| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 010007 | (X3) Date Survey Completed 02/12/2026 |
| Name of Provider or Supplier Mizell Memorial Hospital | Street Address, City, State 702 N Main St, Opp, 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) |
| A2405 | EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This STANDARD is not met as evidenced by: Based hospital Emergency Department (ED) video footage, medical record (MR) review, hospital policy and procedure, Diversion Log, ED Logs, and interviews with staff, it was determined the hospital failed to ensure a central log was maintained for each individual who presented to the ED for emergent care whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This deficient practice did affect one of one patient reviewed via video footage, including Patient Identifier (PI) # 1, who presented to the hospital ED seeking assistance on 2/3/26, and had the potential to affect all patients presenting to this ED. Findings include: Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act)-Emergency Medical Screening, Treatment and Patient Transfer Policy Number: 2001 Revised/Reviewed: 10/9/17 ...Procedure: ...Emergency Room Log. Mizell Memorial Hospital maintains a central log on each individual who comes to the ED seeking assistance and whether the individual refused treatment, was refused treatment, or was transferred, admitted and treated, stabilized and transferred, or discharged... 1. A review of the video recordings from the camera at the ED ambulance entrance was conducted on 2/10/26 at 2:08 PM with Employee Identifier (EI) # 4, Information Technology Director, and EI # 2, Chief Operating Officer. The following is a summary of the video review: On 2/3/26 at 3:45 PM a Sheriff Deputy car stopped under ambulance entrance awning. At 3:47 PM the officer escorted a Caucasian female into the ED entrance. At 4:10 PM the officer and the Caucasian female exited the ED and the female was placed into the Sheriff Deputy's car. At 4:16 PM the Sheriff Deputy car exited the ED parking lot. No other video recordings were available for review. Review of handwritten MR revealed PI # 1 arrived at the ED seeking psychiatric treatment on 2/3/26 at 3:50 PM. Review of the ED Log dated 2/3/26 from 3:28 PM to 4:54 PM revealed no documentation PI # 1 presented to the ED seeking assistance and whether PI # 1 was refused treatment, refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. An interview was conducted on 2/10/26 at 4:30 PM with EI # 3, ED Manager, who stated the hospital had gone on diversion due to a loss of internet and phones. EI # 3 stated the staff were using paper charting during the downtime. An interview was conducted on 2/12/26 at 11:16 AM with EI # 3 who confirmed the hospital failed to ensure each patient arriving at the ED seeking assistance was entered into the ED Log. |