Statement of Deficiencies

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)

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 Emergency Department (ED) video footage, medical record (MR) review, Hospital Medical Staff Rules and Regulations, hospital policy and procedures, Diversion Log, Emergency Department (ED) Logs, Court Order directive, Hospital B Receiving Hospital, MR, Alabama Uniform Incident/Offense Report, and interviews with staff, it was determined the hospital failed to ensure an appropriate Medical Screening Examination (MSE) was provided within the capability of the hospital's ED to determine whether or not an emergency medical condition existed for all patients who presented to the hospital ED. This deficient practice did affect one of one patient reviewed via video footage, including Patient Identifier (PI) # 1, who presented to the hospital ED on 2/3/26 and had the potential to affect all patients presenting to this ED. Findings include: Mizell Memorial Hospital Medical Staff Rules & Regulations Revised: 1/4/24 ...36. All patients presenting to the Emergency Department shall have an appropriate ... MSE by a physician, according to EMTALA (Emergency Medical Treatment and Labor Act) guidelines. No exceptions apply to this rule. 37. The MSE should include the utilization of all medically necessary ancillary services available to the Emergency Department, including on-call physicians, to determine if an emergency medical condition (EMC) exists... Hospital Policy: EMTALA-Emergency Medical Screening, Treatment and Patient Transfer Policy Number: 2001 Reviewed/Revised: 10/9/17 Policy: It is the policy of Mizell Memorial Hospital to provide an appropriate (MSE to any individual who presents to the dedicated emergency department... Procedure: Medical Screening Examination ...When an individual comes to the Emergency Department of Mizell Memorial Hospital ... and a request is made on the individual's behalf for a medical examination or treatment of a medical condition an appropriate medical screening examination, within the capabilities of the Emergency Department (including ancillary services routinely available to the emergency department) shall be provided to determine whether an emergency medical condition exists... Hospital Policy: Emergency Department Diversion Policy Number: Not Listed Effective: 2/14/25 Policy: The purpose of this policy is to establish a standardized approach for emergency room (ER) diversion when capacity is exceeded, or patient safety is at risk... Procedure: 1. Criteria for ER Diversion: ...Infrastructure Failure: Loss of critical utilities, such as power or water, that impact patient care... The ER must continue to provide (MSE) and stabilizing treatment as required by EMTALA, even during diversion. 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's car exited the ED parking lot. No other video recordings were available for review. Review of the ED Log revealed at 3:47 PM the ED had one of seven ED beds available for patient use. No patients had registered and awaited an ED bed. The hospital's ED had the capacity to provide an appropriate MSE to PI # 1 on 2/3/26. 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. Review of PI # 1's handwritten MR revealed the patient presented to the ED seeking psychiatric assistance on 2/3/26 at 3:50 PM. Review of the Diversion Log revealed Mizell Memorial Hospital was on diversion on 2/3/26 from 3:59 PM until 5:55 PM, one hour and 56 minutes. The hospital was not on diversion at 3:50 PM when PI # 1 arrived at the ED seeking psychiatric assistance. Review of the Court Order, dated 2/3/26, attached to the medical record revealed PI # 1 "...is suffering from acute symptoms of a mental disorder and is an immediate danger to herself and others... be detained and confined on an emergency basis at Mizell Memorial Hospital..." Review of the nursing documentation revealed the nurse documented PI # 1 "...appears disheveled, is yelling out, bruising noted to right under eye area. Swelling noted to face and nose with bruising and abrasions..." Review of EI # 9, ED Physician, documentation dated 2/3/26 at 4:00 PM revealed "...The entire Mizell Hospital had been placed on diversion secondary to a complete computer and phone malfunction. As this patient would require medications, labs, and transfer of this data to another hospital that provides psychiatric care, it was realized a long and unacceptable delay would be encountered in trying to treat this patient... I was