courtesy" that PI # 1 wanted to leave AMA. EI # 8 indicated there was not enough time for the physician to see PI #1, once PI # 1 decided to leave AMA. EI # 8 said PI # 1's departure was, "Not really an AMA," but staff still attempts to get the AMA form signed by the patient. According to EI # 8, Hospital 2 does not have an elopement form. The ED Physician reportedly said, "O.K. I haven't even seen him." According to EI # 8, PI # 1's request to leave was abrupt. While walking out of the ED, PI # 1 was "loud and belligerent." PI # 1 said, "You can't keep me here." Minutes later, the ED Liaison (admitting clerk), informed the charge nurse that PI # 1 was reportedly seizing in the ambulance bay. According to the RN, as he and the ED Charge Nurse arrived at the ambulance bay doors, a truck allegedly containing PI # 1, was driving off. The RN could not see the driver or the patient. Later, (time unknown) Hospital 2's ED received a call from Hospital 1's ED asking for PI # 1's history. Hospital 1 reported staff had, "Just pulled PI # 1 out of the truck." The RN said he was informed PI # 1 died. Review of Patient Identifier (PI) # 1's medical records from Hospital # 1 dated 5/27/2013 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 38 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 38 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 revealed PI # 1 returned to Hospital # 1's ED at 07:03 AM by private vehicle. Review of the Medical Screening/Nursing Assessment revealed the patient's chief complaint was Cardiac Arrest ... possible seizure, CPR (cardiopulmonary resuscitation) PI# 1's primary assessment revealed the patient was unresponsive...skin was warm and dry with no movement. Further documentation revealed, "... 35 yom (year old male) presents to ED, POV (privately owned vehicle) for possible seizure ... pt was found to be pulseless and apneic. CPR initiated. Pt taken to TR (Trauma Room) with CPR cont. (continued). 7.0 ETT (endotracheal tube) placed & confirmed with ... BBS (bilateral breath sounds). No epigastric gurgling ... ACLS (Advanced Cardiac Life Support) ... Pt defibrillated ... firing for VF (ventricular fibrillation) with no response except asystole. Heroic measures performed. CPR and defib ... No signs of life... Asystole... pt had been at (Hospital # 2) PTA (prior to arrival) ..." PI # 1's time of death was documented as 07:22 AM. Interview with EI # 5, MD, ED Physician at Hospital 2, 0600 - 1830 Shift, on 6/25/13 at 8:14 PM: Relationship to PI # 1: ER Physician on 5/27/13 when PI # 1 left AMA. The physician was asked if he recalled PI # 1 and he responded," No, I never laid eyes on him." The patient (PI # 1) had already gone when I got ready to see him." When asked if anyone told him about PI # 1, EI # 5 said, "They told me generically that the patient (PI #1) was in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 39 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 39 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 room. I said...I'll get around to him." EI # 5 verified he documented PI # 1's visit on 5/27/2013 was a certified medical emergency in PI # 1's medical record. According to EI # 5, he based this decision on a lay person's definition of an emergency. "If a patient shows up. A lay person would consider the patient's presentation to the Emergency Room an emergency." EI # 5 said he documents every patient who presents to the ED is a certified medical emergency. EI # 5 was advised his documentation in the medical record revealed PI # 1 was stable at discharge. EI # 5 (Physician) was asked to explain how he determined the patient was stable, if he did not assess PI # 1. EI # 5 said, "I assume if the patient (PI # 1) left on his own power the patient was stable." Interview with EI # 6, Protective Services Officer at Hospital 2, 0630 to 1830 Shift, on 6/26/13 at 1:08 PM: Relationship to PI # 1: Conversation with responsible person (driver) who accompanied PI # 1 to Hospital 2's ED on 5/27/13. EI # 6 said when he began the day shift, he was informed by the Protective Services night shift Team Leader that PI # 1 had been removed from the ED due to aggressive behavior and cursing staff. He reported he was advised PI # 1 and the female accompanying PI # 1 had been asked to leave the hospital. According to EI # 6, a truck pulled in and parked in the ambulance bay. EI # 6 said a female was standing outside of the truck. The officer said to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 40 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 40 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 the female, "Ya'll have been asked to leave the property." The female reportedly said, "I don't know what to do." According to the EI # 6, the female did not say anything about PI # 1. The officer stated he said, " I don't know, but you