HCA Florida Jfk Hospital

“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: 29151 Based on medical record review, surveillance video review, policy review, record review and staff interviews, it was determined that, the hospital failed to 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 facility Failed to provide a medical screening examination to a patient, who presented to the Emergency Department (ED) and the patient’s representative (Mother) requested psychiatric evaluation and treatment. This failure affected 1 of 20 sampled patients (Patient #1). Refer to findings in Tag A- 2406”

“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: 29151 Based on Electronic Central Log review, video surveillance review, policy review and staff interview, it was determined, the hospital failed to maintain a central log on each individual who comes to the emergency department, 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. This failure affected 1 of 20 sampled patients (Patient #1). The findings included: The facility’s policy titled “EMTALA- Central Log” Last Approved and Last Revised, on 05/2025 was reviewed. The policy revealed in part, “ POLICY: The hospital will maintain a Central Log containing information on each individual who requests emergency services or care or whose appearance or behavior would cause a prudent layperson observer to believe the individual need examination or treatment, whether he or she left before a medical screening examination could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred admitted or treated, stabilized and transferred or discharged. ..Procedure: All hospitals must maintain the Central Log in an electronic format ... . The logs must contain at a minimum, the name of the individual and whether the individual ...refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged or expired ...A log entry for all individuals who have come to the hospital; seeking medical attention or who appear to need medical attention must be made by the appropriate individual.” Video surveillance review conducted on 04/06/26 revealed on 02/23/26 at 5:55 PM, Patient #1 and her mother presented to the Emergency Department (ED), they spoke to the security guard on duty and entered the lobby area. The patient and mother walked towards the registration kiosk, there was a physical altercation, the patient’s mother hit and pushed the patient to the ground. Review of the facility’s Electric Emergency Department Central Logs dated 02/23/26 revealed the hospital staff failed to maintain a central log for Patient #1. There is no documentation on the central log dated 02/23/26 to indicate whether or not Patient #1 refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized, and transferred or discharged. Interview with Staff F, ED Charge Nurse, conducted on 04/07/26 at 10:27 AM, revealed her recollection of Patient #1, the staff reported the patient’s mother was fighting the patient, she went out to the lobby to see what was happening, the patient was sitting in the lobby, the mother was gone. The patient was not registered because she did not want to be seen and was not aware of what prompted the patient’s mother to bring the patient to the ED. The facility failed to follow their own Policy and Procedure as evidenced by failing to capture Patient #1’s ED visit, on 02/23/26, on the ED central log, when the patient’s mother requested a psychiatric evaluation on the patient’s behalf.”

“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: 29151 Based on medical record review, surveillance video review, policy and procedure review, and staff interviews, it was determined that the hospital failed to 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 facility Failed to provide a medical screening examination to a patient, who presented to the Emergency Department (ED) and the patient’s representative (Mother) requested psychiatric evaluation and treatment. This failure affected 1 of 20 sampled patients (Patient #1). The findings included: The facility’s policy titled EMTALA - Medical Screening Examination and Stabilization, Last approved and Last revised 05/2025 was reviewed. The policy and procedure review revealed in part, “POLICY: An EMTALA obligation is triggered when:1. an individual or a representative acting on the individual’s behalf, ..., requests emergency services and care; or 2. a prudent layperson observer observing an individual who comes to the dedicated emergency department (DED) would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. Further review revealed, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital’s DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists... If an EMC is determined to exist, the individual will be provided necessary treatment to relieve or eliminate the EMC, within the capacity and capability of the facility ... PROCEDURE: MSE is required when: ... a. A request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition ... Who May Perform the MSE: ... ii. Psychiatric QMP. The emergency physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED with psychiatric or behavioral, emergencies. Should an individual with a psychiatric or behavioral emergency present to a behavioral department of a hospital that meets the requirements of a DED, that department is responsible for ensuring that the individual has the appropriate MSE, including any behavioral examination, and providing necessary treatment to relieve or eliminate the EMC. Video surveillance review conducted on 04/06/26 revealed on 02/23/26 at 5:55 PM, Patient #1 and her mother presented to the Emergency Department (ED), they spoke to the security guard on duty and entered the lobby area. The patient and mother walked towards the registration kiosk, there was a physical altercation, the patient’s mother hit and pushed the patient to the ground. The hospital staff notified the detail police officer on duty. The video shows hospital staff including a Mental Health Technician, Nurse Extern, Behavioral Health Nurse, the Charge Nurse, Security Officer and the police interacted with the patient. Patient #1 remained in the lobby area and left the premises at 7:11 PM. Interview with Staff A, Mental Health Technician, conducted on 04/06/26 at 12:43 PM revealed he was walking out the door and saw Patient #1 and the mother arguing about a bottle of water, the mother said to the patient don’t touch the water, then mom grabbed the patient trying to get the bottle of water away from her. Staff A explained at the beginning he thought they were playing with each other, then they started to walk toward the registration kiosk and the mom pushed the patient and they were pushing each other. Staff B (a nurse extern working in the triage area) noticed the interaction they were punching each other and called the police detail on duty. By then the mother had left the ED and the patient was just sitting there, doing nothing, the police came out and found mom in her vehicle; looks like mom was dropping the patient off, the patient returned days later and was admitted to the behavioral health unit. Interview with Staff B, Nurse Extern, conducted on 04/06/26 at 1 PM, revealed she was in the secondary triage room, and looked up and saw the surveillance monitor by the registration kiosk, a woman was slamming another woman into the wall, she called detail police officer, the patient’s mother was walking out of the door, and the patient was getting up from the ground, the patient had an abrasion to her nose, was bleeding a bit; she then called the charge nurse to report the event. The patient’s mother wanted to check the patient in for a psych evaluation. Staff C (Behavioral Nurse) also came out and spoke to the patient and there was no reason for the patient to be here. Staff B remembers they talked about checking her in because her nose was bleeding, the patient had a small cut above bridge of her nose. Interview with Staff C, Behavioral Health Registered Nurse, conducted on 04/06/26 at 1:08 PM, revealed the mother brought the patient in, she was voluntary, the patient did not feel she needed to be here. Staff C stated she spoke to the patient and the patient wasn’t really sure why mom brought her in, stating she was doing well. The patient was alert and responding to her questions, did not want to be seen, and Staff C did not identify a reason for the ED visit, again mentioning the patient was a voluntary status. Staff C went back to the psych unit and did not interact with the patient anymore. She does not recall if the patient was injured, maybe something small, but not sure. Interview with Staff D, Security Guard, conducted on 04/06/26 at 2:57 PM, revealed he was doing rounds and noticed the police officer talking to the patient in the ED lobby, there was an argument over a water bottle and the patient and mother were fighting each other. The mother went outside and recalls the patient saying to the officer that her mother was bringing her here for evaluation and they had an argument. The patient remained in the ED, she was waiting for a ride and came back the following day to be admitted. Interview with Staff E, Security Guard, conducted on 04/06/26 at 3:18 PM revealed she was on duty the day of the event, working at the ED main entrance. The patient said that mom wanted her to get a psych evaluation, but she did not need one. The mother had a bottle of water and put it down on the table, then the daughter grabbed the bottle and the mother said that is not your water and they started going back and forth with the bottle water, the daughter was going towards the registration kiosk and the mom pushed her against the wall and kept trying to get the water bottle away from the patient, but the patient would not let it go. Then the police and the nurse came out, by then the mother was outside and the patient remained in the hospital. Then the patient called her grandmother and was told not to come back to the house and recalls seeing the patient again, the next day, she was a baker act (involuntary admission). Patient #1’s medical record dated 2/25/26 at was reviewed. The medical record revealed Patient #1 returned to the ED on 02/25/26 and was seen by a provider at 4:33 AM. The patient’s Chief Complaint was listed as “[Psych illness]. Further review revealed in part, ..”HPI (history of present illness) Notes: Patient here for Police Baker Act (The Florida Mental Health Act) that allows for the involuntary or voluntary emergency commitment and temporary detention of individuals for mental health evaluation and treatment) and Psychiatric evaluation. Noted bizarre erratic behavior. Noted tangential (means an off -topic thought) disorganized thought. Noted paranoid delusion ...Denies auditory or visual hallucinations. Patient #1 was admitted to the facility’s behavioral health unit on 02/25/26 and remained hospitalized for psychiatric stabilization until 03/04/26. The facility failed to follow their own policy and procedure as evidenced by failing to provide an appropriate MSE to include an behavioral examination that was within the capability of the hospital’s emergency department; when the request was made by the patient’s mother on 2/23/2026 because patient #1 was experiencing a psychiatric emergency medical condition.”

