Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 010001	(X3) Date Survey Completed 08/02/2021
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)

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 the facility policies and procedures, Medical Staff Bylaws and Rules and Regulations, Medical Record (MR) review 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 Emergency Department (ED) prior to the completion of the MSE, including PI # 15 and PI # 11. This deficient practice affected 8 of 23 MR's reviewed and had the potential to affect all patients treated at this facility. Findings include: Facility Policy: Emergency Medical Treatment and 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 ED to provide an appropriate MSE to determine the presence of an Emergency Medical Condition (EMC). Policy Statement: It is the policy of Southeast Health that individuals coming to the ED and who require Emergency Medical Services (EMS) receive an appropriate MSE...as required by the EMTALA law. Scope: EMTALA applies to any individual who presents at a hospital's dedicated ED requesting examination or treatment for a medical condition... Procedure: Patient coming to the ED: 1. Provide an appropriate MSE to any individual who comes to the ED.... ...Procedures by Department:... 2. ED...Patients presenting to the ED seeking acute medical care...given an appropriate MSE by an ED Physician or APP (Advanced Practice Provider) to determine whether the patient has an EMC... Facility Policy: Suicide Precaution Policy Number: None Department: Patient Care Services Effective Date: 10/1/96 Purpose: To provide a safe environment for patients who are a potential for suicide or have a past history of attempted suicide and re-present with Suicidal Ideations (SI) or who have expressed SI. Policy Statement: To provide a safe, secure and structured environment for psychiatric patients who demonstrate suicidal intent, either verbal or non-verbal. These patients will be placed on suicidal precautions. Procedures: Emergency Department: Initiate suicide precautions if the patient has suicidal thoughts. Nursing may initiate 1:1 observation on an emergent basis, but must follow-up with the attending physician, or their delegate, for a physician's order. Never leave the patient alone. 1) Patient will be on constant observation. ...c) If the patient leaves the room, a staff member must accompany him or her, including observation when toileting. 2) A qualified staff member will document the 15 min (minute) observation checks noting patients' behavior.... 1. The facility Medical Staff Bylaws and Rules and Regulations were received from Employee Identifier (EI) # 2, Director of Quality and Regulatory Programs, on 7/27/21. Review of the facility bylaws and rules and regulations on 7/28/21 revealed documentation of "...Assessment and Stabilization (Medical Screening):...For patients who present to the ED proper, by an ED provider..." There was no documentation of who the facility designates as ED providers, a Physician Assistant (PA) and/or a Certified Registered Nurse Practitioner (CRNP) was qualified in the facility bylaws or rules and regulations as qualified to perform the MSE. PI # 23 presented to the facility ED on 1/28/21 at 6:41 AM with a chief complaint of MVC (Motor Vehicle Collision). Review of the MR documentation revealed the MSE was conducted on 1/28/21 at 7:28 AM by a CRNP and not an ED physician. PI # 3 presented to the facility ED on 2/6/21 at 8:09 AM with a chief complaint of Headache and Request for Recheck of Blood Pressure. Review of the MR documentation revealed the MSE was conducted on 2/6/21 at 9:28 AM by a PA and not an ED physician. PI # 4 presented to the facility ED on 2/12/21 with a chief complaint of Dog Bite. Review of the MR documentation revealed the MSE was conducted on 2/12/21 at 10:06 AM by a PA and not an ED physician. PI # 6 presented to the facility ED on 3/20/21 at 12:37 AM with a chief complaint of a 5 day manic episode, which medications were not helping. Review of the MR documentation revealed the MSE was conducted on 3/20/21 at 3:17 AM by a CRNP and not an ED physician. PI # 11 presented to the facility ED on 5/18/21 at 3:36 PM with a chief complaint of being suicidal and also having right foot pain, on 5/18/21 at 5:47 PM with a chief complaint of not being able to stop singing and suicidal, and on 5/19/21 at 11:29 AM with a chief complaint of being Suicidal and Right Foot Pain. Review of the MR documentation revealed the MSE was conducted all 3 visits by a PA and not an ED physician. PI # 14 presented to the facility ED on 6/4/21 at 8:30 PM with a chief complaint of Anxiety and Depression. Review of the MR documentation revealed the MSE was conducted on 6/4/21 at 8:35 PM by a PA and not an ED physician. PI # 18 presented to the facility ED on 7/8/21 at 9:07 PM with a chief complaint of Psychiatric Evaluation due to auditory and visual hallucinations. Review of the MR documentation revealed the MSE was conducted on 7/9/21 at 12:11 AM by a PA and not an ED physician. An interview was conducted with EI # 2, on 7/30/21 at 8:18 AM who confirmed PA's and CRNP's do conduct the MSE in the facility ED. EI # 2 was asked if the facility identified a PA and/or CRNP in the Medical Staff Bylaws or Rules and Regulation as being qualified to perform the MSE. EI # 2 stated, "It says ED provider, so that would include them." 2. PI # 15 presented to the facility ED on 5/13/21 at 8:38 PM with an arrival complaint of SI and attempt. Review of the MR revealed documentation the patient was called for triage at 8:48 PM and again at 8:57 PM. The patient did not respond to either call and was documented as LWBS (Left without being seen) at 8:57 PM. There was no documentation the patient was placed under observation upon arrival to the ED with a complaint of SI and attempt and was allowed to elope from the ED prior to the completion of the MSE. An interview was conducted on 8/2/21 at 8:32 AM with EI # 5, Performance Improvement Coordinator, Emergency Department, who verbalized the facility staff member who took the arrival complaint was a registration clerk and the patient eloped prior to being seen by a clinical person. EI # 5 also verbalized the facility protocol for a patient presenting with a SI and attempt complaint would have been for the registration clerk to place the patient information in the system and notify a nurse. EI # 5 confirmed there was no documentation a nurse was notified of the patient's arrival and complaint. 