were asked to leave here." The female returned to the truck and pulled away. EI # 6 was asked if ED staff were present in the ambulance bay. EI # 6 said, "No. They (staff) came out as the truck was pulling away." Interview with EI # 4, RN, Day shift ED Charge Nurse at Hospital 2, on 6/25/13 at 4:57 PM: Relationship to PI # 1: Charge Nurse when PI # 1 arrived Hospital 2's ED on 5/27/13: EI # 4 stated she was asked by the RN assigned to PI #1 to get security because PI # 1 was irate, belligerent and wants to leave. EI # 4 said she saw a security guard and PI # 1 walking out of the ED. Shortly after PI # 1 left the ED, the ED Liaison came to me and said PI # 1 is back. EI # 4 said she and a staff RN went to the ambulance bay just as the female was driving the truck away from the bay area. "I never saw the patient (PI #1) after he walked out with the security guard." ED staff from Hospital 1 called to, "Let us know the patient (PI # 1) was there." EI # 4 was asked if PI # 1 was seen/evaluated by the ED physician at Hospital 2 and she said, No." Interview with EI # 9, ED Liaison Hospital 2, on 6/26/2013 at 3:30 PM: EI # 9 stated the ED Charge Nurse came to the waiting area on 5/27/13 to obtain assistance from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 41 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 41 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 the security officer to, "Make this patient (PI # 1) leave because he was cursing all of the nurses." From a monitor at the registration desk in Hospital 2's waiting area, EI # 9 said she could see PI # 1 and staff walking outside in the ambulance bay. Although there is no audio monitoring, EI # 9 said she could hear PI # 1 and staff talking when they were in the ambulance bay when the automatic doors opened. According to EI # 9, she heard PI # 1 say, "This is not right. Why are ya'll making me leave. I'm sick." PI # 1 got in a truck and left the ED. "A few minutes later a female driver pulls into the ambulance bay, walks into Hospital 2's ED waiting area and says her boyfriend is having a seizure or something. They just made us leave." EI # 9 said she went into the ED (patient treatment area) and advised a staff RN about the female's complaint. EI #9 alleged the staff RN said, "We're not going to get him (PI # 1) out of the truck. We don't do that." EI # 9 said she then advised the ED Charge Nurse of the situation. According to EI # 9, the Charge Nurse told the staff RN to accompany her to the ambulance bay to check on the patient (PI # 1). 2. EMS Transport of PI # 2 to Hospital 2: Review of the Ambulance Patient Care report dated 3/5/13 revealed PI # 2's chief complaint was weakness and AMS (altered mental status)... Arrived at destination (Hospital 2). Review of the electronic copy of the EMS (Emergency Medical Services) report revealed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 42 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 42 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 the patient's assessment included, "... Pt was transported Code 1 to MIMC (Hospital 2) .. waiting rm (room) with the following incident: After obtaining wheelchair and attempting to assist pt from stretcher to the wheelchair (via stand & pivot) Pt repeatedly refused attempts to get off of the stretcher. Pt pushed attendant 1 away twice, and the second time, Pt picked his legs back up on the stretcher, curling his legs up, Lying back and appearing to take a nap. At this point, ER (Emergency Room) Charge RN (Registered Nurse) attempted to verbally motivate pt to get off the stretcher without success. Ultimately, MIMC (Hospital # 2) ... Security Officer (An off duty Mobile Police Officer) had to physically remove pt from the stretcher, Though pt did not suffer any apparent injuries in this process. Pt was wheeled to waiting rm and checked in (with admissions) with transfer of care, written & verbal report to ER triage RN..." Review of Patient Identifier (PI) # 2's medical record from Hospital # 2 revealed the patient presented to Hospital # 2's ED on 3/5/13 at 9:00 PM by ambulance with weakness and nausea. EI # 15, Triage RN, documented PI # 2's disposition at 2212 (10:12 PM) was AMA/LWBS (Against medical advice/Left without being seen) before triage. Review of the Fire-Rescue Field Triage Sheet dated 3/6/13 revealed the incident location was documented as "Dead end Center St at (Hospital # 2) ..." The Fire-Rescue staff member documented, "... Pt was kicked out of (Hospital # 2) at 2200 per (Hospital # 2) staff. Vitals taken ... (Ambulance company name) ..." (See EMS Report # 2 below) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 43 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 43 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 Review of EMS Report # 2 revealed a call was received at 02:07 AM on 