“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: 29151 Based on policy review, record review, EMS Endcode Log review, surveillance video review, Fire Rescue documents review, and interview, it was determined, the hospital failed to substantiate the provision of emergency services for 1 of 21 sampled patients (Patient #21) as evidenced by failure to perform a Medical Screening Exam (MSE) within the capability of the hospital’s ED, including ancillary services routinely available to the emergency to the ED, to determine whether or not an emergency medical condition exists and if so to provide care and treatment to relieve or eliminate the condition. Refer to findings in citations A-2406”

“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: 29151 Based on record review, video surveillance review, policy review, HCA Florida JFK Hospital, Admissions Electronic Log, and interview, it was determined, the hospital failed to ensure the central log included all individuals who presented to the Emergency Department (ED) seeking treatment. This failure affected 1 of 21 sample patients (Patient #21). The findings included: Facility policy titled “EMTALA Central Log” last reviewed on 05/2025 documents “This policy reflects guidance under the Emergency Medical Treatment and Labor Act (EMTALA) and associated state laws only. Policy: The hospital will maintain a Central Log containing information on each individual who requests emergency services or care or whose appearance or behavior would cause a prudent layperson observer to believe the individual need examination or treatment, whether he or she left before a medical screening examination could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred admitted or treated, stabilized and transferred or discharged. The central log includes the patient logs from the traditional ED and either by direct or indirect reference, patient logs from any other areas of the hospital that may be considered dedicated emergency department’s or where an individual may present for emergency services or receive a medical screening exam, such as labor and delivery. Procedure: All hospitals must maintain the Central Log in an electronic format. An electronic template that includes all federal requirements for EMTALA is available on Medictech for each market or division to customize. The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core information. The logs must contain at a minimum, the name of the individual and whether the individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged or expired. A log entry for all individuals who have come to the hospital; seeking medical attention or who appear to need medical attention must be made by the appropriate individual. Further. The Central Log of individuals who have come to the hospital seeking medical attention or who appear to need medical attention will be available within a reasonable amount of time for surveyor review and must be retained for a minimum of five years from the disposition of the individual.” Review of the surveillance video conducted on 08/13/25 revealed the following: On 08/05/25 starting at 4:59 AM, a Fire Rescue vehicle pulled up to the ambulance entrance. The Fire Rescue was transporting Patient #21 to the Emergency Department. At 5:00 AM, two hospital staff members are observed putting a sign on the entrance door. The Fire Rescue emergency crew is seen walking around towards the other side of the vehicle talking on the phone. At 5:09 AM, the Fire Rescue crew is seen at the ambulance entrance, looking at the sign. At 5:16 AM, the crew gets back in vehicle. At 5:19 AM, the Fire Rescue vehicle leaves the premises. The facility’s Log titled, “HCA Florida JFK North Hospital “Admissions” Electronic Central Log dated dated 8/5/2025 was reviewed. Review of the Electric Central Log failed to revealed that Patient #21 was entered on the ED log on August 5, presented to the hospital via Fire Rescue on 08/05/25 seeking medical assistance. Review of the Fire Rescue documents dated 08/05/25 documents the unit was dispatched to a suicide attempt, upon arrival they found a 14-year-old female walking down stairs, accompanied by a police officers and parents. The patient appeared to be in moderate distress. “Baker Act” Police officer stated the patient posted that she took medication on social media, and a friend called her parents. Patient states she took 24 capsules of 25 mg Benadryl. Pt has 2 small superficial lacerations to left forearm ... ...Rescue drove to HCA Florida JFK North Hospital (Hospital A) as per protocol; while encoding Hospital A advised they are on diversion and after talking to another rescue unit the patient was diverted to Hospital B. Interview with Staff A, a Registered Nurse, conducted on 08/13/25 at 9:30 AM, revealed she worked the night shift on 08/04/25. The nurse explained the emergency department was busy, they were holding critical patients in the hallway, and the charge nurse told her they were going on diversion. The staff stated she continued to care for her patients. Later, she and the secretary put a sign on the ambulance entrance door, the staff can’t recall exactly what the sign said, something to the effect of “Diversion” and does not know who removed the sign. Staff A confirmed she saw an ambulance in the bay when the sign was being placed but she did not speak to them and the emergency personnel never came in. Interview with Staff B, Unit Secretary, conducted on 08/13/25 at 9:36 AM revealed on 08/04/25 the ED was busy, she recalled they were holding many patients. The charge nurse told her the hospital was going on diversion. The staff was asked what that meant and stated that means they are not accepting patients now. The secretary explained it was her idea to put the sign up, the sign said, “behavioral diversion”. The staff stated she placed the sign up around 5 AM and she took the sign down about 30 minutes later, because they were off diversion by 6 AM. Interview with the Charge Nurse on duty on 08/05/25 was conducted on 08/13/24 at 10:27 AM, revealed the staff recalled Fire Rescue called over the radio and she told him that they were diversion, she did see a Fire Rescue unit outside, but they never came in. The charge nurse does not recall if the crew gave any patient information or where they were at the time of the call, she just remembers telling them they were on diversion. Interview with the representative from the Fire and Rescue Department conducted on 08/14/25 at 3:46 PM revealed the crew involved notify him that the hospital turned away an adolescent Baker Act patient on 08/05/25 and he subsequently notified the hospital’s Chief Executive Officer. Emergency personnel provided details of the event on 08/21/25. The Fire Rescue crew reported while transporting Patient #21 to the hospital, the patient was turned away based on their diversion status. When the crew arrived at Hospital A’s emergency department, they were working on alternate destination and observed the hospital staff placing a sign on the door indicating the hospital was on diversion.”

“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: 29151 Based on policy review, record review, EMS Endcode Log review, surveillance video review, Fire Rescue documents review, and interview, it was determined, the hospital failed to substantiate the provision of emergency services for 1 of 21 sampled patients (Patient #21) as evidenced by failure to perform a Medical Screening Exam (MSE) within the capability of the hospital’s ED, including ancillary services routinely available to the emergency to the ED, to determine whether or not an emergency medical condition exists and if so to provide care and treatment to relieve or eliminate the condition. The findings included: Facility policy titled “EMTALA Medical Screening Examination and Stabilization” dated 05/2025 documents: “Purpose: To establish guidelines for providing appropriate medical screening examinations (“MSE”) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA, 42 U.S.C. S 1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder, as well as section 395.1041, Florida Statutes, and all related administrative rules. Policy: An EMTALA obligation is triggered when: 1. an individual or a representative acting on the individual’s behalf, including EMS or a transferring hospital, requests emergency services and care; or 2. a prudent layperson observer observing an individual who comes to the dedicated emergency department (“DED”) would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition (“EMC”). Further, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital’s DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists.... If an EMC is determined to exist, the individual will be provided necessary treatment to relieve or eliminate the EMC, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Emergency treatment shall be applied in a non-discriminatory manner...or any other basis prohibited. Procedure: 1. When an MSE is Required A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: (i) to any individual,... (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual’s appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC.... An MSE is required when: a. A request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition. ii. The individual arrives as a transfer from another hospital or health care facility. Upon arrival of a transfer, a physician or qualified medical person (“QMP”) must perform an appropriate MSE. The physician or QMP shall provide any additional screening and treatment required to relieve or eliminate the EMC. The MSE of the individual must be documented. This type of screening cannot be performed by the triage nurse. If an EMC is determined to exist and the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under EMTALA ceases. Note: The MSE and other emergency services need not be provided in a location specifically identified as a DED. The hospital may use areas to deliver emergency services that are also used for other inpatient or outpatient services. MSEs or necessary treatment may require ancillary services available only in areas or facilities of the hospital outside of the DED. b. The individual arrives on the hospital property other than an Off-Campus Emergency Department (OED) and makes a request or another makes a request on the individual’s behalf for examination or treatment for an EMC. i. Screening where the individual presented: If an individual is initially screened in a department or location on-campus other than the OED, the individual may be moved to another hospital department or facility on-campus to receive further screening or stabilizing treatment without such movement being a transfer. The hospital shall not move the individual to an off-campus facility or department (such as an urgent care center or satellite clinic) for an MSE. ii. Transporting to the DED: The hospital may determine that movement of an individual to the hospital’s OED may be necessary for screening. However, common sense and individual Emergency Medical Services (EMS) personnel may request an