Adventhealth Daytona Beach

“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: 42310 Based on record review, interviews and policy and procedure reviews, it was determined the hospital failed to adhere to their provider agreement under CFR §489.20 (l) of the provider’s agreement requiring that hospitals comply with 42 CFR §489.24, Special Responsibilities of Medicare Participating Hospitals in Emergency Cases. Specifically, the hospital failed to ensure that 1 of 20 sampled patients found to have an Emergency Medical Condition (EMC), was appropriately transferred to a receiving facility for continued psychiatric/medical treatment. (Patient #3) Findings include: Cross refer to A-2409. .”

“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: 42310 Based on central log, interviews, and policy review, the facility failed 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 for one out of 20 sampled patients. (Patient #1) The findings include: A review of the central log for the off-campus emergency department, Adventhealth Port Orange ER (AHPO) revealed no documentation related to Patient #1 arriving to the Emergency Department (ED) on February 09, 2023, at approximately 2:00 AM. On 03/26/24 at 10:45 AM an interview was conducted with the Clinical Regulatory Coordinator. He confirmed that there was no documented encounter for Patient #1 at Adventhealth Port Orange. Patient #1 was not on the ED central log. He stated that Patient #1 should have been on the AHPO ED central log. A review of Adventhealth’s policy and procedure titled “EMTALA” with a last reviewed date of August 2023 was conducted. Page one stated, “All Adventhealth hospital entities, provider based urgent care centers, and free-standing emergency departments must maintain a central log that identifies each individual who comes to the emergency department seeking assistance and includes the circumstances of the treatment or non-treatment provided. Documentation within the central log must also include whether the patient refused treatment, was refused treatment, or whether the patient was transferred, admitted, and treated, stabilized, and transferred, or discharged.””

“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: 14762 Based on medical record reviews, staff interviews, and policy review, it was determined the hospital failed to ensure that 1 of 20 sampled patients found to have an Emergency Medical Condition (EMC), was appropriately transferred to a receiving facility for continued psychiatric/medical treatment. (Patient #3) The findings include: A review of Adventhealth Hospital medical records revealed on January 10, 2023 at approximately 11:32 PM, Patient #3 presented to the Emergency Department (ED) via ambulance with expressions of anxiety. On January 11, 2023, at 12:31 AM, Patient #3 received a Medical Screening Examination (MSE) by an ED physician and was noted to have reports of suicidal ideations and a history of suicide attempts, bipolar disorder, post-traumatic stress disorder (PTSD), depression and alcohol abuse. A psychiatrist conducted a tele-health consultation with Patient #3 and recommended Patient #3 to be continued under Baker Act (Chapter 394, Florida Statutes which provides for voluntary and involuntary assessment/treatment of a person with mental illness), be closely monitored, and when medically cleared, be transferred to a Baker Act receiving facility. On January 11, 2023, at 3:18 AM a case manager initiated referrals to 8 receiving facilities for pending transfer. On January 11, 2023, Patient #3 experienced an escalation of agitation, required numerous medications in attempts to manage the symptoms, and at 5:45 PM was ultimately placed in 4-point soft wrist restraints. At 10:21 PM, Patient #3 broke free from his restraints and struck one of the hospital security officers. On January 12, 2023, at 12:18 AM Volusia County Sheriff’s personnel were present to transfer Patient #3 to another hospital. (Facility B) On January 12, 2023, at 12:33 AM, a registered nurse (RN G) at Facility B documented that an RN (A) from Adventhealth Hospital was calling and attempting to give report on a violent patient that was enroute. RN G from Facility B informed RN A that the protocol for transferring was to be received by the transfer center or by a physician/psychiatrist. RN A continued to provide the report and stated, “I don’t care if you take report or not, but you’re going to want it and the patient is on his way.” On January 12, 2023, at 12:53 AM Patient #3 presented to the ED at Facility B, received a triage and an MSE at 1:44 AM. The ED physician’s examination revealed Patient #3 was transferred by law enforcement to Facility B at the request of Adventhealth Daytona Beach. On March 27, 2024, at approximately 8:44 AM, an interview was conducted with RN A. She recalled Patient #3 and the events surrounding his transfer to Facility B. She confirmed that Patient #3 was under a Baker Act and patients under Baker Act are considered to have an EMC and would normally be transferred with the consultation and agreement from physician to physician for a transfer. On March 27, 2024, at approximately 9:04 AM, a video conference interview was conducted with Adventhealth Daytona Beach’s Director of Emergency Department. He confirmed that a patient under Baker Act would be considered to have an EMC and would require an accepting physician at a receiving hospital prior to transfer. A review of Adventhealth’s policy and procedure titled Transfer/Transport of Patients to an Acute Care Facility (effective 7/1/22), revealed, “If it is determined that the individual has an emergent medical condition and if the transferring physician’s opinion the patient requires transfer to another facility and the benefit of such a transfer outweighs the potential risks to the patient’s condition. Transferring Department: Explains the risk of the transfer to the patient or to the patient’s representative and has the patient or patient representative sign the transfer consent portion of the Transfer/Transport Consent Form. Makes the necessary transfer arrangements with the receiving facility to ensure the receiving facility has sufficient capacity for treatment and agrees to accept the patient and documents the same on the transfer/transport requirement form. Baker Act/Marchman Act transfers are treated as an emergent medical condition.” A review of Patient #3’s records from Adventhealth Daytona Beach and Facility B revealed there was no evidence the transferring hospital requested and received an acceptance from the receiving hospital, evidence of risks and benefits of transfer and that Patient #3 was transferred by qualified personnel.”