3/6/13 for "One Down" (person down on the ground). EMS arrived at the location and found PI # 2 on the ground for "4 hours" after security told to leave (Hospital # 2) ... Pt has weakness and AMS (altered mental status). Pt would not speak. Pt skin very cold. Pt unknown for any other complaints ... Pt given supportive care ... Pt moved to stretcher ...Pt transported to (Hospital 3)..." Review of PI # 2's medical record from Hospital 3: Emergency Department ER (Emergency Room) Nursing Triage Note on 3/6/13 at 02:47 AM revealed the patient's Chief complaint included, "... This 24 year old male patient admitted with chief complaint of pt picked up outside (Hospital 2) laying on the ground for the past several hours. EMS says pt was brought to (Hospital 2) around 2200 last night for AMS but was not seen bc (because) he was thrown out for misbehaving ..." The patient's vital signs were documented: Temperature 94.7 rectally, blood pressure 119/93, heart rate 146, and respiration 24. The Triage nurse documented the patient was unable to communicate pain level, opened eyes spontaneously, withdraws from painful stimuli with no verbal response. The Triage nurse documented the patient's physical assessment revealed the patient's skin turgor was good, normal and cool, the patient was alert and oriented times 3 and there was no verbal response. The patient was admitted to room 5 via stretcher per EMS and connected to a monitor. The ED physician was at the bedside. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 44 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 44 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 Review of the ED physician's Note dated 3/6/13 at 03:36 AM revealed the patient's chief complaint was decreased responsiveness. The ED physician documented, "EMS provides history. This 24 year old male patient presents with moderate gradual worsening decreased responsiveness beginning several hours prior to arrival. Pt picked up outside (Hospital # 2) laying on the ground for the past several hours. EMS says pt was brought to (Hospital # 2) around 2200 last night for AMS but was not seen bc (because) he was thrown out for misbehaving. apparently he has been non-compliant with meds (medications) and hasn't been seen for a few days. Pt unable to provide any history ..." Review of the ED physician's Note revealed PI # 2's physical examination revealed the patient was well developed, well nourished and nontoxic appearance with a fruity odor to breath. PI # 2's heart rate was regular and lungs were clear bilaterally. The following tests were ordered with their abnormal findings: Blood gases: PCO2 (Partial pressure of Carbon Dioxide) (reflects the amount of Carbon Dioxide dissolved in the blood) = 25.6 (low) PO2 (Partial Pressure of Oxygen) (amount of Oxygen dissolved in the blood) = 123 (high) Base Deficit: (quantitative measure of the body's effort to neutralize acids in the blood stream) = 11 (high) HCO3 (Bicarbonate) (neutralizes acids in the blood stream) = 14.2 (low) TCO2 (Total Carbon Dioxide content) = 15 (low) O2 Sat calculated (Oxygen saturation) (measures the percent of hemoglobin which is fully combined FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 45 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 45 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 with Oxygen = 99 (high) Hematology: WBC (White blood count) = 10.7 (high) RBC (Red blood count) = 3.40 (low) Hemoglobin = 8.5 (low) Hematocrit = 25.4 (low) Urinalysis: Protein = 3+ (high) Urine RBC's = >100 Urine Bacteria = 4+ Basic Metabolic Panel: Sodium = 133 (low) Chloride = 92 (low) CO2 (Carbon dioxide) = 13 (low) BUN (Blood urea nitrogen) (one of the measures of kidney function) = 135 (high) Creatine (a measures of kidney function) = 10.58 (high) CPK (Creatine phosphokinase) (a measure of possible injury or stress to muscle tissue, heart or brain) = 945 (high) Troponin I (measures the amount of proteins Troponin I and Troponin T, which are released in the blood stream when there is heart muscle damage) = 0.119 (Intermediate for myocardial injury) Radiology findings: Chest X-ray - No acute abnormality and CT (Computerized tomography) head - no acute hemorrhage or mass effect. The ED physician documented the diagnostic impression of PI # 2 was altered mental status and anion-gap acidosis. PI # 2's final disposition was transferred to ICU (Intensive Care Unit) of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 46 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 46 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 Hospital #3. Interview with EI # 11, RN ED Charge Nurse at Hospital 2, on 6/26/13 at 10:00 AM. Relationship to PI # 2: Charge Nurse when PI # 2 presented to the ED on 3/5/13. EI # 11 stated PI # 2 arrived via EMS at Hospital 2 on 3/5/13. EI # 11 directed EMS staff to