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An unannounced federal Emergency Medical Treatment & Labor Act (EMTALA) complaint survey, AL41422 and AL41464, was conducted at Southeast Health Medical Center on August 2, 2021, specifically for the review of EMTALA requirements. The Chief Executive Officer, Chief Medical Officer and Director of Quality and Regulatory Programs were notified on September 13, 2021 at 12:15 pm that Immediate Jeopardy (IJ) existed.
Based on review of the facility policies and procedures, Medical Staff Bylaws and Rules and Regulations, Southeast Health Medical Center (SH, Hospital A) Medical Record (MR) review, transferring hospital (Hospital C and Hospital D) medical record (MR), receiving hospital (Hospital B) MR, ambulance run report(s), facility Physician Link Transfer Line documentation, Physician Link Transfer Line audio files, Southeast Health Diversionary Status Report, SH Unassigned Emergency Room (ER) Call Roster(s), facility Critical Care Unit (CCU), Family Birth Center (FBC) and Neonatal Intensive Care Unit (NICU) bed census documentation, and interviews with staff it was determined the facility failed to: 1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the facility bylaws or rules and regulations, including Patient Identifier (PI) # 23, PI # 3, PI # 4, PI # 6, PI # 11, PI # 14 and PI # 18. (2) Prevent a patient at risk for suicide from leaving the ED prior to the completion of the MSE, including PI # 15 and PI # 11. (3) Ensure the staff implemented steps to prevent a patient(s) with Suicidal Ideation (SI) from leaving prior to receiving stabilizing treatment, including placement of the patient(s) in a safe environment area, initiation of 1:1 observation and/or constant observation, and documenting every 15 minute observations of the patient(s) behavior per the facility policy, including PI # 11 and PI # 15. (4) Ensure a patient having hallucinations was re-evaluated for the dangerousness of the hallucinations and the family was apprised of the risks and benefits of leaving given the patient's hallucinations, including PI # 18. (5) Accept from referring hospitals (Hospital C and Hospital D) an appropriate transfer, of: (A) PI # 2, who was experiencing a possible ST-Segment Elevation Myocardial Infarction (STEMI), and required SH 's specialized capabilities. SH had the capability and capacity to treat PI # 2, when contacted by the transferring hospital (Hospital C) which did not have the capability of treating PI # 2. (B) PI # 22, who was 35 weeks pregnant and in active labor and required SH's specialized capabilities. SH had the capability and capacity to treat PI # 22, when contacted by the transferring hospital (Hospital D) which did not have the capability of treating PI #22.
The hospital's failures to provide stabilizing treatment as required, and accept PI #2 and PI #22 requests for transfer posed an immediate and serious threat to patients health and safety and inappropriately delayed treatment for emergency medical conditions.
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.
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