Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 010005 (X3) Date Survey Completed 09/29/2022
Name of Provider or Supplier Marshall Medical Centers South Campus Street Address, City, State 2505 U S Highway 431 North, Boaz, 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 abbreviated unannounced federal Emergency Medical Treatment & Labor Act (EMTALA) complaint survey, AL00042070, was conducted at Marshall Medical Centers, North Campus, part of the Huntsville Hospital Health System, on September 29, 2022 specifically for review of EMTALA requirements. The hospital was found to be not in compliance with the Federal Regulations at 42 CFR 489.24 (a), Responsibilities of Medicare Participating Hospitals in Emergency Cases, and and CFR 489.24(d), Necessary Stabilizing Treatment for Emergency Medical Conditions. Please refer to findings at A 2400 and A 2406. The following is a description of the non-compliance: Patient Identifier (PI) # 1 presented to the Emergency Department (ED) at Marshall Medical Centers North (Hospital A) on 8/5/22 at 12:31 AM, via private vehicle, accompanied by family, with a chief complaint of a broken and leaking central venous line. Review of the Huntsville Hospital (Hospital B) History and Physical Report, dated 8/5/22, revealed Employee Identifier (EI) # 6 (Hospital B physician) documented PI # 1 had/has an underlying mitochondrial genetic disorder that required continuous infusion of TPN (total parenteral nutrition) via a central venous line. Per interview of the complainant (a family member of PI # 1) conducted 9/28/22 at 8:30 AM, the complainant made Hospital A EI # 2, ED Registered Nurse (RN) aware PI # 1 required TPN twenty four hours a day. Review of the Hospital A ED Medical Record (MR) for PI # 1 revealed PI # 1 received a Triage assessment at 12:53 AM by Employee Identifier (EI) # 3, RN, and a nursing assessment at 1:00 AM by EI # 2. There was no documentation a medical screening examination (MSE) was conducted. Further review of the ED MR revealed EI # 2 informed PI # 1's family that he/she had consulted with EI # 4 (Hospital A ED physician), that the services required for repair/replacement of the central venous line were not available at the facility at that time, and EI # 4 recommended following up with the surgeon who had placed the central venous line immediately in the morning. PI # 1 then left the ED at Hospital A via private car, and went to the ED at Hospital B. Review of the Hospital B MR revealed PI # 1 received a MSE by the ED physician, and stabilizing treatment with peripheral intravenous (IV) fluids, until a surgeon removed the broken/leaking central venous line and placed a new central venous line to continue TPN. An interview with the complainant on 9/28/22 at 8:30 AM confirmed PI #1's family was told services needed were not available at Hospital A, and was advised to return that morning to the surgeon's office that had initially placed the central venous line. The complainant also confirmed PI # 1 received no treatment at Hospital A other than vital signs. Review of the on-call surgery schedule for Hospital A revealed a surgeon was on-call from 5 PM on 8/4/22 to 7 AM on 8/5/22 when PI # 1 presented to Hospital A's ED, that could have provided the stabilizing treatment needed. In an interview conducted 9/29/22 at 11:00 AM with EI # 5 (on-call surgeon) for 8/4/22, EI # 5 stated he/she did not remember being contacted for a case like PI # 1. In an interview with EI # 1, Chief Nursing Officer, on 9/29/22 at 3:23 PM, EI # 1 confirmed that Hospital A did not provide a MSE for PI # 1.
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 Medical Records (MR), facility policy and definitions, Medical Staff Rules and Regulations, and interviews with staff, it was determined the facility failed to: 1. Provide a Medical Screening Exam (MSE) for a patient presenting to the Emergency Department (ED). 2. Provide stabilizing treatment for all patients presenting to the ED. These deficient findings did affect one of two MR's reviewed with a disposition of left without being seen (LWBS), including Patient Identifier (PI) # 1, and had the potential to affect all patients served by the facility ED. Findings Include: Refer to findings in tag A 2406.
A2406 MEDICAL SCREENING EXAM
CFR(s): 489.24(a) & 489.24(c)

(a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual's source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital's dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition.