take PI # to triage. EI # 11 was asked to identify the criteria used to determine PI #2 's appropriateness for triage versus direct placement in an ED bed. EI # 11 verified the criteria as PI # 2 's complaint of weakness, noncompliance with medications per EMS staff, PI # 2's age and vital signs. EI # 11 said PI # 2 did not want to get off of the stretcher and into a wheelchair, but was eventually compliant without assistance. EI # 11 said she was advised PI #2 did not want to be treated and "walked off." EI # 11 stated she was informed PI # 2 told the triage nurse, "Get your "f....g hands off me." The only information documented in PI # 2's medical record on 3/5/13 includes, "2100: Arrived ED. 22:12: AMA/LWBS - LWBS (Left Without Being Seen) before triage. 22:13: Pt. (patient) dismissed." Interview with EI # 12, ED Staff RN Hospital 2, on 6/26/13 at 9:25 AM: According to EI # 12, the Charge Nurse directed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 47 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 47 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 PI # 1 to triage after PI # 2 arrived in the ED via ambulance. EI #12 reported seeing EMS staff and hospital security attempting to move PI #2 from a stretcher to a wheelchair. EI # 12 described the patient as "kind of combative." "He (PI # 2 ) was sitting up and all of a sudden refused to do anything." Interview with ED Admission Assistant at Hospital 2, EI # 13, on 6/26/13 at 2:20 PM: EI # 13 stated she was asked by a paramedic on 3/5/13 to notify security was needed because PI # 2 was refusing to get off a stretcher and into a wheelchair after his arrival via ambulance at Hospital 2's ED. PI # 2 was assisted to a wheelchair and brought to the ED waiting area. PI # 2 was taken to the triage room. EI # 13 reports she heard screaming. PI # 2 was out of the wheelchair and saying he did not want to be seen. EI # 13 reports PI # 2 was walking as he was escorted by a security officer out of the triage room. Interview with EI # 14, Director Protective Services at Hospital 2, on 6/25/13 at 2:36 PM: According to EI # 14, PI # 2 had been disruptive and non-compliant in the triage area. PI # 2, "Went to the ground" at the ambulance bay doors when exiting the ED on 3/5/13. PI # 2 was put in a wheelchair and escorted off hospital property by a security officer no longer employed by Hospital 2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 48 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 48 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 Review of Hospital # 2's Policy and Procedures revealed: Policy Title: Emergency Medical Condition Assessment Policy Emergency medical conditions are those manifesting themselves by acute symptoms of sufficient severity including severe pain, psychiatric disturbances, symptoms of substance abuse, and/or women in labor such that the absence of immediate medical attention could reasonable be expected to result in: 1) Placing the health of the individual in serious jeopardy ... Procedure if an emergency medical condition exists: 1) Personnel should immediately begin stabilizing measures. 2) Emergency medical conditions must be stabilized within the capabilities of the hospital ... 5) Consent for screening and/or treatment may be implied if the patient is incapable of giving consent and no representative is available or any delay to obtain consent would jeopardize the patient's safety. 6) If a patient or person acting on the individual's behalf refuses to consent to the medical screening exam or treatment: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 49 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2407 Continued From page 49 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2407 a. Inform the patient or person acting on the individual's behalf of the risks of refusal of the proposed examination or treatment and of the potential benefits. b. If the patient is unstable, attempt to have the physician complete the Informed Consent for Transfer to Acute/Care Speciality form ... The hospital failed to ensure that their policies were followed as evidenced by failing to ensure that patients presenting to the Emergency Department manifesting themselves by acute symptoms receive immediate stabilizing treatment and must be stabilized within the capabilities of the hospital. Patient # 1 presented to the ED on 5/27/2013 on his second visit with a complaint of seizure (manifestation of an acute symptom) as stated by his/her representative, seeking medical care for an identified emergency medical condition, as identified and verified by Hospital # 3. Patient # 2 was picked up by EMS at his residence on 3/5/2013 with a complaint of weakness with altered mental status (manifestation of an acute symptom). The patient responded to verbal stimuli, but was not alert and oriented