41624 3. PI # 11 presented to the ED 4 times within a 24 hours timeframe. PI # 11 first presented to the ED on 5/18/21 at 3:36 PM with a chief complaint of, "I am suicidal, I want to jump off a bridge. I'm also having right foot pain." Review of the triage assessment dated 5/18/21 at 3:37 PM revealed documentation of "Neurological ...Within Defined Limits...Psychiatric evaluation...I am suicidal, I want to jump off a bridge. I'm also having right foot pain." Review of the Physician Assistant (PA) assessment dated 5/18/21 at 3:43 PM revealed documentation, " ...Psychiatric/Behavioral...positive for dysphoric mood, hallucinations and suicidal ideas, negative for confusion...Neurological...Mental Status...alert and oriented to person, place and time...Psychiatric...Attention normal...Does not perceive auditory or visual hallucinations...Mood and Affect... normal,...Speech...normal, Behavior...cooperative,...Thought Content...Is not paranoid. Does not include homicidal or suicidal ideation." Review of the Q (every) 15 (minute) Safety Precautions Form revealed the following documentation: At 3:45 PM, PI # 11's behavior was calm At 4:00 PM, PI # 11's behavior was calm At 4:15 PM, PI #11's behavior was bizarre. At 4:30 PM, PI # 11's behavior was bizarre and demanding. At 4:34 PM. documentation revealed "patient walked out." There was no documentation of the type of bizarre behavior PI # 11 displayed and the ED provider was notified of PI # 11's bizarre and demanding behavior. Review of the Columbia Suicide Severity Risk Assessment dated 5/18/21 at 4:19 PM revealed documentation of a risk score of .... low risk. Review of the PA documentation dated 5/18/21 at 5:25 PM revealed, "Patient left the ED without completing the entire evaluation." There was no documentation of a Psychiatric Consult. PI # 11 was allowed to leave from the ED prior to the completion of the MSE. PI # 11 presented a second time to the ED on 5/18/21 at 5:47 PM, with a chief complaint of, "I can't stop singing and I am suicidal." Review of the triage assessment dated 5/18/21 at 5:58 PM revealed documentation of " Neurological ..."Within Defined Limits"... Psychiatric evaluation..."I can't stop singing and I am suicidal." Review of the PA assessment on 5/18/21 at 5:59 PM documented, "States (he/she) took some ecstasy today...Review of Systems... Psychiatric/Behavioral...Positive for confusion, the patient is nervous/anxious...Neurological...Mental status alert...Psychiatric...Mood and Affect..."Mood is elated, Affect is inappropriate...Thought Content...Delusional...Cognition and Memory...Cognition is impaired." Review of the nursing notes dated 5/18/21 at 7:42 PM revealed documentation of "Called Pt (Patient) and received no answer." The documented disposition was AMA (against medical advice) at 8:02 PM. There was no documentation of a Psychiatric Consult, or that the patient was placed under observation upon arrival to the ED with a complaint of SI, and PI # 11 was allowed to leave from the ED prior to the completion of the MSE. PI # 11 presented a third time to the ED on 5/19/21 at 3:13 AM with a chief complaint of suicide attempt. The triage assessment on 5/19/21 at 3:17 AM documented the patient stated, "I caught my boyfriend having f***** my mom. I'm suicidal and want to kill myself. I walked out in front of a car about 20 minutes ago." Review of the nursing notes dated 5/19/21 at 3:52 AM revealed documentation of..."Pt has left ER (emergency room) 3 times now. (He/She) states, "Nevermind I'm fine. I don't want to be seen." Review of the nursing notes dated 5/19/21 at 5:32 AM revealed documentation of ..."Disposition was set to LWBS (left without being seen) after triage. There was no documentation of a Psychiatric Consult, the patient was placed under observation upon arrival to the ED with a complaint of SI and was allowed to leave from the ED prior to the completion of the MSE. PI # 11 presented to the ED a fourth time on 5/19/21 at 11:29 AM with a chief complaint of Suicidal and Foot Pain. Suicide safety measures were implemented, a psychiatric hold was initiated, and the patient was admitted to the inpatient psychiatric unit under the care of a psychiatrist with diagnosis Psychotic Disorder, R/O (rule out) Schizophrenia, Cannabis Use Disorder. An interview was conducted on 7/30/21 at 1:07 PM with EI # 4, Director of Emergency Services, regarding PI # 11's third ED visit on 5/19/21 at 3:13 AM. EI # 4 was asked if the physician, PA, or the CRNP on duty was notified of the patient's three attempts to leave as documented by the nurse at 3:52 AM after voicing SI/attempted suicide? EI # 4 answered there was nothing documented the nurse got the physician or midlevel to do the MSE. EI # 4 was also asked if the patient was placed on 1:1 observation and a suicide risk assessment performed? EI # 4 stated, "Not on this visit. On suicide attempts we try to get them in a room as soon as possible, then 1:1 is put into place. We do have a policy for 1:1 observation once placed in a room." EI # 4 was asked if any ED staff witnessed the patient leaving? EI # 4 stated, "It's not clear based on charting. Don't know if witnessed or not. We had the AMA form ready to sign." In a second email interview conducted 8/6/21 at 1:07 PM for the patient visits on 5/18/21, EI # 5 was asked if the attending ED provider was notified that the patient's behavior had changed from calm, to bizarre and demanding by ED staff on visit 5/18/21 at 3:36 PM? EI # 5 answered no. EI # 5 also confirmed there was a Psychiatrist on call 5/18/21, but the patient left before completing treatment on both visits to determine if one needed to be consulted. EI # 5 was also asked if the patient was placed in a safe environment on visit 5/18/21? EI # 5 stated the patient was never placed in a room.