informed that the location of the order was to be amended and the patient was being taken to (Hospital B)." There was no documentation an appropriate MSE, including an ED Provider examination, laboratory testing, and/or diagnostic testing was performed, within the capability of the hospital's ED. Review of the Alabama Uniform Incident/Offense Report dated 2/3/26 revealed the Deputy Sheriff documented the ED Physician stated the ER (Emergency Room) "was on lockdown, I am unable to send reports, I am unable to access the system, I am unable to get (PI # 1) a sedative to calm (him/her) down. Can you take (him/her) somewhere else?" An interview was conducted on 2/10/26 at 3:58 PM with EI # 11, Covington County Deputy, who stated (he/she) called the Judge and got the court order changed to take the patient to (Hospital B). EI # 11 also verbalized the ED physician and nurse were aware the patient was leaving the ED. An interview was conducted on 2/11/26 at 1:30 PM with EI # 13, Director of Radiology, who stated the radiology department performed five to six outpatient procedures including one Computed Tomography (CT) scan during the time of the downtime. EI # 13 further stated the x-rays were sent to be read by the radiologist after the internet came back up. An interview was conducted on 2/12/26 at 12:07 PM with EI # 9, ED Physician, who stated "...I noticed a lot of swelling under each eye and (PI # 1's) nose looked broken, I was thinking of possible head injury or a bleed...I'm thinking I'm going to have to transfer (PI # 1) because it is a huge mistake to keep (him/her) with a possible head injury...I have an order from the Judge saying (he/she) has to be treated here. I can't handle this patient...I asked the officer if the Judge could change the order...When I come back, I find they are leaving..." EI # 9 was asked if an MSE was completed, EI # 9 responded "(He/She) would not let us near (him/her) to do vital signs or anything else...I felt the best option for (him/her) was to get (him/her) out of here. It would have been a delay to get the ambulance..." The medical record from Hospital B was reviewed. The section of the MR titled ED- Physician Note dated 2/3/26 20:36 (8:36 PM) the ED physician documented in part, "37 yrs (years) old ...presents to the ED ...with complaints of Psych (psychiatric) Problem ...The patient presents to the emergency department with Apparent altered mental status ...brought in by police ... under a court order ... due to some usual behavior ...this started a couple hours prior to arrival ... difficult to arouse but arousable ... unable to give a story to tell us whether ...consumed any usual substances medications ...street drugs ...unable to tell us ...suicidal homicidal depressed ...psych history is unknown ...02/04 15:55 (3:55 PM) ED Course: CASE DISCUSSED WITH PSYCHIATRIST. PATIENT HAS BEEN MEDICALLY CLEARED. AWAITING PSYCHIATRIC PLACEMENT. SHE/HE IS HEMODYNAMICALLY STABLE ...This is a Certified Medical Emergency: yes ...02/05 07:48 (7:48 AM) ED course: ... Patient's UDS (Urine drug screen) does have evidence of substances on board and phentermine (medication used temporary aid for weight loss), methamphetamines (a synthetic drug that increases alertness, energy, and concentration) and benzodiazepines (medication used for anxiety and panic disorders) and marijuana (mind altering drug) ...have reviewed ...labs and medical record and ...is medically cleared to a psych facility. Patient did have evidence of urinary tract infection ...currently going to get a dose of Bactrim (medication used most commonly to treat urinary tract infection) ...09:14 (9:14 AM) ED Course: have discussed the case with tele psych physician and after his evaluation he does not see any signs of suicidal or homicidal ideation therefore patient can be discharged for follow up on an outpatient basis. Laboratory testing, a portable chest x-ray, and a Psychiatric consult were obtained. The patient was discharged home on 2/5/26. An interview was conducted on 2/12/26 at 11:16 AM with EI # 3 who confirmed there was no documentation an appropriate MSE was completed. The facility failed to ensure the hospital policy and procedure was followed as evidenced by failing to ensure on 2/3/2026 PI # 1, who was court ordered to be evaluated at Mizell Memorial Hospital, receive an appropriate medical screening examination to include utilization of all medically necessary ancillary services available to the ED to determine if an EMC existed as stated in the policy.