Adventhealth Orlando

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 13640 Based on interview, hospital policy, and record review, the facility failed to comply with Emergency Medical Treatment and Labor Act (EMTALA) requirements pertaining to appropriate transfers. Findings include: AdventHealth Orlando failed to ensure emergency medical records were sent during transfer of a patient to the receiving facility for one (1) of 20 sampled patients, (Patient #1). Cross Refer to 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: 13640 Based on interview, hospital policy, and record review, the facility failed to ensure emergency medical records were sent during transfer of a patient to the receiving facility for one (1) of 20 sampled patients, (Patient #1). Findings: Review of patient #1’s medical record showed an ED (Emergency Department) Provider note of 2/15/26 at 12:15 AM by MD-1 which read: “26 y.o. (years old) M (male), no past medical history, presents to the ED (Emergency Department) with GSW (Gun Shot Wound) to the right inguinal region and right sided chest just prior to arrival, brought in by family. . . . Differential Diagnosis: Trauma or fall - Pneumothorax / hemothorax, rib fracture, intraabdominal hemorrhage, retroperitoneal hemorrhage, or others. Shared decision making made with patient for final disposition of transfer Osceola regional.” A nurse’s note at 11:31 PM read: Assign nurse ( RN-1).” This nurse had entries in the record which reflected the performance of various patient care tasks, but she did not make any entries regarding plans or implementation of a transfer, which occurred early the next morning. Regarding the transfer, she did not have any entries which mentioned a provision of the patient’s medical record to the transport service staff who had come to the ED to transfer the patient. The document Transfer Intake of 2/14/26 revealed the following: “11:32 PM: Call from (MD-2). (MD-2) approved transfer. . . . Conf (MD-1 / MD-2) - 26 YO male c/o (complaint of) multiple GSW to right inguinal area and right chest. . . . Accepted to HCA Osceola ER. . . . “ During an interview of HUC-1 on 2/24/26 at 3:10 PM, she stated that she did not print out the record to send to HCA Florida Osceola Hospital and she did not have access to printing. She could not confirm whether or not the nurse had printed out the medical record. The patient was discharged at 12:15 AM. Regarding the sending of documentation to HCA Florida Osceola Hospital, there is no evidence in the medical record that this was done. A review of the medical record from HCA Florida Osceola Hospital (transfer destination) did not reveal the provision of medical record documentation from AdventHealth Kissimmee Hospital (sending location) operating under AdventHealth Orlando. A review of facility policy “Transfer to Non-AdventHealth Orlando Medical Facility (effective date 7/31/25) revealed the following pertaining to a transfer of medical record documentation to a receiving hospital: “”Complete Nurse Certification of the EMTALA Transfer Documentation which includes: . . . Copies of medical record sent; . . . “ Also: “For transfers to a non-AdventHealth Orlando Medical facility, a copy of the medical record documents relevant to the patient’s current medical condition shall be provided to the receiving facility. Documents may include: Emergency Department records; History and Physical; Consent forms; Advanced Directives; Legal forms original, i.e.: Baker/Marchman Act; (Yellow) Florida State Do Not Resuscitate Order; Consults; Laboratory reports; Diagnostic Reports (Radiology, EKG, EEG, etc.); Interdisciplinary Progress Notes; Nursing notes as relevant; Surgical and procedural reports and notes; Medication administration records.” There was no evidence that the patient’s medical record had been sent with transport to HCA Florida Osceola Hospital (receiving facility). During an interview of the Risk Manager on 2/24/26 at approximately 5:00 PM, she confirmed the preceding.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 13640 Based on interview, record review and a review a facility documentation, the facility failed to ensure the supervision and evaluation of nursing care for each patient concerning compliance with physician orders for the use of telemetry in one of three sampled patients. (#1) Findings: A review of the medical record of patient #1 was performed. The patient was admitted to the Emergency Department on 9/9/25 at 9:33 AM. A physician note of 9/9/25 at 1:02 PM read: “Patient states that he is feeling more than fine today and does not have any acute concerns. The majority of this history is obtained from the sheriff’s as well as his daughter. . . . At this time she states he is no longer combative but continues eloping. She states he eloped several times a day and she is not strong enough to always bring him back home. . . “ Also: “At this juncture, no interventions / medications are indicated. Findings and disposition communicated with patient, who is agreeable to observation.” Also: “Patient will be admitted for further workup and care. A nurse’s note of 9/9/25 at 3:56 PM read: “Patient transferred: From room E47 to room OTF (off the floor).” A nurse’s note of 9/9/25 at 4:10 PM (just over 10 minutes after the prior nurse indicated a transfer of the patient) read: “Patient arrived on unit AOX1 to self only with no signs of distress. Physician orders of 9/9/25 at 8:35 PM read: “Telemetry Monitoring 24 hours TIA. . . . Frequency: Routine until discontinued 09/09/25 8:35 PM - 24 hours.” Also: Indication for 24 hour hour telemetry: TIA, Can the patient be off telemetry for activities (including therapy, ambulation, off-unit procedures, showers, bathroom)? No.” Also: “Notify provider for change in rhythm.” Regarding the above mentioned telemetry order of 9/9/25 at 8:35 PM , the Central Monitoring Unit Communication and Escalation Log indicated that the patient was placed on telemetry at 9:06 PM on 9/9/25. The Central Monitoring Unit Communication and Escalation Log indicated the following at 4:10 PM on 9/10/25: “Leads off / patient confused.” It indicated under the column RN (Registered Nurse) Notification Name: “(Staff member RN -1).” It was therefore documented that the patient was effectively removing his leads due to a state of confusion. On 9/23/25 at approximately 2:30 PM, she stated that the patient was not put back on the leads after the patient removed them. She stated there was no evidence of the physician having been notified of the discontinuation of telemetry for this patient. She stated that they did uncover telemetry concerns in their investigation, but they did not pertain to physician notification of an inability to maintain telemetry. Thus, there was no evidence of physician notification regarding the inability to maintain leads on the patient as alluded to in policy (for rhythm changes). On 9/23/25 at 12:40 PM, RN-1 (who worked on 9/10/25 from 6:47 AM to 8:27 PM) stated that when she started the shift, the patient’s leads were off (text below reveals they were ordered on 9/9/25). She stated she was told by the night nurse that he was not on telemetry because he was refusing. She said she spoke to the daughter at some point, who said that the patient did not want all the cords. The RN stated that she did not notify the MD regarding this. The patient eloped from the facility on 9/10/25 at approximately 6:20 PM. A review of facility policy Telemetry Monitoring revealed the following: “Notify physician of dysrhythmias, changes in rhythm, . . . or changes in clinical condition. Document assessments, physician notifications, and interventions in the electronic medical record.” When telemetry is discontinued: Notify the Central Monitoring unit.” As indicated above, the physician had not been notified. When the leads were unattached, there was no way to know whether or not the patient had any rhythm changes.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 35339 Based on interview, and record review, the facility failed to ensure documentation of medication administration route was accurately entered into the patient electronic health record (EHR) for 1 of 10 patients reviewed for medication reconciliation administration of home medications, out of a total sample of 10 patients, (#8). Findings: The electronic medical record (EHR) showed patient #8 was admitted in the emergency room on 5/22/24, with diagnoses of dementia, congestive heart failure, seizures, and gastrostomy tube (Peg tube). Review of the nutritional consult note dated 5/23/24 at 4:12 PM, showed Registered Nurse (RN) reported patient #8’s son stated patient does not eat by mouth (PO). Physician diet order dated 05/23/24 revealed diet nothing by mouth (NPO) except tube feed (TF). Review of pharmacy report for administration of medications showed Zyvox 600 mg tablet ordered orally every 12 hours and documented by nurses as administered orally on 05/23/24 at 12:54 PM, 05/23/24 at 8:17 PM, 05/24/24 at 8:35 PM, 05/25/24 at 10:04 AM, 05/25/24 at 8:22 PM, 05/26/24 at 8:46 AM, 05/26/24 at 9:48 PM, 05/27/24 at 10:24 AM, and 05/27/24 at 8:04 PM. On 05/27/24 at 7:34 PM, Levetiracetam (Keppra) 500 mg tablet, a one time dose was also documented as given orally. The report reflected a total of 10 doses of oral medication documented as administered by nursing to patient #8 over a 5-day timeframe. On 08/27/24 at 2:46 PM, Nurse Manager (A), and Director of Nursing (B), both confirmed nursing documentation reflects medications were given orally to patient #8. Nurse Manager (A) stated patient is NPO except for TF and no sips of H20 or ice chips were ordered by the physician. On 08/28/24 at 12:32 PM, Nurse Professional Development (NPD) Practitioner stated computer displays the administration route to nursing, and it is automatically processed by the placement of the physician order. If the route does not match, the expectation and hospital process for a peg tube is that nurses follow the five rights for medication administration (right patient, right drug, right dose, right time, and right route). She stated the physician’s order should reflect the correct route and if it does not, the nurse needs to reach out and contact the physician to clarify the orders. On 08/28/24 at 12:59 PM, Nurse Manager (A), stated she spoke with 6 out of the 8 nurses and confirmed they all administered the medication through the peg tube as the patient was not be able to swallow oral medications. She, too, stated the hospital policy is for nursing to call and have the physician order clarified for the right route. They can either contact the physician or the pharmacy, whomever placed the order. Review of hospital policy SOP# CFD.MM.SOP.33 for Medication Administration with an effective date 4/3/24, showed under the heading for process and procedures that medications will be administered to the patient only upon the order of the physician and the medications will be administered by oral route if the patient is able to take PO. The hospital did not ensure accuracy of medication administration documentation in the medical record for patient #8.”