Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 010001	(X3) Date Survey Completed 10/02/2019
Name of Provider or Supplier Southeast Health Medical Center	Street Address, City, State 1108 Ross Clark Circle, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
A0000	An unannounced federal Emergency Medical Treatment & Labor Act (EMTALA) complaint survey, AL36479, was conducted at Southeast Alabama Medical Center on October 2, 2019, specifically for the review of EMTALA requirements. The Regulatory Director and Interim Quality Director were notified on December 17, 2019 at 1:25 p.m. that Immediate Jeopardy (IJ) existed. Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) related policy, Medical Staff Bylaws and Rules and Regulations, Hospital # 2 Emergency Department (ED) medical record (MR), and interviews with staff it was determined Southeast Alabama Medical Center (Hospital # 1) failed to provide a Medical Screening Examination (MSE) for a patient that presented to the wound care clinic, located on the hospital campus, for care. The wound clinic staff notified 911 of the need to transport the patient to the Emergency Department (ED) for evaluation and treatment. The patient was not taken to the on-campus ED, but was transported to Hospital #2's ED for treatment. Southeast Alabama Medical Center failed to provide a MSE, provide stabilizing treatment and arrange for an appropriate transfer to Hospital #2. The hospital's failure to provide stabilizing treatment as required posed an immediate and serious threat to Patient #21's health and safety and inappropriately delayed treatment for his emergency medical condition. The patient's condition was not stable at the time of transfer, as this resulted in an inappropriate transfer. The hospital was found to be not in compliance with the Federal Regulations at 42 CFR 489.20 and CFR 489.24, Responsibilities of Medicare Participating Hospitals in Emergency Cases. The following is a description of the non-compliance.
A2400	COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This STANDARD is not met as evidenced by: Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) related policy, Medical Staff Bylaws and Rules and Regulations, Hospital # 2 Emergency Department (ED) medical record (MR), and interviews with staff it was determined Southeast Alabama Medical Center (Hospital # 1) was not in compliance with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to provide a Medical Screening Examination (MSE) and appropriate transfer for a patient requiring emergency services located on the hospital campus. This deficient practice affected Patient Identifier (PI) # 21, 1 of 1 hospital based wound care center records reviewed, and had the potential to negatively affect all patients served by the facility. Findings include: Refer to Tag 2406 and 2409
A2406	MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must (i) provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (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 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 review of the facility policies and procedures, facility diversionary status listing, ambulance patient care report, ED (Emergency Department) Physician Transfer Line Form Medial Record (MR) from hospital based outpatient wound center, and interviews with facility staff it was determined the facility failed to provide a Medical Screening Examination (MSE), related to diversionary status, for a patient requiring emergency services located on the hospital campus. This deficient practice affected Patient Identifier (PI) # 21, 1 of 1 hospital based wound care center records reviewed, and had the potential to negatively affect all patients served by the facility. Findings include: Policy: Emergency Medical Treatment and Active Labor Act (EMTALA) Administrative Policy Effective Date: 4/1/19 Purpose: To comply with the EMTALA, which requires a Medicare participating hospital with a dedicated emergency department (DED) to provide a MSE to determine the presence of an emergency medical condition (EMC)... Scope: ...EMTALA also applies to any individual with what a prudent layperson believes to be an EMC, who presents at a hospital - based outpatient department (HOPD)... or anywhere on a hospital campus that has a DED... which must occur within the appropriate Southeast Health (Southeast Alabama Medical Center) DED. Examples include: 1. Individual arrives on hospital property...within 250 yards of hospital... ...4. Individual presents to a HOPD for unscheduled visit presumably needing emergency medical treatment for an apparent life-threatening emergency... EMTALA Requirements: ...1. Provide an appropriate MSE to any individual who comes to the emergency department (ED)... Policy: Physicians Wound Care (PWC) Subject: PWC Scope of Service Effective Date: 1/12/17 Policy: ...Southeast Wound Care is an Outpatient