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As a result of the investigation Southern Regional Medical Center was not in compliance with 42 CFR Parts 489.20 and 489.24, Responsibilities of Medicare Participating Hospital in Emergency Cases, the following deficiencies were cited:

Cross refer to A-2406 as it relates to failure to provide an appropriate Medical Screening Examination (MSE).

Cross refer to A-2407 as it relates to failure to provide an appropriate stabilizing treatment.

Cross refer to A-2409 as it relates to failure to provide an appropriate transfer.

Based on review(s) of the facility's policy and procedure, and " Patient Complaint/Grievance", Central Log, and Witness/Interview Statement, and interview the facility failed to ensure that a medical record was created for one (1) of twenty- one (#21) sampled patients who presented to the Emergency Department (ED).
Findings include:
Review of a "Witness Interview/Statement" dated October 7, 2013, with the police officer revealed that the patient arrived to the emergency department ramp, with patient #21, in the police car on October 1, 2013. The officer stated that as entering the hospitals parking area, he was notified that the facility was on diversion from staff in the emergency room via radio. The officer, entering the registration area of the emergency room, and ask if a nurse could come to the police car. He said he ask the first staff member who came out if they would accept the patient. The officer stated that the staff said, we are on diversion and can't take the patient, that we do not have enough nurses trained to handle these patients and told the officer to take the patient to another facility. The officer stated that Southern Regional Medical Center Emergency Room refused to triage the patient.

Review of the facility's policy titled "Examination Treatment and Transfer of Patients Presenting with Emergency Medical Condition", effective May 5, 2012, revealed, patient records will be maintained for at least six (6) years form the date of transfer. and reflect findings of the medical screening examination (MSE) including results of any tests performed and analysis including the determination that a medical emergency does not exist."
A review of the Central Log was conducted on 10/15/2013 at 11:30 a.m., with the Director of Risk Management who acknowledged the patient was not entered into the computer and that a medical record or any other information was found for patient #21. Interview on October 15, 2013 at 1:30 p.m., the Director of Risk Management acknowledged that there was no medical record for patient #21 on 10/1/2013.

Review the "Patient Compliant/Grievance, " dated April 3, 2013 through October 3, 2013, revealed that on October 1, 2013, a fifteen (15) year old patient was brought to the ED via police escort. The officer was informed after entering the facility property that the facility was on diversion status. The officer entered the registration area of the ED and requested treatment for patient #21, which was denied and was instructed to take the patient to another facility. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to maintain a medical record for patient #21 on October 1, 2013, when he/she presented for medical care.

Based on review of policies and procedures, facility's Central Log, and interview, the facility failed to ensure that the central log was maintained for one (1) patient twenty-one (#21) of the sampled twenty-one patients who presented to the Emergency Department (ED) seeking medical assistance.

Findings include:

Review of facility policy entitled, "EMTALA - Central Log", revealed that the hospital will maintain a Central Log containing information on each individual who comes to the hospital emergency department.

During a review of the facility's Central Log on 10/15/2013 at 11:30 a.m., with the Director of Risk Management, the director acknowledged the patient (#21) was not entered into the computer. Interview on October 15, 2013 at 1:30 p.m., the Director of Risk Management acknowledged no evidence that patient #21 was not entered into the ED central log. The facility failed to ensure that patient #21 was entered into the ED Central Log on October 1, 2013, when he/she presented to the ED seeking medical assistance.

Based on review of medical records, facility's policies and procedures, Patient Compliant/Grievance, Central Log, and witness interview/statements from facility staff, the facility failed to ensure that one (1) of twenty- one (#21) sampled patients who presented to the Emergency Department (ED) received a medical screening examination that was within the capability of the emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed.

Findings include:
Review of the ED record from the facility the officer took patient #21 on 10/1/2013, revealed, that patient #21 ( a 15 year old) arrived at the facility on October 1, 2013 at 10:36 a.m. via police escort. Review of the Emergency Department Nurse ' s revealed that patient #21 acuity level was triaged as "Emergent." Further review revealed in part, " Care prior to arrival: None. Transition of care: patient was not received from another setting of care. The patient has not recently seen a physician .... Continued review of the ED record revealed patient #21, to be depressed, sad and hopeless, guarding and poor visual contact. The patient remained on every fifteen (15) minute observational checks while in the ED. The physician assessment included that the patient was depressed, and had been depressed since the death of the patient's father on the last year. A mental health practitioner evaluated the patient and recommended an involuntary commitment (1013), and an accepting mental health facility was notified and the patient was transferred via ambulance at 3:52 p.m. The final diagnosis was, Major Depression with Suicidal Ideation, Adjustment Disorder with Mixed Anxiety.