evaluation or treatment on an individual’s behalf. c. The individual arrives on the hospital property, either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment. 3. Extent of the MSE a. Determine if an EMC exists. The hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely “log in” or triage an individual with a medical condition and not provide an MSE. Triage is not equivalent to an MSE. Triage entails the clinical assessment of the individual’s presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be screened by a physician or other QMP. b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. c. An on-going process. The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does, until the EMC is relieved or eliminated or the individual is appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer. Review of the surveillance video conducted on 08/13/25 revealed the following: On 08/05/25 starting at 4:59 AM, a Fire Rescue vehicle pulled up to the ambulance entrance. At 5:00 AM, a Fire Rescue crew member gets out of the vehicle and is on the phone. At 5:00 AM, two hospital staff members are putting a sign on the entrance door. The Fire Rescue emergency crew is seen walking around towards the other side of the vehicle talking on the phone. At 5:01 AM, the two hospital staff members are seen leaving the area. At 5:02 AM to 5:05 AM, a Fire Rescue crew member is seen walking towards door and talking on phone. At 5:09 AM, the Fire Rescue crew is seen at the ambulance entrance, looking at the sign. At 5:13 AM, the Fire Rescue crew is seen walking and talking on the phone. At 5:14 AM, the Fire Rescue vehicle driver comes out of the vehicle and speaks to the other crew member At 5:16 AM, the crew gets back in the vehicle. At 5:19 AM, the Fire Rescue vehicle leaves the premises. The video surveillance confirmed that Patient #21 did not receive a medical screening examination. Review of the EMS Endcode Log revealed no evidence that Fire Rescue personnel contacted the hospital regarding Patient #21. Review of Fire Rescue documents dated 08/05/25 documents the unit was dispatched to a suicide attempt, upon arrival they found a 14-year-old female walking downstairs, accompanied by a police office and parents. The patient appeared to be in moderate distress. “Baker Act” Police officer stated the patient posted that she took medication on social media, and a friend called her parents. Patient states she took 24 capsules of 25 mg Benadryl. Pt has 2 small superficial lacerations to left forearm ... ...Rescue drove to HCA Florida JFK North Hospital (Hospital A) as per protocol; while encoding Hospital A advised they are on diversion and after talking to another rescue unit the patient was diverted to Hospital B. Interview with Staff A, a Registered Nurse, conducted on 08/13/25 at 9:30 AM, revealed she worked the night shift on 08/04/25. The nurse explained the emergency department was busy, they were holding critical patients in the hallway, and the charge nurse told her they were going on diversion. The staff stated she continued to care for her patients. Later, she and the secretary put a sign on the ambulance entrance door, the staff cannot recall exactly what the sign said, something to the effect of “Diversion” and does not know who removed the sign. Staff A confirmed she saw an ambulance in the bay when the sign was being placed but she did not speak to them and the emergency personnel never came in. Interview with Staff B, Unit Secretary, conducted on 08/13/25 at 9:36 AM revealed on 08/04/25 the ED was busy, she recalled they were holding many patients. The charge nurse told her the hospital was going on diversion. The staff was asked what does that mean and stated that means they are not accepting patients now. The secretary explained it was her idea to put the sign up, the sign said, “behavioral diversion”. The staff stated she placed the sign up around 5 AM and she took the sign down about 30 minutes later, because they were off diversion by 6 AM. Interview with the Charge Nurse on duty on 08/05/25 was conducted on 08/13/24 at 10:27 AM, revealed the staff recalled Fire Rescue called over the radio and she told him that they were diversion, she did see a Fire Rescue unit outside, but they never came in. The charge nurse does not recall if the crew gave any patient information or where they were at the time of the call, she just remembers telling them they were on diversion. Interview with the representative from the Fire and Rescue Department conducted on 08/14/25 at 3:46 PM revealed the crew involved notified him that the hospital turned away an adolescent Baker Act patient on 08/05/25 and he subsequently notified the hospital’s Chief Executive Officer. Emergency personnel provided details of the event on 08/21/25. The Fire Rescue crew reported while transporting Patient #21 to the hospital, the patient was turned away based on their diversion status. When the crew arrived at HCA Florida JFK North Hospital emergency department, they were working on alternate destination and observed the hospital staff placing a sign on the door indicating the hospital was on diversion. Based on record review, surveillance video review and interview, it was determined that the hospital failed to provide a medical screening exam to Patient #21, an adolescent under Baker Act (involuntary examination for an individual with mental illness that poses a danger to themselves or others) due to suicide attempt. The patient presented via Fire Rescue to the hospital property and was turned away by the charge nurse during endcode due to the hospital diversion status and in addition, the staff placed a behavioral health diversion sign on the ambulance bay entrance to deter patients from entering the emergency department.”

“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: 29151 Based on record review, video surveillance review, policy review and staff interview, it was determined, the hospital failed to adopt and enforce a policy to ensure compliance with the EMTALA requirements at 42 CFR 489.20 and 489.24 as evidenced the following: Failure to provide a medical screening exam to a patient, who presented to the Emergency Department (ED) seeking medical care. The failure affected 1 of 21 sampled patients (Patient #21) as detailed in citation A-2406. Cross Refer to A-2406.”

“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: 29151 Based on record review, video surveillance review, policy review and interview, it was determined, the hospital failed to ensure the central log included all individuals who presented to the Emergency Department (ED) seeking treatment. This failure affected 1 of 21 sample patients (Patient #21). The findings included: Review of the facility policy titled “EMTALA Central Log” last reviewed on 05/2025 documents, “This policy reflects guidance under the Emergency Medical Treatment and Labor Act (EMTALA) and associated state laws only. It does not reflect any requirements of the Joint Commission or other regulatory entities. Policy: The hospital will maintain a Central Log containing information on each individual who requests emergency services or care or whose appearance or behavior would cause a prudent layperson observer to believe the individual need examination or treatment, whether he or she left before a medical screening examination could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred admitted or treated, stabilized and transferred or discharged. The central log includes the patient logs from the traditional ED and either by direct or indirect reference, patient logs from any other areas of the hospital that may be considered dedicated emergency department’s or where an individual may present for emergency services or receive a medical screening exam, such as labor and delivery. Procedure: All hospitals must maintain the Central Log in an electronic format. An electronic template that includes all federal requirements for EMTALA is available on Medictech for each market or division to customize. The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core information. The logs must contain at a minimum, the name of the individual and whether the individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged or expired. A log entry for all individuals who have come to the hospital; seeking medical attention or who appear to need medical attention must be made by the appropriate individual. Further. The Central Log of individuals who have come to the hospital seeking medical attention or who appear to need medical attention will be available within a reasonable amount of time for surveyor review and must be retained for a minimum of five years from the disposition of the individual.” Review of the surveillance video conducted on 06/05/25 at approximately 12 noon revealed the following: On 05/01/25 at 4:10 PM, a Police Officer and Patient #21 are observed entering the emergency department through the main entrance. At 4:11 PM, the officer interacts with the hospital Sheriff Police Officer and is directed to the triage desk. At 4:11:49 PM, the officer and Patient #21 interacted with the triage nurse, later identified as Staff B. At 4:13 PM, the officer and Patient #21 interacted with another staff that came over to the triage desk. The staff was later identified as Staff A (a translator). At 4:15 PM, the officer and patient walked to the waiting room. The Officer asked the patient to sit in the lobby and got on the phone. At 4:17 PM, the officer got off the phone, and the patient and officer were seen leaving the emergency department. The video surveillance confirmed Patient #21 was not registered in the emergency department. A phone interview with Staff A, Registered Nurse, was conducted on 06/04/25 at 12:50 PM. Staff A recalled the event and stated that she was called in to assist with translation, as Patient #21 spoke Spanish. Staff A explained the police told her the patient was under arrest and she was pregnant, looks like 35 weeks or so, the officer was supposed to take her to jail, but he wanted medical clearance. The staff recalls explaining that most likely due to her condition, she would need to be transferred to another hospital and then the officer took her. Staff A denied getting the patient’s name to complete a registration and does not recall any further details. A phone interview with Staff B, Registered Nurse, was conducted on 06/04/25 at 12:55 PM. Staff B recalled she was working at the triage desk on 05/01/25 and stated she does not recall the patient or the event, she is on vacation and there was a bad reception. Staff B was unable to explain why the patient was not registered and not seen by the provider. Staff B stated pregnant patients over twenty weeks most likely would be transferred to their sister facility for obstetric services and was unable to provide any further details regarding the interaction with Patient #21. Review of the facility Emergency Department Central Logs dated 05/01/25 revealed the facility failed to maintain a record of every patient presenting to the emergency department. There was no record of Patient #21.”