department of Southeast Alabama Medical Center... Policy: PWC Subject: Transporting of Patients Effective Date: 7/1/18 Policy: To educate staff of proper procedures when transporting patients from out center to the ER (emergency room)... Purpose: To ensure safe transport of patient from PWC to the hospital. Procedure: Conditions which warrant being taken to the hospital: ...2. Patients who need ER services... ...After 911 is called the staff will activate the emergency code 9 for immediately adjacent response area assistance...As soon as the wound care physician evaluates the patient they will call the ER and speak with a physician and report the condition of the patient and that they should expect the patient in the ER... PI # 21 presented to the wound care center on 8/22/19 for a Diabetic Foot Ulcer wound care follow up visit. Review of the Wound Care Center Progress Note dated 8/22/19 revealed the following summary of events: PI # 21 was observed in the wound care center waiting area by a Employee Identifier (EI) # 4, Registered Nurse (RN) Wound Care Center, who then told the RN Team Leader that the patient looked like "he/she is ready to fall out." PI # 21 was wheeled into the wound care center hallway and vital signs including, pulse of 49, blood pressure of 125/58, and respiration rate of 16 were performed. While in the hallway, EI # 7, Medical Doctor, "came out to observe patient and noticed that he/she was ill appearing cachexic (condition that causes extreme weight loss and muscle wasting), nauseated and dry heaving in a clear plastic bag. He/She appeared severely dehydrated, eyes sunken and termporal (temporal) waisting (wasting)..." EI # 7 recommended the patient be evaluated in the ER (Emergency Room). PI # 21 refused to go to the ED for evaluation and then requested to go to the restroom. While in the restroom, PI # 21 had a bowel movement (BM) which EI # 7 documented "had a strong odor not unlike melena (dark sticky feces containing partly digested blood)." EI # 7 attempted to speak with PI # 21 following the BM and documented "his/her mental status was waxing and waning in and out of consciousness." EI # 7 instructed EI # 4 to call 911. PI # 21 was then taken to wound care exam room with the EI # 4 who waited with PI # 21 until Emergency Medical Services (EMS) arrived. When EMS arrived EI # 7 went into the exam room with PI # 21 and was notified by EMS that Southeast Alabama Medical Center was on diversion. EI # 7's documented response to EMS on the diversionary status was "he/she for sure needs emergent care and should not be discharged to his/her home without being evaluated in (the) ER." EMS placed PI # 21 on a stretcher and left the wound center. Review of the Ambulance Patient Care Report dated 8/22/19 revealed documentation the ambulance was dispatched at 9:02 AM to Southeast Alabama Medical Center Wound Care and arrived at 9:08 AM. Emergency Medical Services (EMS) documented PI # 21's vitals signs as pulse 46, blood pressure 92/54, and respiration rate of 18. Further review of the Ambulance Patient Care Report dated 8/22/19 revealed PI # 21 was transported to hospital # 2 at 9:26 AM. Review of the ED Physician Transfer Line Form dated 8/22/19 revealed no documentation of a call from the Southeast Alabama Medical Center Wound Care. Review of the Southeast Alabama Medical Center diversionary status listing revealed the facility was on a Med (Medical) Surg (Surgical) diversion from 8/21/19 at 11:30 PM until 8/22/19 at 2:50 PM. The facility failed to provide a MSE for PI # 21 who required emergency services and was located on the hospital campus. Interviews: 1. An interview was conducted on 10/2/19 at 8:20 AM with EI # 2, Director of Emergency Services, to determine the facility's transfer practices related to outpatient departments and ED diversionary status. EI # 2 was asked the process for transferring patient's from an outpatient department of the hospital, such as the wound care center, to the ED. EI # 2 stated "anything that's in the main hospital there is a code 9. A team from the ED would go there or the department would bring the patient to the ED. Outside of the actual building would be a 911 call or if we are notified we would still respond to those areas." When asked if a med/surg diversion should affect a patient that required ED services within an outpatient department/clinics of the hospital campus. EI # 2 stated, "if someone is on our immediate campus the patient should be brought to us regardless of a diversionary status." EI # 2 was asked if the wound care center was on the hospital campus. EI # 2 stated, "it meets the 250 yard rule." 2. An interview was conducted on 10/2/19 at 8:43 AM with EI # 3, Director of Quality Management, to determine the facility's transfer practices related to outpatient departments and ED diversionary status. EI # 3 was asked what the process was for the outpatient departments/clinics to transfer a patient to the ED for evaluation. EI # 3 stated, "they call 911 and they are supposed to notify the ED..." When asked if a med/surg diversion should affect a patient that required ED services within an outpatient department/clinics of the hospital campus. EI # 3 stated, "If they are on campus it should not affect the patient. If EMS is called, they should bring the patient here..." EI # 3 confirmed the wound care center was within 250 yards of the hospital campus. 