Review of facility policy titled, "Examination, Treatment and Transfer of Patients Presenting with Emergency Medical Conditions", effective May 3, 2012 revealed, if an individual presents to the dedicated ED and a request is made for examination or treatment of a medical condition, then an appropriate medical screening must be provided to that individual.

Review of the facility policy titled, "Diversion Patient Flow", revised August 29, 2012, revealed, " 8. patients presenting to the Emergency Department of the hospital during a general and/or specific diversion status shall receive an appropriate initial medical screening examination."

Review of "Witness/Interview/statement Form" by the officer who brought patient #21 to the ED on October 1, 2013 revealed, the facility was on diversion status. The officer revealed that patient #21, was a minor and the officer felt the patient was a risk because the patient had threatened self-harm, and acting weird, screaming at his family one minute, the becoming really quiet, avoiding eye contact and not responding verbally, the patient was painted in black. The officer stated, arriving at the ED, entering the registration area and asking for treatment for the patient. The officer revealed that the halls of the ED were clear and the lights were off at the end of the hall. The officer stated, that staff instructed him to take patient #21, to another facility. The facility failed to ensure that their policy and procedure as evidenced by failing to ensure that an appropriate medical screening examination was provided to determine whether or an an emergency medical condition existed, when the request for an examination of a medical/psychiatric condition was made by the police officer for patient #21 on October 1, 2013.

Review of "Witness/Interview/statement Form", by Registered Nurse (RN) #1, revealed that patient #21, presented to the facility ED by a police car at 9:25 a.m. October 01, 2013. The patient was in the police car escorted by an officer who requested the patient to be seen. The RN stated, explaining to the officer the facility was on diversion and directed the officer to triage to start the process. The officer asked of any other facilities the patient could go to and the nurse identified other hospitals. The RN discussed the room availability and the officer's request for a 1013 (involuntary commitment- the purpose of involuntary commitment is to get proper medical assistance for a person who has become a danger to himself or others due to mental illness). The officer explained the need for safety of the minor patient and being placed in a secure room The RN indicated no room was available and the patient would need to go through the triage process to be seen and eventually placed in a padded secure room. The RN stated after speaking with officer, the officer was referred to the charge nurse on duty for that day for any additional information. The RN indicated assisting the officer to the area where the charge nurse was working. Additionally, the facility failed to ensure that their Diversion Flow policy was followed by failing to provide an initial medical screening examination for patient #21 on 10/1/2013,when he/she presented to the ED even though the facility was on diversion.

Review of "Witness/Interview/statement Form", by RN #2, revealed the RN advised the dispatch the facility was on diversion and they needed to call and alert the unit that was reroute to take the patient to another facility. The RN stated, the officer came to the facility anyway. The RN met with the officer at the back door area and explained to the officer the facility was on diversion status. The nurse reported the patient was a 16 year old with complaint of depression, and discussed with the officer an appropriate facility with the capacity to care for the patient.

Review of the "Patient Compliant/Grievance," dated April 3, 2013 through October 3, 2013, 4/3/13, revealed on October 1, 2013 a fifteen (15) year old patient was brought to the ED via police escort. The officer inquired about diversion status and local hospitals accepting patients after learning that ED was on total diversion. RN #2, explained the patient needed to be routed through the ED triage, the officer decided to take the patient to another facility.

During a review of the facility's Central log was conducted on 10/15/2013 at 11:30 a.m., with the Director of Risk Management, the director acknowledged that the patient was not entered into the computer and neither a medical screening evaluation was performed on the patient was found. Interview on October 15, 2013 at 1:30 p.m., the Director of Risk Management acknowledged that patient #21 did not receive a Medical Screening Examination (MSE) on 10/1/2013.

Based on review of the facility's policies and procedures, Patient Complaint Grievance, and witness interview/statements from facility staff, and interview, the facility failed to ensure that one (1) of twenty- one (#21) sampled patients who presented to the Emergency Department (ED) was provided stabilizing treatment that was within the capability of the hospital's emergency department as required to stabilize the medical condition.