“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: 29151 Based on policy review, record review, surveillance video review and interview, it was determined, the hospital failed to substantiate the provision of emergency services for 1 of 21 sampled patients (Patient #21) as evidenced by failure to perform a Medical Screening Exam (MSE) to determine if a medical condition exist and if so to provide care and treatment to relieve or eliminate the condition. The findings included: Review of the facility policy titled “EMTALA Medical Screening Examination and Stabilization” dated 05/2025 documents: “Purpose: To establish guidelines for providing appropriate medical screening examinations (“MSE”) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA, 42 U.S.C. S 1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder, as well as section 395.1041, Florida Statutes, and all related administrative rules. Policy: An EMTALA obligation is triggered when: 1. an individual or a representative acting on the individual’s behalf, including EMS or a transferring hospital, requests emergency services and care; or 2. a prudent layperson observer observing an individual who comes to the dedicated emergency department (“DED”) would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition (“EMC”). Further, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital’s DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary treatment to relieve or eliminate the EMC, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Emergency treatment shall be applied in a non-discriminatory manner (e.g., no different level of care because of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited. Procedure: 1. When an MSE is Required A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: (i) to any individual, including a pregnant woman having contractions, who requests such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual’s appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC or a pregnant woman is in labor. An MSE is required when: a. A request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition. b. The individual arrives on the hospital property other than a OED and makes a request or another makes a request on the individual’s behalf for examination or treatment for an EMC. f. If a law enforcement official requests hospital emergency personnel to provide medical clearance for incarceration, the Hospital has an EMTALA obligation to provide an MSE to determine if an EMC exists. 3. Extent of the MSE a. Determine if an EMC exists. The hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely “log in” or triage an individual with a medical condition and not provide an MSE. Triage is not equivalent to an MSE. Triage entails the clinical assessment of the individual’s presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be screened by a physician or other QMP. b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. c. An on-going process. The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does, until the EMC is relieved or eliminated or the individual is appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer. ii. Pregnant Women: The medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membranes (i.e., ruptured, leaking and intact), to document whether or not the woman is in labor. A woman experiencing contractions is in true labor unless a physician, certified nurse-midwife or other QMP acting within his or her scope of practice as defined by the hospital’s medical staff bylaws. Review of the surveillance video conducted on 06/05/25 at approximately 12 noon revealed the following: On 05/01/25 at 4:10 PM, a Police Officer and Patient #21 are observed entering the emergency department through the main entrance. At 4:11 PM, the officer interacts with the hospital Sheriff Police Officer and is directed to the triage desk. At 4:11:49 PM, the officer and Patient #21 interacted with the triage nurse, later identified as Staff B. At 4:13 PM, the officer and Patient #21 interacted with another staff that came over to the triage desk. The staff was later identified as Staff A (translator). At 4:15 PM, the officer and patient walked to the waiting room. The Officer asked the patient to sit in the lobby and got on the phone. At 4:17 PM, the officer got off the phone, and the patient and officer were seen leaving the emergency department. The video surveillance confirmed Patient #21 did not receive a medical screening examination. A phone interview with Staff A, Registered Nurse, was conducted on 06/04/25 at 12:50 PM. Staff A recalled the event and stated that she was called in to assist with translation, as Patient #21 spoke Spanish. Staff A explained the police told her the patient was under arrest and she was pregnant, looks like 35 weeks or so, the officer was supposed to take her to jail, but he wanted medical clearance. The staff recalls explaining that most likely due to her condition, she would need to be transferred to another hospital and then the officer took her. Staff A denied getting the patient’s name to complete a registration and does not recall any further details. A phone interview with Staff B, Registered Nurse, was conducted on 06/04/25 at 12:55 PM. Staff B recalled she was working at the triage desk on 05/01/25 and stated she does not recall the patient or the event, she is on vacation and there was a bad reception. Staff B was unable to explain why the patient was not registered and not seen by the provider. Staff B stated pregnant patients over twenty weeks most likely would be transferred to their sister facility for obstetric services and was unable to provide any further details regarding the interaction with Patient #21. Interview with the Police Department Representative conducted on 06/06/25 at 11:46 AM revealed the sergeant, supervisor on duty on 05/01/25, replied to the surveyor’s request for information and explained the hospital told the officer that was escorting Patient #21, that because the patient was 9 month pregnant, they could not monitor her or the baby and that it would be most beneficial to go to Hospital A for obstetric services. Review of the facility Emergency Department records dated 05/01/25 revealed the facility failed to provide a Medical Screening Exam (MSE) to Patient #21.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33162 Based on record review and interview, the facility failed to ensure Monitor Techs followed Policies and Procedures to initiate a Code Blue response for 1 of 1 patients (Patient #1) with a lethal heart rhythm. The findings included: The facility’s Policy titled “Telemetry Monitoring,” origination 02/2024 and last revised 07/2024 documents, “In the event that a suspected life-threatening rhythm is detected the Monitor/Telemetry Technician will initiate the following procedure: a. Life Threatening arrhythmias include: i. Sustained ventricular tachycardia: 30 second strip of V-tach or >30 beat run of V-Tach ii. Ventricular fibrillation iii. 3rd degree heart block (new onset) iv. Asystole b. Activate a “Code Blue” response to the patient’s bedside c. Subsequently notify the Primary RN or Charge RN and document communication within the EHR [electronic health record], or Facility approved pathway. d. Capture a copy of rhythm disclosure with interpretation and send to unit.” Patient #1’s History and Physical documents he was over 80 years old and was brought to the Emergency Department by Fire Rescue after he was found wandering outside and had a low blood pressure. Patient #1’s History and Physical documents his medical history included congestive heart failure (condition in which the heart can’t pump enough blood resulting in fluid buildup), atrial fibrillation (type of irregular heartbeat), a CT scan showed pulmonary edema (fluid in the lungs) and large volume ascites (fluid collection within the abdomen). Patient #1’s laboratory tests revealed acute kidney injury and elevated troponin (heart enzyme) levels suspicious for a type 2 MI (type of Myocardial Infarction or heart attack) and consults were ordered for cardiology (heart specialist) and nephrology (kidney specialist). Patient #1 was admitted to the hospital, had a physician order on 12/05/24 at 4:40 PM for telemetry monitoring (remote heart monitoring), and was transferred to an inpatient unit on 12/05/24 at 9:50 PM. Review of Patient #1’s telemetry print outs reveal on 12/05/24 between 9:49 PM and 10:15 PM his heart rhythm was primarily atrial fibrillation. Patient #1’s telemetry print out at 10:15 PM shows his heart rate increased from 60 to 116 and the rhythm identified by the telemetry software was “V tach” (Ventricular tachycardia, a fast irregular heartbeat that starts in the heart’s lower chambers and can become life threatening if it lasts for more than a few seconds at a time), and later that minute his heart rhythm was identified as V fib/V tach (V fib, or ventricular fibrillation, is a life threatening arrhythmia caused when the lower chambers of the heart quiver rather than beat normally which prevents the heart from pumping blood and leads to cardiac arrest. This is an emergency that requires immediate attention.) Patient #1’s telemetry print out identifies from 10:16 PM to 10:19 PM he alternated between asystole (cardiac arrest, when the heart stops beating) and V fib/V tach, then was in atrial fib at 10:19 PM for approximately 40 seconds before converting to and staying in asystole for 9 minutes until the time a Code Blue was called at 10:25 PM. Patient #1’s