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)

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.