3. An interview was conducted on 10/2/19 at 9:18 AM with EI # 5, RN, Inpatient Wound, Ostomy, and Continence Nurse, who was the first person to observe PI # 21's condition. EI # 5 stated, "I was taking wound vac's to the wound center. As a car left the building I saw a man/woman holding onto the handrail. His/Her color was awful. I got a wheelchair and took him/her in the lobby. I told (employee identified) at the window they need to get him/her help. He/She really looked like he/she might die." 4. An interview was conducted on 10/2/19 at 9:25 AM with EI # 4, RN, Wound Care Center Team Leader, to describe what he/she knew about the care of PI # 21. I was told "you have a patient out there that doesn't look good. Do you want me to bring him/her back?" I told him/her yes. I started to get his/her vitals. Medical Doctor (MD) came down. MD said he/she needed to go to the ER. The patient refused and went to the bathroom. MD talked with him/her again and then told me to call 911 because he/she was in and out of consciousness. I called 911, took him/her to a room, and sat with him/her until 911 got there. The EMS said, 'you know southeast health is on diversion.' MD said well he/she can't go home. The EMS asked if he/she (referring to EI # 7) wanted him/her to go to (hospital # 2 identified). MD said he/she can't go home, take him/her to Hospital # 2 then. EI # 4 was asked what the process was to transfer a patient to the ED for an evaluation from the wound care center. EI # 4 stated, "We call 911. We call a code 9 and give report to the ER." During a follow up interview with EI # 4 on 10/2/19 at 2:32 PM, EI # 4 confirmed there was no documentation a code 9 was initiated or a report was given to the ER for PI # 21.
A2409	APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (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. (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 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 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 review of the facility policies and procedures, facility diversionary status listing, ambulance patient care report, ED (Emergency Department) Physician Transfer Line Form Medial Record (MR) from hospital based outpatient wound center, and interviews with facility staff it was determined the staff inappropriately permitted EMS (Emergency Medical Services) to transfer the patient to a different hospital related to ED diversionary status. This deficient practice affected Patient Identifier (PI) # 21, 1 of 1 hospital based wound care center records reviewed, and had the potential to negatively affect all patients served by the facility. Findings include: PI # 21 presented to the wound care center on 8/22/19 for a Diabetic Foot Ulcer wound care follow up visit. Review of the Wound Care Center Progress Note dated 8/22/19 revealed the following summary of events: PI # 21 was observed in the wound care center waiting area by a Employee Identifier (EI) # 4, Registered Nurse (RN) Wound Care Center, who then told the RN Team Leader that the patient looked like "he/she is ready to fall out." PI # 21 was wheeled into the wound care center hallway and vital signs including, pulse of 49, blood pressure of 125/58, and respiration rate of 16 were performed. While in the hallway, EI # 7, Medical Doctor, "came out to observe patient and noticed that he/she was ill appearing cachexic (condition that causes extreme weight loss and muscle wasting), nauseated and dry heaving in a clear plastic bag. He/She appeared severely dehydrated, eyes sunken and termporal (temporal) waisting (wasting)..." EI # 7 recommended the patient be evaluated in the ER (Emergency Room). PI # 21 refused to go to the ED for evaluation and then requested to go to the restroom. While in the restroom, PI # 21 had a bowel movement (BM) which EI # 7 documented "had a strong odor not unlike melena (dark sticky feces containing partly digested blood)." EI # 7 attempted to speak with PI # 21 following the BM and documented "his/her mental status was waxing and waning in and out of consciousness." EI # 7 instructed EI # 4 to call 911. PI # 21 was then taken to wound care exam room with the EI # 4 who waited with PI # 21 until EMS arrived. When EMS arrived EI # 7 went into the exam room with PI # 21 and was notified by EMS that Southeast Alabama Medical Center was on diversion. EI # 7's documented response