Resuscitation Record reveals CPR (cardiopulmonary resuscitation) started 12/05/24 at 10:25 PM and ACLS (Advanced Care Life Support) was attempted but unsuccessful in regaining spontaneous circulation, and the patient died when CPR was stopped in accordance with his representative’s direction on 12/05/24 at 10:36 PM. The Monitor Room Escalation and Resolution Log dated 12/05/24 got Monitor Tech, Staff A documents one entry for Patient #1 with a “1st escalation” of “[name of Unit Secretary] V fib 22.16” and “2nd escalation” of “[name of nurse] V fib 22:18 [10:18 PM].” During telephonic interview on 01/09/25 at 4:51 PM Monitor Tech, Staff A confirmed she monitored telemetry for Patient #1 the evening of 12/05/24 and stated when Patient #1 had a “burst” of V fib, which she clarified as a couple seconds, she called the Unit Secretary who told her the patient had just arrived and was in a room near her and Staff A told the Unit Secretary about the burst of V fib and asked her to tell the nurse to check Patient #1; that when Patient #1 had another burst of V fib less than a minute later she called the Charge Nurse; then she heard pages for a “Rapid Response” and then a “Code Blue”; that Staff A did not call a Code Blue but did what she was supposed to in having the nurse check the patient; and when asked what she should have done Staff A says to have the nurse check the patient which is what she did and that since it was a burst of V fib and return to A fib “we don’t call a Code Blue for that.” Staff A did not acknowledge Patient #1 was in a lethal rhythm for 10 minutes before a Code Blue was called, during which Staff A should have called a Code Blue per the facility’s Telemetry Policy and Procedures or that Staff A would call a Code Blue for lethal rhythms in the future. Review of Monitor Tech schedules from 12/22/24 to 01/04/25 revealed Staff A monitored telemetry since Patient #1’s death, on the night shifts of 12/31/24 and 01/01/25. During interview on 01/10/25 at 3:50 PM with the Chief Nursing Officer (CNO), she reported Staff A had a meeting with her manager about this incident and to go over the Telemetry Policy and Procedures but Staff A walked out of the meeting without receiving or agreeing to follow the policy because Staff A did not think she had done anything wrong. The CNO could provide no evidence that Staff A reviewed the Telemetry Policy and Procedures and/or agreed to follow them to protect patients in lethal rhythms before she worked again as a Monitor Tech.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 33162 Based on record review and interview, the facility failed to ensure Monitor Techs followed Policies and Procedures to initiate a Code Blue response for 1 of 1 patients (Patient #1) with a lethal heart rhythm and after this was identified that it was addressed to prevent other patients from harm. The findings included: The facility’s Policy titled “Telemetry Monitoring,” origination 02/2024 and last revised 07/2024 documents, “In the event that a suspected life-threatening rhythm is detected the Monitor/Telemetry Technician will initiate the following procedure: a. Life Threatening arrhythmias include: i. Sustained ventricular tachycardia: 30 second strip of V-tach or >30 beat run of V-Tach ii. Ventricular fibrillation iii. 3rd degree heart block (new onset) iv. Asystole b. Activate a “Code Blue” response to the patient’s bedside c. Subsequently notify the Primary RN or Charge RN and document communication within the EHR [electronic health record], or Facility approved pathway. d. Capture a copy of rhythm disclosure with interpretation and send to unit.” Patient #1’s History and Physical documents he was over 80 years old and was brought to the Emergency Department by Fire Rescue after he was found wandering outside and had a low blood pressure. Patient #1’s History and Physical documents his medical history included congestive heart failure (condition in which the heart can’t pump enough blood resulting in fluid buildup), atrial fibrillation (type of irregular heartbeat), a CT scan showed pulmonary edema (fluid in the lungs) and large volume ascites (fluid collection within the abdomen). Patient #1’s laboratory tests revealed acute kidney injury and elevated troponin (heart enzyme) levels suspicious for a type 2 MI (type of Myocardial Infarction or heart attack) and consults were ordered for cardiology (heart specialist) and nephrology (kidney specialist). Patient #1 was admitted to the hospital, had a physician order on 12/05/24 at 4:40 PM for telemetry monitoring (remote heart monitoring), and was transferred to an inpatient unit on 12/05/24 at 9:50 PM. Review of Patient #1’s telemetry print outs reveal on 12/05/24 between 9:49 PM and 10:15 PM his heart rhythm was primarily atrial fibrillation. Patient #1’s telemetry print out at 10:15 PM shows his heart rate increased from 60 to 116 and the rhythm identified by the telemetry software was “V tach” (Ventricular tachycardia, a fast irregular heartbeat that starts in the heart’s lower chambers and can become life threatening if it lasts for more than a few seconds at a time), and later that minute his heart rhythm was identified as V fib/V tach (V fib, or ventricular fibrillation, is a life threatening arrhythmia caused when the lower chambers of the heart quiver rather than beat normally which prevents the heart from pumping blood and leads to cardiac arrest. This is an emergency that requires immediate attention.) Patient #1’s telemetry print out identifies from 10:16 PM to 10:19 PM he alternated between asystole (cardiac arrest, when the heart stops beating) and V fib/V tach, then was in atrial fib at 10:19 PM for approximately 40 seconds before converting to and staying in asystole for 9 minutes until the time a Code Blue was called at 10:25 PM. Patient #1’s Resuscitation Record reveals CPR (cardiopulmonary resuscitation) started 12/05/24 at 10:25 PM and ACLS (Advanced Care Life Support) was attempted but unsuccessful in regaining spontaneous circulation, and the patient died when CPR was stopped in accordance with his representative’s direction on 12/05/24 at 10:36 PM. The Monitor Room Escalation and Resolution Log dated 12/05/24 got Monitor Tech, Staff A documents one entry for Patient #1 with a “1st escalation” of “[name of Unit Secretary] V fib 22.16” and “2nd escalation” of “[name of nurse] V fib 22:18 [10:18 PM].” During telephonic interview on 01/09/25 at 4:51 PM Monitor Tech, Staff A confirmed she monitored telemetry for Patient #1 the evening of 12/05/24 and stated when Patient #1 had a “burst” of V fib, which she clarified as a couple seconds, she called the Unit Secretary who told her the patient had just arrived and was in a room near her and Staff A told the Unit Secretary about the burst of V fib and asked her to tell the nurse to check Patient #1; that when Patient #1 had another burst of V fib less than a minute later she called the Charge Nurse; then she heard pages for a “Rapid Response” and then a “Code Blue”; that Staff A did not call a Code Blue but did what she was supposed to in having the nurse check the patient; and when asked what she should have done Staff A says to have the nurse check the patient which is what she did and that since it was a burst of V fib and return to A fib “we don’t call a Code Blue for that.” Staff A did not acknowledge Patient #1 was in a lethal rhythm for 10 minutes before a Code Blue was called, during which Staff A should have called a Code Blue per the facility’s Telemetry Policy and Procedures or that Staff A would call a Code Blue for lethal rhythms in the future. Review of Monitor Tech schedules from 12/22/24 to 01/04/25 revealed Staff A monitored telemetry since Patient #1’s death, on the night shifts of 12/31/24 and 01/01/25. During interview on 01/10/25 at 3:50 PM with the Chief Nursing Officer (CNO), she reported Staff A had a meeting with her manager about this incident and to go over the Telemetry Policy and Procedures but Staff A walked out of the meeting without receiving or agreeing to follow the policy because Staff A did not think she had done anything wrong. The CNO could provide no evidence that Staff A reviewed the Telemetry Policy and Procedures and/or agreed to follow them to protect patients in lethal rhythms before she worked again as a Monitor Tech. During interview on 01/10/25 at 2:06 PM the Patient Safety Director provided 27 “Education Acknowledgement/Attestation Sheets” for the policy on Telemetry Monitoring and information on responding to life-threatening arrythmias and stated all but 2 Monitor Techs who only worked “as needed” had completed this education. Further review of this documentation and comparison to the Monitor Tech schedules for 12/22/24 to 01/04/25 revealed 8 Monitor Techs who worked during this time had not completed the re-education, including Staff A, and these Monitor Techs worked a total of 17 12-hour shifts. Most notably, 3 of 6 night shift Monitor Techs (MTs) on duty 12/27/24, 3 of 5 night shift MTs on 12/28/24, and 4 of 6 night shift MTs on 01/03/25 did not have evidence of this re-education.”

“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: 29151 Based on policy review, medical record reviews, surveillance video review, Central Log review and interviews, it was determined the facility failed to ensure that an appropriate medical screening examination was provided 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 existed for 1 (Patient#1) of 21 sampled patients. Please refer to citation at A Tag A 2406.”