Findings include:
Review of facility policy titled, "Examination, Treatment and Transfer of Patients Presenting with Emergency Medical Conditions", effective May 3, 2012 revealed, if an individual presents to the dedicated ED and a request is made for examination or treatment of a medical condition. then an appropriate medical screening must be provided to that individual. Review of the facility policy titled, "Diversion Patient Flow", revised August 29, 2012, revealed, " 8. patients presenting to the Emergency Department of the hospital during a general and/or specific diversion status shall receive . . . necessary stabilization. "

Review of "Witness/Interview/statement Form" by the officer who brought patient #21 to the ED on October 1, 2013 revealed, the facility was on diversion status. The officer revealed that patient #21, was a minor and the officer felt the patient was a risk because the patient had threatened self-harm, and acting weird, screaming at his family one minute, the becoming really quiet, avoiding eye contact and not responding verbally, the patient was painted in black. The officer stated, arriving at the ED, entering the registration area and asking for treatment for the patient. The officer stated, that staff instructed him to take patient #21, to another facility.

Review of "Witness/Interview/statement Form", by Registered Nurse (RN) #1, revealed that patient #21, presented to the facility ED by a police car at 9:25 a.m. October 01, 2013. The patient was in the police car escorted by an officer who requested the patient to be seen. The RN stated, explaining to the officer the facility was on diversion and indicated no room was available and the patient would need to go through the triage process to be seen and eventually placed in a padded secure room.

Review of "Witness/Interview/statement Form", by RN #2, revealed the RN met with the officer at the back door area and explained to the officer the facility was on diversion status. The nurse reported the patient was a sixteen (16) year old with complaint of depression, and discussed with the officer an appropriate facility with the capacity to care for the patient.

Review of the "Patient Compliant/Grievance," dated April 3, 2013 through October 3, 2013, revealed on October 1, 2013 a fifteen (15) year old patient was brought to the ED via police escort. The officer inquired about diversion status and local hospitals accepting patients after learning that ED was on total diversion. RN #2, explained the patient needed to be routed through the ED triage, the officer decided to take the patient to another facility.

Interview on October 15, 2013 at 1:30 p.m., the Director of Risk Management
acknowledged that patient #21 did not receive stabilizing treatment. The facility failed to ensure that stabilizing treatment was provided as required for patient #21 on 10/1/2013 as stated in their policies and procedures.

Based on review of policy and procedure , and witness interview/statements from facility staff, and interview the failed to ensure that an appropriate transfer was provided to another facility by failing to provide medical treatment within its capacity to minimize the risks of the individual health for one (1) of twenty- one (#1) sampled patients who presented to the Emergency Department (ED).

Findings include:
Review of facility policy titled, " Examination, Treatment and Transfer of Patients Presenting with Emergency Medical Conditions", effective May 3, 2012 revealed, if an individual presents to the dedicated ED, and a Medical Emergency Condition is determined that the facility cannot provide care for, and appropriate facility would be located and transfer would occur. ... "3. No transfer, although certified by the physician, shall be made unless all of the following occurs: a. a. Medical Treatment is provided by the hospital, within its capacity, to minimize the risk to the health of the patient; ...b. receiving facility has available space and qualified personnel to treat the condition; c. The receiving facility and a member of its medical staff have agreed to accept the transfer and provide appropriate treatment; d. Hospital forwards to the receiving all medical records related to emergency condition, including observations, tests results, treatment provided, and forwards the physician's certification."

Review of "Witness/Interview/statement Form" by the officer who brought patient #21 to the ED on October 1, 2013 revealed, the facility was on diversion status. The officer revealed that patient #21, was a minor and the officer felt the patient was a risk because the patient had threatened self-harm, and acting weird, screaming at his family one minute, the becoming really quiet, avoiding eye contact and not responding verbally, the patient was painted in black. The officer stated, arriving at the ED, entering the registration area and asking for treatment for the patient. The officer stated, that staff instructed him to take patient #21, to another facility.


Interview on October 15, 2013 at 1:30 p.m., the Director of Risk Management acknowledged that the facility failed to arrange for an appropriate transfer to a receiving facility. The facility failed to ensure that their policy and procedure regarding an appropriate transfer was followed for patient #21 on 10/1/2013, as evidenced by; failing to provide medical treatment with the capacity of the ED; failed to notify a receiving facility to determine if they have available space and qualified personnel the individual ; and failing to obtain acceptance of the transfer of the individual to the receiving hospital in order to provide appropriate treatment .