to EMS on the diversionary status was "he/she for sure needs emergent care and should not be discharged to his/her home without being evaluated in (the) ER." EMS placed PI # 21 on a stretcher and left the wound center. Review of the Ambulance Patient Care Report dated 8/22/19 revealed documentation the ambulance was dispatched at 9:02 AM to Southeast Alabama Medical Center Wound Care and arrived at 9:08 AM. Emergency Medical Services (EMS) documented PI # 21's vitals signs as pulse 46, blood pressure 92/54, and respiration rate of 18. Further review of the Ambulance Patient Care Report dated 8/22/19 revealed PI # 21 was transported to hospital # 2 at 9:26 AM. Review of the ED Physician Transfer Line Form dated 8/22/19 revealed no documentation of a call from the Southeast Alabama Medical Center Wound Care. Review of the Southeast Alabama Medical Center diversionary status listing revealed the facility was on a Med (Medical) Surg (Surgical) diversion from 8/21/19 at 11:30 PM until 8/22/19 at 2:50 PM. The facility failed to provide documentation the patient was transferred to the ED for stabilizing treatment, a physician signed certification that contained a summary of the risks and benefits to the patient required for transfer, the receiving hospital had been contacted and accepted the patient, and the receiving hospital was provided the patient's medical records. Interviews: 1. An interview was conducted on 10/2/19 at 8:20 AM with EI # 2, Director of Emergency Services, to determine the facility's transfer practices related to outpatient departments and ED diversionary status. EI # 2 was asked the process for transferring patient's from an outpatient department of the hospital, such as the wound care center, to the ED. EI # 2 stated "anything that's in the main hospital there is a code 9. A team from the ED would go there or the department would bring the patient to the ED. Outside of the actual building would be a 911 call or if we are notified we would still respond to those areas." When asked if a med/surg diversion should affect a patient that required ED services within an outpatient department/clinics of the hospital campus. EI # 2 stated, "if someone is on our immediate campus the patient should be brought to us regardless of a diversionary status." EI # 2 was asked if the wound care center was on the hospital campus. EI # 2 stated, "it meets the 250 yard rule." 2. An interview was conducted on 10/2/19 at 8:43 AM with EI # 3, Director of Quality Management, to determine the facility's transfer practices related to outpatient departments and ED diversionary status. EI # 3 was asked what the process was for the outpatient departments/clinics to transfer a patient to the ED for evaluation. EI # 3 stated, "they call 911 and they are supposed to notify the ED..." When asked if a med/surg diversion should affect a patient that required ED services within an outpatient department/clinics of the hospital campus. EI # 3 stated, "If they are on campus it should not affect the patient. If EMS is called, they should bring the patient here..." EI # 3 confirmed the wound care center was within 250 yards of the hospital campus. 3. An interview was conducted on 10/2/19 at 9:18 AM with EI # 5, RN, Inpatient Wound, Ostomy, and Continence Nurse, who was the first person to observe PI # 21's condition. EI # 5 stated, "I was taking wound vac's to the wound center. As a car left the building I saw a man/woman holding onto the handrail. His/Her color was awful. I got a wheelchair and took him/her in the lobby. I told (employee identified) at the window they need to get him/her help. He/She really looked like he/she might die." 4. An interview was conducted on 10/2/19 at 9:25 AM with EI # 4, RN, Wound Care Center Team Leader, to describe what he/she knew about the care of PI # 21. I was told "you have a patient out there that doesn't look good. Do you want me to bring him/her back?" I told him/her yes. I started to get his/her vitals. Medical Doctor (MD) came down. MD said he/she needed to go to the ER. The patient refused and went to the bathroom. MD talked with him/her again and then told me to call 911 because he/she was in and out of consciousness. I called 911, took him/her to a room, and sat with him/her until 911 got there. The EMS said, 'you know southeast health is on diversion.' MD said well he/she can't go home. The EMS asked if he/she (referring to EI # 7) wanted him/her to go to (hospital # 2 identified). MD said he/she can't go home, take him/her to Hospital # 2 then. EI # 4 was asked what the process was to transfer a patient to the ED for an evaluation from the wound care center. EI # 4 stated, "We call 911. We call a code 9 and give report to the ER." During a follow up interview with EI # 4 on 10/2/19 at 2:32 PM, EI # 4 confirmed there was no documentation a code 9 was initiated or a report was given to the ER for PI # 21.