times 2 only (manifestation of an acute symptom). A review of Mobile Infirmary's medical record reveals the arrival complaint, in part, as "weakness" (manifestation of an acute symptom). The hospital failed to ensure that stabilizing treatment was provided as required to stabilize the medical condition fro Patient #1 and Patient #2. A2409 489.24(e)(1)-(2) APPROPRIATE TRANSFER A2409 (1) General If an individual at a hospital has an emergency FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 50 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 50 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual's behalf) requests the transfer, after being informed of the hospital's obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 51 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 51 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1) (ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital's files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 52 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 52 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This STANDARD is not met as evidenced by: Based on interviews, medical record reviews, review of Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures and review of the hospital's security video, Hospital 2 failed to provide appropriate medical screening examinations and stabilizing treatment resulting in inappropriate transfers of Patient Identifier (PI) # 1 and PI # 2. The hospital also inappropriately discharged an unstable patient, PI # 2. This affected two of 29 sampled patients who presented to Hospital 2's Emergency Department (ED). This deficient practice has the potential to effect all patients who present to Hospital 2's ED. Findings include: Review of PI # 1's medical record dated 5/27/2013 from Hospital # 2 revealed the following: Patient arrived in ED at 04:20 AM. Triage began at 04:30 AM. The following documentation was included in the Triage notes: 04:34:12 - Pt c/o (complained of) SOB (shortness of breath) with occas. (occasional) CP (Chest pain) on & off for the last month. Worse tonight, "I feel like I can't catch my breath". Some n/v (nausea/vomiting) when pain is worst. 04:38:33 Patient was taken to ED room 24. 04:54:24 the nurse documented, "Awaiting MD (Medical Doctor) eval (evaluation)." 06:34 AM - EI # 5, ED physician documented, "This case is a certified medical emergency ..." 06:46:22 - EI # 8, RN documented, "... RN went to pts (patient's) room. Pt asked to see (doctor)FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 53 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 53 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 RN asked what this was concerning and pt became belligerent... Security called. Pt wants to leave ama (against medical advice). EI # 5, ED physician informed. Pt informed of risks of leaving ama. Pt refused to sign AMA form... Pt states, "You can't keep me here, I am not under arrest... Pt walked to truck by own power with security. Threatening security along the way ..." 06:48:58 - ED disposition set to eloped documented by EI # 5, ED physician. 06:49 - EI # 5 documented, "... Chest pain: SOB (Shortness of breath)... The patient became hostile and belligerent and had to be removed from the emergency department prior to my evaluation. I did not lay eyes on this patient ... Patient Progress: stable ..." Review of Patient Identifier (PI) # 1's medical records dated 5/27/2013 from Hospital # 1 revealed PI # 1 returned to Hospital # 1's ED at 07:03 AM by private vehicle. Review of the Medical Screening/Nursing Assessment revealed the patient's chief complaint was Cardiac Arrest ... possible seizure...PI# 1's primary assessment revealed the patient was unresponsive... skin was warm and dry ...no movement. Further documentation revealed, "... 35 yom (year old male) presents to ED, POV (privately owned vehicle) for possible seizure ... pt was found to be pulse less and apneic. CPR initiated. Pt taken to TR (Trauma Room) with CPR cont. (continued) 7.0 ETT (endotracheal tube) placed & confirmed with ... BBS (bilateral breath sounds) (no) epigastric gurgling ... ACLS (Advanced Cardiac Life Support) ... Pt defibrillated ... firing for VF (ventricular fibrillation) with no response except asystole. Heroic measures performed. CPR and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 54 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 54 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 defib ... No signs of life. Unable to gain ... Asystole... pt had been at (Hospital # 2) PTA (prior to arrival) ..." PI # 1's time of death was documented as 07:22 AM. Hospital 2 failed to provide a medical screening examination and stabilizing treatment for PI # 1 upon his return to Hospital 2's ED, which ultimately resulted in the responsible representative transporting PI # 1 to Hospital 1 via private car. Hospital 2's failure to provide medical screening examination and stabilizing treatment resulted in an inappropriate transfer to Hospital 1. 