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)

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 medical record (MR) review, hospital policy and procedure, Court Order directive, Hospital B, Receiving Hospital MR, and interviews with staff, it was determined the hospital failed to ensure an appropriate transfer was arranged and completed for a patient who presented to the Emergency Department (ED) for a court ordered psychiatric evaluation and treatment. This deficient practice did affect one of one patient reviewed via video footage, including Patient Identifier (PI) # 1, who presented to the hospital ED for emergency care on 2/3/26, and had the potential to affect all patients presenting to this ED. Findings include: Hospital Policy: Transfer from Emergency Department Policy Number: Not Listed Revised: 5/21/25 Purpose: To ensure safe, timely, and appropriate transfer of (ED) patients to another facility when services required exceed the hospital's capabilities. ...Procedure: ...3. Need for Transfer If the patient requires services not available at Mizell Memorial Hospital or at the request of the patient/legal representative: The ED provider documents the medical necessity for transfer. Patient or legal representative must be informed of the benefits and risks of the transfer. 4. Acceptance by Receiving Facility The receiving facility must have the capability and capacity to treat the patient. The receiving facility and a physician at that facility must accept the patient before the transfer... 5. Consent for Transfer Obtain written consent from the patient or legal representative... Responsibilities ED Physician/Provider: Assess, stabilize, determine need for transfer, contact receiving provider, and complete documentation... 1. 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 Court Order attached to the medical record revealed PI # 1 was to be "...detained and confined on an emergency basis at Mizell Memorial Hospital..." Review of EI # 9, ED Physician, documentation revealed "... I was informed that the location of the order was to be amended and the patient was being taken to (Hospital B)." Review of Hospital B, receiving hospital, which is located approximately 17 miles away, ED physician documentation, revealed PI # 1 was brought to the ED by police under a court order and was assessed at 4:55 PM for complaints of altered mental status. There was no documentation of Mizell Memorial Hospital sending Hospital B medical records or copies therefore related to the identified EMC for PI # 1 on 2/3/26. An interview was conducted on 2/12/26 at 11:16 AM with EI # 3 who confirmed there was no documentation an appropriate transfer was completed. There was no documentation an appropriate transfer was completed including informing the patient or the person acting on behalf of the patient of the risks and benefits of transfer, the receiving facility and physician acceptance of the patient, patient consent for transfer, physician certification of the risks and benefits of the transfer, or transfer by qualified personnel for PI # 1 on 2/3/26.