“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: 29151 Based on policy review, medical record reviews, surveillance video review, Central Log review and interviews, it was determined the facility failed to ensure that an appropriate medical screening examination was provided 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 existed for 1 (Patient#1) of 21 sampled patients. The findings included: Facility policy, titled, EMTALA Medical Screening Examination and Stabilization, last revised 10/2024 revealed, in part, “Procedure: ... An MSE (Medical Screening Examination) is required when: a. A request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition ... 1. When an MSE is Required: A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED (Dedicated Emergency Department), to determine whether or not an EMC (Emergency Medical Condition) exists: (i) to any individual ... (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual’s appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC.” Observation of the surveillance video in the security office while accompanied by Vice President of Quality, the Director of Patient Safety and the ED Director conducted on 12/10/24 at 12:18 PM revealed the following: On 10/27/24 at 02:51 AM, Patient #1 and parents arrived at the ED and interact with Staff A. Staff A is seen leaving the triage desk. At 02:53 AM, ARNP (Advanced Registered Nurse Practitioner) and Staff A returned to the triage desk and the practitioner is seen interacting with the family and leaves the area at approximately 02:55 AM. At 02:55 AM, Family interacts with Staff A and then leave the ED at 02:57 AM. Review of the central log indicated Patient #1 returned to the ED on 10/27/24 at 02:51 AM. The medical record for Patient #1’s second visit to the hospital’s ED was reviewed. The stated complaint was listed as “Abdominal Pain.” Review of the Nurse’s notes dated 10/27/24 at 02:59 AM documentation revealed, “Parents of patient do not want child to be seen by a doctor at this time.” Patient #1 left the ED at 03:03 AM. The record failed to provide evidence that a medical screening examination was provided. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC existed for Patient #1 when a request made on her behalf for medical examination or treatment of a medical condition on 10/27/2024. Medical record review revealed that Patient #1 arrived a Hospital B on 10/27/24 at 3:37 AM with chief complaint of Shortness of breath, left side pain, cough and previously diagnosed with Pneumonia. Medical screening exam 10/27/2024 0356 Chief Complaint Sob (shortness of breath), left side pain, coughing/ diagnosed with pneumonia Arrival Mode to Facility: Walking (10/27/24 03:37:00) History of Present Illness 6-year-old female who was diagnosed with pneumonia earlier tonight brought in for complaint of left-sided chest pain. The family state that the child developed cough and fever for which she was evaluated at a peripheral facility where she was diagnosed with pneumonia and discharged home on Augmentin (antibiotic used to treat infections) few hours ago. They state that on returning home she complained that her left side was hurting and was short of breath for which they brought her in for reevaluation. No medication was given prior to arrival. The child currently has no such complaints. Physical Exam: Triage Vitals and Measurements: 10/27/24 03:37 T: 36.7 Deg (degrees) C (Centigrade) Temperature Oral; HR (heart rate):141(HI) bpm (beats per minute)Peripheral Pulse; Rate RR (respiratory rate); 22; and SpO2 (oxygen saturation): 97 %: Room air Oxygen General: Alert, no acute distress Head: Atraumatic ENMT(ear,nose, mouth and throat): Normal inspection Respiratory: No respiratory distress Cardiovascular: Regular rate and rhythm Gastrointestinal: Abdomen is soft Skin: No rash Medical Decision Making/Documents Reviewed 6-year-old female who was diagnosed with pneumonia earlier tonight brought in for complaint of chest pain/shortness of breath. Physical exam is unremarkable, the child is in no obvious distress. Family was counseled on supportive care and follow-up Reevaluation Reassessed 10/27/24 04:27 HR: 108 bpm Peripheral Pulse Rate RR: 20 SpO2: 98 % Assessment/Plan 1. Upper respiratory tract infection Acute upper respiratory infection, unspecified 2. Pneumonia: Pneumonia, unspecified organism DISCHARGE INFORMATION ED Discharge Disposition: Home ED Checkout Date and Time: 10/27/2024 04:29:46 Interview with the Vice President of Quality, the Ethics and Compliance Officer and the ED Director conducted on 12/09/24 at 11:14 AM revealed the facility identified the incident and self-reported the possible violation. The nurse was not clear on the medical screening process, suggested to the patient’s parents to go to Hospital B for pediatric care, and corrective actions have been initiated. Interview with Staff A, the Registered Nurse who triaged Patient #1 was conducted on 12/10/24 at 11:19 AM. Staff A explained his recollection of the events as follows: the family arrived with a little girl around 11:00 PM, the parents were scared as she was having shortness of breath, the nurse was placing patients and put the child in the fast-track area. The patient was treated and discharged. Then they came back, a couple of hours later, saying they were having the same symptoms, and that the child was not better. Staff A advised the practitioner (ARNP) who previously treated the patient of the child’s return and asked her to speak to the patient. The practitioner then explained to the parents that the child had Pneumonia and that she has to take her medication. Staff A stated to the family that they could see her again, or if they would like to go to a pediatric hospital and the family replied yes, that they would like to go to a pediatric hospital, and Staff A then gave them the information about Hospital B. Staff A realizes that he made a mistake, and no patient should be deterred from being seen and receiving a medical screening exam. Interview with the ARNP conducted on 12/10/24 at 11:38 AM revealed the practitioner had no recollection of Patient #1. After review of the electronic record, she recalled the first visit when the patient was treated and discharged but stated she does not see patients in the lobby, she would see them in the back and does not recall talking to the family during the second visit to the ED. Interview with the ARNP conducted on 12/10/24 12:55 PM revealed, after seeing the video, recalled the child returned, she had received the first dose of antibiotic, the family was concerned that they could not get the medication during the night, she explained that the child did not need the medication until the next morning, and that was it. The ARNP stated she would have seen the patient, but they left.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 29151 Based on clinical record review, interview and review of the Risk Management and Safety Plan, it was determined, the facility failed to implement appropriate corrective actions and mechanism to minimize risk of injury to patients. The deficient practice is evidenced by failure to develop facility wide corrective action plans addressing the root cause of 1 of 1 adverse incident reviewed involving Patient #1. The event resulted in delay in care and services and subsequent patient’s death. The facility failed to develop and implement facility wide monitoring tools to minimize reoccurrence. The findings included: Review of the investigation of the adverse event involving Patient #1 was conducted on 04/18/24 and 04/19/24. The investigation indicates multiple failures that may have contributed to the patient’s death. The facility investigated and reported the adverse event. Interview with The Assistant Chief Nursing Officer and The Director of Patient Safety conducted on 04/18/24 at approximately 9:55 AM revealed the facility offers centralized telemetry monitoring. Telemetry beds are assigned throughout the hospital units. Review of the facility corrective actions implemented after the event, failed to include facility wide staff education and the development of facility wide monitoring tools to sustain compliance. Interview conducted on 04/19/24 at approximately 1:36 PM with The Vice President of Quality and The Director of Patient Safety revealed the facility corrective actions provided to the surveyor only addressed staff education for the telemetry monitoring technicians and 3rd floor clinical staff. In addition, the audit tool developed to monitor compliance documents the tool captures the 3 North and 3 North West units. The Director of Patient Safety stated the plan was to start with the 3rd floor (where the event took place) and later expand the corrective actions to the rest of the hospital. Patient Safety and Risk Management Plan, last revised 01/2024 documents: Goals The goal of the Patient Safety and Risk Management Plan is to reduce medical errors and hazardous conditions by utilizing a systematic, coordinated and continuous approach to the improvement of patient safety. This approach centers on the establishment of mechanisms that support effective responses to actual occurrences and hazardous conditions; ongoing proactive reductions in medical/health care errors; and integration of patient safety priorities in the design and redesign of all relevant organizational processes, functions and services. A proactive ongoing systematic approach for the detection and resolution of events which may or do impact patient safety will be supported through: Recognition and acknowledgement of the potential for medical/health errors and/or injuries and risks to patient safety; Initiation of actions to reduce these risks; Internal reporting of what has been found and the actions taken Process and system focused corrections to reduce related failures including thorough and credible Serious Event Analysis and routine Failure Mode and Effects/Criticality Analysis (FMEA/FMECA) Minimization of individual blame or retribution for involvement in a medical/health care error; Organizational learning about medical/health care error; and, The support of sharing of lessons learned to effect behavioral changes organizational wide and across other health care organizations.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 29151 Based on policy review, clinical record review and interview, it was determined, the nursing staff failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 2 of 5 sampled patients (Patient #7 and #8) as evidenced by failure to follow physician’s orders for insulin administration. The findings included: 1) Clinical record review conducted on 04/18/24 and 04/19/24 revealed Patient #7 has physician’s orders for Lispro insulin moderate sliding scale before meals and at bedtime. If Blood Sugar (BS) 71-150 No coverage BS 151-200 Give 4 units BS 201-250 Give 8 units BS 251-300 Give 10 units BS 301-350 Give 12 units BS 351-400 Give 16 units BS greater than 400 give 18 units and call physician. Medication administration records dated 04/18/24 documents Patient #7 had blood sugar reading of 155 at 12:54 PM. The record indicates the patient received the wrong insulin dose, 2 units. According to the scale the patient should have received 4 units. 