2. Review of the Ambulance Patient Care report dated 3/5/13 revealed PI # 2's chief complaint was weakness and AMS (altered mental status)... Arrived at destination (Hospital # 2) at 20:45. Review of Patient Identifier (PI) # 2's medical record from Hospital 2 revealed the patient presented to Hospital 2's ED on 3/5/13 at 9:00 PM by ambulance with weakness and altered mental status. EI # 15, Triage RN, documented PI # 2's disposition at 2212 (10:12 PM) was AMA/LWBS (Against medical advice/Left without being seen) before triage. During a review of the hospital's security tape, (dated 3/15/2013), the patient was seen lying on the floor between the ED and the ambulance bay. A security officer picked up the patient and placed him in a wheelchair. Next, the officer was seen pushing the wheelchair in the driveway of the ambulance bay away from the Emergency Department. During an interview with EI # 4 on 6/25/13 at 2:36 PM, the Director Protective Services, said the officer transported the patient FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 55 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 55 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 (PI # 2) off hospital property. Review of EMS Report # 2 revealed a call was received at 02:07 AM on 3/6/13 for "One Down" (person down on the ground). EMS arrived at the location and found PI # 2 on the ground for "4 hours" after security told to leave (Hospital # 2) ... Pt has weakness and AMS (altered mental status). Pt would not speak. Pt skin very cold. Pt unknown for any other complaints ... Pt given supportive care ... Pt moved to stretcher ... Pt transported to (Hospital # 3)..." Review of PI # 2's medical record from Hospital # 3: Emergency Department ER (Emergency Room) Nursing Triage Note on 3/6/13 at 02:47 AM revealed the patient's Chief Complaint included, "... This 24 year old male patient admitted with chief complaint of pt picked up outside (Hospital # 2) laying on the ground for the past several hours. EMS says pt was brought to (Hospital # 2) around 2200 last night for AMS but was not seen bc (because) he was thrown out for misbehaving ..." Review of the ED physician's Note dated 3/6/13 at 03:36 AM revealed the patient's chief complaint was decreased responsiveness. The ED physician documented, "EMS provides history. This 24 year old Male patient presents with moderate gradual worsening decreased responsiveness beginning several hours prior to arrival. Pt picked up outside (Hospital # 2) laying on the ground for the past several hours. EMS says pt was brought to (Hospital # 2) around 2200 last night for AMS but was not seen bc (because) he was thrown out for misbehaving. apparently he has been non-compliant with meds (medications) and hasn't been seen for a few days. Pt unable to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 56 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 56 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 provide any history ..." The ED physician documented the diagnostic impression of PI # 2 was altered mental status and anion-gap acidosis (increase in plasma acidity). PI # 2's final disposition was transferred to ICU (Intensive Care Unit) of Hospital # 3. The patient expired on 3/18/2013. The hospital discharged Patient # 2, which was an inappropriate discharge of an unstable patient who was manifesting acute symptoms of altered mental status. The hospital failed to provide a Medical Screening Examination (MSE) to determine whether or not an emergency condition existed, failed to provide stabilizing treatment prior to discharging / dumping Patient #2 out of a wheelchair, off of hospital property on 3/5/2013. Hospital # 2's Policy and Procedure: Transfer/Discharge of Unstabilized patient to another acute care/specialty facility An appropriate transfer of an unsteadied patient may occur only when the patient (or responsible person acting on the individual's behalf) is informed of hospital's obligation to provide stabilizing treatment and informed of the medical risks and benefits of transfer. The Transfer to Acute Care/Speciality Facility Summary form is completed to document the communication of the hospital' s obligation, explanation of risks and benefits for transfer and the reason for the request to transfer ... Transfer/Discharge of an unstabilized patient to another acute care/speciality facility procedure. 