This STANDARD is not met as evidenced by:
Based on review of Medical Records (MR), facility policy review, Medical Staff Rules and Regulations review, on-call physician's schedules review, and interviews with staff, it was determined the facility failed to provide an appropriate medical screening exam (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the Emergency Department (ED) to determine whether or not an emergency medical condition (EMC) exists. This deficient practice affected one of two MR's reviewed with a disposition of left without being seen (LWBS) including Patient Identifier (PI) # 1, and had the potential to affect all patients served by the facility ED. Findings include: Health System Policy: EMTALA (Emergency Medical Treatment and Labor Act) - General Requirements and Definitions Reference Number: None Effective Date: 8/29/22 II. Policy: It is the policy of The Health Care Authority of the City of Huntsville, for all Huntsville Hospital Health System (HHHS) acute-care or specialty hospitals to comply with the Medicare Conditions of Participation ...otherwise known as ...EMTALA or 42 CFR 489.24. III. Overview of EMTALA: All persons presenting for emergency care at HHHS Hospitals will be considered to have "come to the hospital" if a request is made by the individual or on the individual's behalf for emergency medical care. Each individual shall receive a MSE and stabilizing treatment within the capacity and capabilities of the hospital... A. EMTALA General Requirements: ...2. The MSE will be performed by a Physician, Advanced Practice Provider, Physician Assistant, or trained Labor and Delivery Registered Nurse as defined and/or described by each hospital's medical staff by laws or other governing body document. ...4. The hospital provides care in response to the patient's request and need, provided the patient's request and need are consistent with the hospital's capability and capacity. ...10. Maintain a list of physicians who are on-call to provide further examination and/or treatment necessary to stabilize an individual with an EMC... Definitions: The following terms and definitions are used throughout the HHHS policies and procedures to demonstrate consistency and compliance with all state and federal regulations related to EMTALA. ...2. Capabilities of a medical facility or hospital provider mean the physical space, equipment, supplies and services...available at the hospital. The capabilities of the hospital's staff mean the level of care that the hospital's personnel can provide within the training and scope of their professional licenses, including coverage available through the hospital's on-call roster. 3. Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment...Capacity encompasses such things as numbers and availability of qualified staff, beds, equipment... ...16. On-Call List refers to the list that the hospital is required to maintain that defines those Physicians who are on the hospital's medical staff or who have privileges at the hospital,...and are available to provide treatment necessary after the initial examination to stabilize individuals with EMC's. Policy: Medical Staff Rules and Regulations Policy Number: None Effective Date: 8/12/22, approved by Advisory Board ...Section V. 1. A MSE will be provided for all individuals presenting to the hospital for emergency care. The purpose of the examination is to determine whether or not a medical emergency exists...The MSE will be performed by a physician or an approved midlevel provider... The August 2022 ED Unattached Surgery Call Schedule was reviewed. The On-Call schedule revealed a surgeon (Capability) was on-call 8/4/22 from 5 PM to 7 AM 8/5/22, when PI # 1 presented to the emergency department. 1. Review of the Marshall Medical Centers North (Hospital A) ED MR revealed PI # 1 presented to the facility ED via private vehicle, accompanied by family, on 8/5/22 at 12:31 AM with a chief complaint of a broken and leaking central (venous) line. PI # 1 received Triage Assessment by Employee Identifier (EI) # 3, Registered Nurse (RN) at 12:53 AM. Review of EI # 2's (ED RN) Physical Assessment and Nursing Progress Notes dated 8/5/22 1:00 AM revealed, "After consult with EI # 4 (Hospital A ED physician), it was relayed to pt (patient) mother that the services required for repair/replacement of indwelling central line is not available at this facility at this time." " EI # 4 recommends following up with (surgeon who placed the current central line) immediately in AM." Review of the MR Disposition/Discharge dated 8/5/22 1:33 AM revealed EI # 2 documented, "The patient left the ED without being seen by a physician."..."He/she notified staff prior to leaving the department and stated is leaving (services unavailable)." "Notified the ED physician and charge nurse of patient departure." EI # 2 also documented the patient left ambulatory, via private vehicle, and signed a LWBS form prior to leaving. Review of the signed facility form, "LWBS Or Against Medical Advice" revealed LWBS was circled, and signed by PI # 1's family member on 8/5/22 at 1:13 AM. The documented patient stated reason for leaving was, "Services Unavailable." In an interview conducted with EI # 1, Chief Nursing Officer, on 9/29/22 at 3:23 PM, EI # 1 confirmed PI # 1 did not receive a MSE. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that on 8/5/22 PI # 1 received an appropriate medical screening examination to determine if an emergency medical condition existed. The patient's identified emergency medical condition was the patient's broken and leaking central line. The facility had the capability (surgeon on call) to replace the broken and leaking central line.