2) Clinical record review conducted on 04/18/24 and 04/19/24 revealed Patient #8 has physician’s orders for Lispro insulin mild sliding scale before meals and at bedtime. If Blood Sugar (BS) 71-150 No coverage BS 151-200 Give 2 units BS 201-250 Give 4 units BS 251-300 Give 6 units BS 301-350 Give 8 units BS 351-400 Give 10 units BS greater than 400 give 12 units and call physician. Medication administration records dated 04/02/24 documents Patient #8 had blood sugar reading of 243 at 8:30 PM and received the incorrect dose of insulin 2 units. According to the sliding scale the patient should have received 4 units. Medication administration records dated 03/28/24 documents Patient #8 had blood sugar reading of 157 at 2:35 PM and received the incorrect dose of insulin 0 units. According to the sliding scale the patient should have received 2 units. The record validates the prior blood sugar reading was obtained at 9:21 AM and there is no clinical justification for the omission. Medication administration records dated 03/27/24 documents Patient #8 had blood sugar reading of 352 at 12:59 PM and received the incorrect dose of insulin 8 units. According to the sliding scale the patient should have received 10 units. Medication administration records dated 03/27/24 documents Patient #8 had blood sugar reading of 393 at 9:41 AM and received the incorrect dose of insulin 15 units. According to the sliding scale the patient should have received 10 units. The record provides no evidence of additional insulin orders. Interview with The Assistant Chief Nursing Officer/Informatics, who navigated the electronic clinical record, verified there are no written physician’s orders to validate the deviation from the insulin sliding scale documented above. Facility policy titled “Medication Administration” last revised 01/2024 documents as follows: PURPOSE: To promote safety by ensuring to Provide Parameters and General Guidelines for Proper and Safe Medication Administration. Implementation is successful within a culture that promotes teamwork and where all individuals feel empowered to ensure patient safety. POLICY: Drugs shall be administered only upon order of a member of the Medical Staff, an authorized member of the house staff, or other individual who has been granted privileges to write such orders. Medications or routes of administration not addressed in this policy will be assessed based on the clinical needs of the patient and skills required for safe administration and monitoring. GENERAL GUIDELINES: 1. Drugs should be administered as soon as possible after the dose is prepared, particularly medications for parenteral administration. I. Never leave medication unattended. J. Remember medication principles: i. Right Patient: Check identification band and ask patient his name. Use 2 identifiers. ii. Right time iii. Right medication iv. Right dose v. Right mode of administration vi. Right education vii. Right documentation 3. Before administration, the individual administering the medication does the following. A. Verifies that the medication selected matches the medication order and product label. B. Visually inspects that the medication for particulates, discoloration, or other loss of integrity. C. Verifies that the medication has not expired. D. Verifies no contraindications exist. E. Verifies the medication is being administered at the proper time, in the prescribed dose, and by the correct route. 4. Any unresolved concerns about the medication are discussed with the patient’s LIP, prescriber and/or staff that is involved with the patient’s care, treatment, and services. Before administering a new medication, the patient or family is informed about any potential clinically significant adverse drug reactions or other concerns regarding administration of a new medication.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 29151 Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 1 of 1, out of 5 sampled patients reviewed for nursing services, (Patient #11) as evidenced by failure to reassess patient’s condition during a blood transfusion as specified per facility protocols. The findings included: Facility policy titled “Blood Products Administration” revised 11/2023 documents: SCOPE: To provide guidelines for safe administration of blood and blood products within the facility. PURPOSE: 1. To promote safety by ensuring to inform nursing personnel of hospital policy regarding the guidelines for the safe administration and refusal of blood and blood products 2. Provide guidelines to rapidly identify and appropriately respond to suspected transfusion reactions. Implementation is successful within a culture that promotes teamwork and where all individuals feel empowered to ensure patient safety. POLICY: 9. PROCEDURE FOR MONITORING AND DOCUMENTATION A. The RN will stay with the patient and continuously assess for signs and symptoms of blood transfusion reaction for the first 1 5 minutes for each transfused product. For patient areas utilizing the vital sign neuron capsule the RN will document assessment and vital signs in the BCTA desktop by clicking the “capture” button. All other patient areas will document assessment and vital signs by clicking “document” the button. All patient areas will document vitals and any potential transfusion reactions at the following intervals: i. 5 minutes after initiation of transfusion and as patient condition required. ii. 1 5 minutes after initiation of transfusion and as patient condition requires iii. 30 minutes after initiation of transfusion and as patient condition requires. iv. 1 hour after initiation of transfusion and as patient condition requires. v. Every hour thereafter until transfusion is complete. B. Upon documentation of final vital signs click: END on BCTA Desktop. C. A final set of vital signs should be documented 30 minutes after END time in BCTA. D. Repeat above steps to verify and transfuse subsequent units. E. Enter through to populate date and time fields and record volume of blood product and NS infused. Clinical record review conducted on 04/19/24 revealed Patient #11 was prescribed a blood transfusion on 04/05/24. The record indicates the staff obtained pre transfusion vital signs at 7:52 AM; the transfusion started at 8 AM. The staff monitored the patient at 8:06 AM and 8:30 AM. The transfusion ended at 11:21 AM and the next monitoring was documented at 11:23 AM. The nurse failed to follow the facility policies and procedures for blood transfusion monitoring, as evidenced by lack of monitoring hourly and 30 minutes after the completion of the blood transfusion. Interview with the Assistant Chief Nursing Officer/Informatics (ACNO), who navigated the electronic record, was conducted on 04/19/24 at 12:05 PM. The ACNO stated she will research the record for further documentation. At approximately 2:01 PM, the ACNO provided copies of the blood transfusion monitoring, validating the staff did not follow the blood transfusion protocols.”

“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: 29151 Based on Policy review, Clinical record review, Transfer Log review, Patient Care Report, and interview, it was determined the facility failed to ensure that a transfer was appropriate to another hospital with available capability and capacity was provided for 1 of 20 sampled patients with an unstable emergency medical condition; and failed to obtain a confirmed acceptance of patient #1 prior to transfering patient #1 to the receiving hospital. Refer to findings in citation A-2409.”

“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: 29151 Based on Policy review, Clinical record review, Transfer Log review, Patient Care Report, and interview, it was determined the facility failed to ensure that a transfer was appropriate to another hospital with available capability and capacity was provided for 1 of 20 sampled patients with an unstable emergency medical condition; and failed to obtain a confirmed acceptance of patient #1 prior to transfering patient #1 to the receiving hospital. The findings included: Review of the facility policy, titled, EMTALA - Florida Transfer Policy, dated 10/22, documented, in part, the following: “This policy reflects guidance under the Emergency Medical Treatment and Labor Act (EMTALA) and associated State laws only... Policy: Any transfer of an individual with an EMC [Emergency Medical Condition] must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual’s behalf or by a physician order with the appropriate physician certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC apply to any emergency department (“ED”) or dedicated emergency department (“DED”) of a hospital whether located on or off the hospital campus and all other departments of the hospital located on hospital property...1. Transfer of Individuals Who Have Not Been Stabilized: a. If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions: The individual or a legally responsible person acting on the individual’s behalf requests the transfer, after being informed of the hospital obligations under EMTALA and of the risks and benefits of such transfer. The request must be in writing and indicate: The reasons for the request as well as indicate that the individual is aware of the risk and benefits of transfer;...b. A transfer will be an appropriate transfer if: i. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health ...; ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment...c. Higher Level of Care - A higher level of care should be the more likely reason to transfer an individual with an EMC that has not been stabilized. The following are examples of a higher level of care: i. A receiving hospital with specialized capabilities or facilities that are not available at the transferring hospital ...must accept an transfer of an individual with EMC who requires specialized capabilities or facilities if the hospital has capacity to treat the individual....c. Request To Transfer Made to Receiving Facility. The transferring hospital must call the receiving hospital or the Transfer Center if the facility is part of a Transfer Center network to verify the receiving hospital has available space and qualified personnel for the treatment of the individual. The receiving hospital must agree to accept the transfer and provide appropriate treatment. The transferring hospital must obtain permission from the receiving hospital to transfer an individual. This may be facilitated by a Transfer Center. Such permission should be documented on the medical record by the transferring hospital, including the date and time of the request and the name and title of the person accepting transfer. The transferring physician shall ensure that a receiving hospital and physician that are appropriate to the medical needs of the individual have accepted responsibility for the individual’s medical treatment and hospital care. If utilizing the services of a Transfer Center, the Transfer Center may facilitate this step in the process but does not take the place of the transferring physician. ...Request. The transferring hospital must document its communication with the receiving hospital, including the request date and time and the name of the person accepting the transfer...” Clinical record review conducted on 