1) Reason for transfer is to be documented on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 57 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 57 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 the Transfer to Acute/Speciality Facility Summary Form, selecting from the following: a. The patient (or responsible person acting on the individual's behalf) requests the transfer to another facility. b. Physician determines that transfer benefits outweigh risks. c. Patient requires services and facility lacks current capacity as determined by Administration. (i.e. cath lab full, no ICU beds) I. THE PHYSICIAN CERTIFIES IN WRITING THE SUMMARY OF RISKS AND BENEFITS OF TRANSFER. Have the physician complete the summary of risks and benefits of transfer on the Informed Consent for Transfer to Acute Care/Speciality Facility form. II. CONTINUE TO PROVIDE MEDICAL TREATMENT WITHIN THE HOSPITAL'S CAPACITY THAT MINIMIZES THE RISKS TO THE INDIVIDUAL'S HEALTH AND, IN THE CASE OF A WOMAN IN LABOR, THE HEALTH OF THE UNBORN CHILD. III. CALL THE RECEIVING FACILITY FOR APPROVAL TO TRANSFER. The receiving facility must have available space and qualified personnel for the treatment of the patient and must agree to accept the transfer. Document on the Transfer to Acute Care/Speciality Facility Summary form the communication with the receiving facility including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 58 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 58 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 the name and title of the person accepting the transfer. IV. THE TREATING PHYSICIAN IS RESPONSIBLE FOR ARRANGING FOR A PHYSICIAN TO ACCEPT THE PATIENT AT THE RECEIVING FACILITY. V. ARRANGE FOR TRANSPORT OF THE PATIENT ... VI. SEND ALL MEDICAL RECORDS RELATING TO THE EMERGENCY MEDICAL CONDITION WITH THE PATIENT ... VII. FULLY COMPLETE THE TRANSFER TO ACUTE CARE/SPECIALITY FACILITY SUMMARY FORM AND ATTACH THE PHYSICIAN ' S COMPLETED INFORMED CONSENT FOR TRANSFER OR REFUSAL TO ACUTE CARE/SPECIALITY FACILITY FORM, if applicable. Send the original with patient and retain the copy for the medical record. Consent for screening and/or treatment may be implied if the patient is incapable of giving consent and no representative is available or any delay to obtain consent would jeopardize the patient's safety. VIII. DOCUMENT PATIENT'S INFORMED DECISION REGARDING TRANSFER/DISCHARGE OR REFUSAL FOR TREATMENT. A. If the benefits of transfer outweigh the risks and the patient or person acting on his behalf refuses to transfer, inform the patient or person acting on his behalf of the risks and benefits of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 59 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 59 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 the transfer. Take all reasonable steps to secure the individual's (or that of a person acting on his or her behalf) written refusal in the applicable section of the Transfer to Acute Care/Speciality Facility Summary. The document must reflect that the risks and benefits to transfer were explained and the reasons for refusal. If the patient is unstable, have the physician complete the Informed Consent for Transfer to Acute/Care Speciality form. B. If the patient requests transfer to another facility and the risks of transfer outweigh the benefits, inform the patient or person acting on his behalf of the risks and benefits of the transfer. Take all reasonable steps to secure the individual's (or that of a person acting on his or her behalf) written request for transfer on the Transfer to Acute/Care Speciality Facility Summary form. The documentation must reflect that the risks and benefits to transfer were explained and the reasons for refusal. If the patient is instable, have the physician complete the Inform Consent for Transfer to Acute/Care Speciality form. C. If patient or person acting on his or her behalf refuses to sign follow the above procedures for Appropriate Transfer/Discharge of and Unstabilized Patient to Another Acute/Care Speciality Facility. D. Record final disposition. Hospital # 2 failed to follow their EMTALA policy and procedure as it relates to the appropriate transfer of PI # 1 on 5/27/13 to Hospital # 1 and the inappropriate discharge of an unstable patient FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 60 of 61 DOCUMENT 1182 PRINTED: 03/17/2014 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED C 010113 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5 MOBILE INFIRMARY CIRCLE MOBILE INFIRMARY (X4) ID PREFIX TAG 06/26/2013 MOBILE, AL 36652 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2409 Continued From page 60 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A2409 (PI # 2) on 3/5/13 to Hospital #3. Hospital 2 failed to: 1. Provide an appropriate medical screening exam and stabilizing treatment, which the facility had the capacity and capability to perform. 2. Arrange for receiving physicians at Hospitals 1 and 3 to accept care of PI # 1 and PI # 2. 3. Provide and complete an informed consent for transfers for PI # 1 and PI # 2. 