02/13/24 revealed that Patient #1 presented to the Emergency Department (ED) at Hospital A seeking care for an emergency medical condition (EMC). The patient presented via fire rescue on 12/28/23 at 11:01 PM, with chief complaints of being unresponsive and bleeding. The patient was triaged at 11:05 PM with an emergent acuity. The nurse documented vital signs as: blood pressure 71/37, ( Blood Pressure reading under 90/60 is considered abnormally low)respirations 16, temperature 36.7 and heart rate 120 bpm [beats per minute] ( normal heart rate 60-100). The oxygen saturation was noted at 98% on 2 liters of oxygen via nasal cannula. The physician completed a Medical Screening Exam (MSE) at 11:05 PM, documenting the patient was here for evaluation of Gl (Gastrointestinal) bleed, and the presentation included stool bright red blood and syncope (fainiting or passing out). Laboratory studies revealed critical low hemoglobin of 5.4 d/gl (normal range 12-14 d/gl). Patient #1 was stabilized with a blood transfusion, medications and intravenous (IV) fluids. Hospital A did not have GI coverage and initiated a transfer to a sister facility (Hospital B) located fifteen miles away. Hospital B accepted the patient. Record review indicated Patient #1 had a change in condition and became unstable at approximately at 2:05 AM. The physician documented the patient became less responsive, noted bradycardia (Low heart rate), agonal breathing (irregular breathing, grasping breaths, indicates a sever medical emergency), and required intubation (person has breathing tube inserted through their mouth or nose into the windpipe connects to a machine that delivers air or oxygen), and a Dopamine infusion drip (medication used to treat low blood pressure). The physician decided to transfer the patient to Hospital C, located two miles away for clinical safety. Hospital C instructed Hospital A that they would return the call for acceptance pending approval of GI services. Record review indicated at 3:20 AM, the transportation company left Hospital A with the patient enroute to Hospital C, while Hospital A was still waiting on acceptance from Hospital C for Patient #1. Review of the documents, titled, EMTALA Memorandum of Transfer, did not document whether the patient was stable or unstable for transfer. The physician certified the transfer on 12/29/23 at 1:00 AM and the transfer was medically indicated for GI services not available at Hospital A. The medical risks associated with the transfers were documented. Hospital C was noted under the receiving facility, but there was no receiving physician name on the document. The form documented the nurse gave report to an ‘RN’ (Registered Nurse) but no name was noted, and the vital signs at 3:00 AM, prior to transfer, were noted as: pulse 48, respirations 10 (normal respiratory rate 12-20 breaths per minute), blood pressure 69/32 and oxygen level 97% on four liters of oxygen. The patient was being transported with advance life support, via a private transportation company with a paramedic and the patient was receiving a Protonix infusion (treat conditions that cause too much stomach acid, like heartburn and reflux disease).. The memorandum did not document Patient #1’s clinical presentation: the patient was intubated, receiving Dopamine drip, and had a nasogastric (NG) tube in use. Review of the ‘Transfer Center detailed call logs’ documented Hospital C did not accept Patient #1. On 12/29/23 at 3:56 AM, Hospital C informed Hospital A’s transfer center that Patient #1 was not accepted, but the patient had arrived at Hospital C and was subsequently sent to Hospital B due to lack of capacity and capability. Review of the Transportation Company document, titled, Patient Care Report, dated 12/29/23, indicated Patient #1 left Hospital A at 3:25 AM, arrived at the Emergency Room (ER) of Hospital C, was not accepted at Hospital C due to lack of capacity and capability per the nurse and ER physician, and arrived at Hospital B at approximately 4:02 AM. The facility failed to ensure that their poliy was followed as evidenced by failing to ensure that the receiving hospital had accepted the responsibility of patient #1 on 12/28/2023 medical treated and hospital care as stated in the facility policy. Interview with the Emergency Department (ED) Physician at Hospital A conducted on 02/13/24 at 11:45 AM revealed his recollection of Patient #1. The patient presented with GI bleed, they did not have GI On-Call, the patient was clinically stable, his vital signs were good and occult blood was positive. The diagnostic studies were completed, the patient was anemic and received blood. The physician stated a transfer to their sister facility (Hospital B) was initiated for GI services. The physician stated he followed the protocol, but later, the patient’s condition changed, he became hypotensive, unresponsive, and required immediate intubation. The intubation proceeded with no issues and then he contacted Hospital B to update them on the patient’s condition. The patient was unstable now, and he then decided to send the patient to Hospital C, the closest hospital with GI services and the physician from Hospital B agreed with the plan. The ED physician then spoke to the ED physician at Hospital C, who was receptive to the transfer but needed to check with the GI consultant prior to accepting the patient as the facility was over capacity. The ED physician recalled, he went to see another patient, and when he returned Patient #1 was gone. The transport company had showed up, basically scooped up the patient and proceeded to take the patient to Hospital C without his approval. He, the physician, did not see the patient leave, but this was told to him by the Charge Nurse. The physician stated he did not think from the medical point of view that he did anything wrong, as he followed the protocol. When asked how a patient leaves the ED without the staff being aware of the transport, and what actions could be taken to prevent the incident, the physician replied, maybe the communication within transportation and the nurses could be better, maybe he could be more vigilant about the patients. Interview conducted on 02/13/24 at 12 noon with the ED Medical Director (ED-MD) of Hospital A revealed he was made aware of the event. The ED-MD revealed the facility does not always have GI coverage. The patient was transported to Hospital C without proper approval. The ED-MD was asked what they could do better and stated maybe they should not give the transfer paperwork to the transport company until the transfer has been approved. The ED-MD stated the facility has implemented the following corrective actions: EMTALA education to providers regarding the transfer policy and documentation of stable versus unstable. Interview with Staff A, the Charge Nurse, conducted on 02/13/24 at 3 PM, revealed she was the charge nurse on 12/28/23, her shift is 7 PM - 7AM, she had never done charge duties before, she is a new nurse, and that night she did not have a unit secretary. Staff A recalled the patient needed to be transferred out. She called the Transfer Center (TC) and informed them. The TC personnel asked for patient information and then the physician spoke to them. The patient was initially going to Hospital B, the patient was accepted, but later during the shift, the patient started to decline, and the physician asked her to call the TC to send the patient to a closer hospital. They spoke to the doctor at Hospital C and the patient was accepted pending GI approval. Staff A confirmed she prepared the paperwork for transfer to Hospital C, walked away from the desk, and when she returned the patient was gone. Staff A elaborated that the paramedic wanted to take the patient to Hospital C from the beginning and she told him that Patient #1 had not been accepted yet. Interview with Staff B, the Primary Nurse, was conducted on 02/14/24 at 10:05 AM. Staff B recalled Patient #1 came in via fire rescue, he was in and out of consciousness, and he was a GI bleed with melena. They followed the GI bleed protocol: did an EKG, he received intravenous fluid and a blood transfusion. Staff B stated at first, the patient was going to be transferred to Hospital B, then the paramedic came, and he was not comfortable taking the patient there. Staff B stated she was not sure why, as there have been many patients more unstable and other paramedics transported them to Hospital B with no issues. The Charge Nurse stated she did not know she could challenge the paramedic, and he (paramedic) made the call. She recalls the paramedic talking to the ED physician but is not sure of what was said. Staff B stated the patient deteriorated and was intubated. Prior to that, he was alert and responding. She was aware the paramedic was taking the patient to Hospital C, and again stated she did not know what else to do. She stated she knows Hospital C is the trauma center and they always have surgeons available, so she did not push back on the paramedic. The nurse confirmed she did not give report to Hospital C, as she was not able to do so after the patient’s change in condition. Interview with the Director of the Transfer Center and the Transfer Center Registered Nurse (TCRN), who assisted with Patient #1’s request for transfer, was conducted on 02/15/24 at 7:20 AM. The TCRN revealed she received the intake call from Hospital A, the facility was requesting a transfer to Hospital B for GI services not available at Hospital A. The patient was accepted, and transportation was arranged. As far as she knew, the case was closed and completed. The TCRN stated, later, she was not clear on what was happening, and called Hospital A to inquire about the case, as she saw that Hospital C had been contacted. When she called, the charge nurse told her that the transportation company had taken the patient to Hospital C, without their acceptance, and she then contacted Hospital C’s Transfer Center for notification. The TCRN verified the TC is responsible for contacting the transferring facility with acceptance or denial of all transfers. The decisions are not communicated by the nurse or physician on duty, as they (TCs) are the ones making all the necessary arrangements including transportation. Interview conducted with the paramedic of the Transport Company on 02/20/24 at 1:47 PM revealed he responded to the call to transport Patient #1. When he arrived, the patient was hypotensive and barely breathing, and told the nurse he needed to be intubated. The physician intubated and started the pressors. The nurse told him the patient was going to Hospital B. He told them the patient was unstable and should go to Hospital C, as they were closer. He proceeded to transfer the patient to the stretcher and waited. He kept telling them the patient was going to code and he needed to transport the patient. They did say Hospital C was ‘on hold’; but he proceeded to take the patient to Hospital C based on the patient’s condition. He called Hospital C to advise them of the patient, and they responded, ok, we will see you when you get here. When he arrived, the nurse and doctor told him they did not have GI on-call. He was at Hospital C less than five minutes and was told to take the patient to Hospital B and he did so. .”