4. Supply Hospitals 1 and 3 with a copy of the medical record for PI # 1 and PI # 2. 5. Record the final dispositions of PI # 1 and PI # 2. PI # 1 and PI # 2 were inappropriately transferred/discharged from Hospital 2 to Hospitals 1 and 3 due to Hospital 2's failure to provide appropriate medical screening examinations and stabilizing treatment, which Hospital 2 had the capacity and capability to perform to minimize the risks to these patients' health on 3/5/2013 and 5/27/2013. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWRJ11 Facility ID: H4904 If continuation sheet Page 61 of 61 EXHIBIT Department of Hee Human Services Centers for Medica re dz Medicaid Services 61 Street, SW, Suite 4T20 Atlanta, Georgia 3030343909 CENTERS FOR MEDICARE MEDICAID SERVICES Reference: 111: Mobile n?rmary 11012013 CCN AK 29174 23 day termination ~exhibit letter 204 doc. November l, 20i3 *Amending letter dated 11/1/2013 Mt. Joe Stough, Administrator Mobile In?rmary 5 Mobile lnfirmary Circle Mobile, Alabama 36652 Re: CMS Certi?cation Number (CCN): 01?0113, Mobile in?rmary EMTALA Complaint Control Number: AL 29174* Dear Mr. Stough: To participate in the Medicare program, a hospital must meet the requirements established under title ofthe Social Security Act (the Act) and the regulations established by the Secretary of Health and Human Services under the authority contained in ?186 of the Act. Further, ?1866(b) of the Act authorizes the Secretary to terminate the provider agreement of a hospital that fails to meet these provisions. Your hospital was surveyed June 26, 2013, by the Alabama Department of Public Health based on an allegation ofroncompliance with the requirements at 42 CFR 489.24, Special responsibilities of iv edicare hospitals in emergency cases and/or the related requirements at 42 CFR 489.20. After 2: careful review ofthe findings, we have determined that your hospital violated the requirements at 42 CFR 489.24 based on the hospital?s failure to provide medical screening examinations and stabilizing treatment to individuals who presented to the emergency department manifeSI ing acute of suf?cient severity that placed the health of these individuals in seriousjeopardy. The hOSpitals failure to provide appropriate medical screening examinations and stabilizing treatment resulted in inapprOpriate transfers of two individuals who presented to the emergency department. in addition, we have determined that your hospital violated the requirements at 42 CFR 489.20, related to failing to maintain a central emergency services log for an individual who came to the emergency department seeking medical The deficiencies identified are listed in detail on the enclosed Form CMS-2567, Statement of De?ciencies. We have determiner; that the deficiencies are so serious that they constitute an immediate and serious threat to the health and safety of any individual who comes to the emergency department and requests examination or treatment for an emergency medical condition. Further, under 42 CFR 489.53, a hosp tal that violates the provisions of 42 CFR 489.24 is subject to termination ofits provider agreement. Consequently, we plan to terminate Mobile Hospital participation in the Medicare program. FOIA CMS 130 Mr. Stough Page 2 November I, 2013 This preliminary determination letter serves to notify you of the vioiation. The projected date on which your agreement will terminate is November 24, 2013. You will receive a ?notice of termination letter? on November 20, 20l3. This ?nal notice will be sent to you concurrentiy with notice to the public, in accordance with regulations at 42 CFR 489.53. You may avoid tern ination action and notice to the public either by providing prior to the projected public not ?cation date a credible allegation of correction ofthe de?ciencies, or credible evidence the, deficiencies did not exist. Enclosed you will ?nd the requirements for an acceptable Plan ofC orrection (Plan of Con'ection/Credibie Allegation). A credible allegation of correction by the hospital requires a resurvey prior to the projected termination date, and must be received by this off: 3e within 10 calendar days of receipt ofthis letter, to permit timely resurvey to verify the corrections. If we verify your corrective action, or determine that the ?ndings contained in this letter were in error, your planned termination from the Medicare program will be rescinded. If you have any questions concerning this preliminary determination letter, please contact Brenda J. Davaiie at 404662?7462, e?mail address Brenda.Bavalie@cms.hhs.gov. incerely yours, gar/ms M. Pace 1 Associate Regional A ministrator Enclosure: Form Statement of De?ciencies, 5 Day Q10 report, and Plan of Correction/Credible Allegation cc: State Survey Agency Q10 OCR OIG Complainant *Amending letter to change AL 29714 to AL 29174 FOIA CMS 131