Uf Health Leesburg 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: 49777 Based on medical records reviews, Medical Staff Bylaws review, Medical Staff Rules, Regulations and Policy Manual review , Hourly Rounding Log review , Ambulance Run Sheet review, Policy and Procedure review, and staff interviews, it was determined the facility failed to provide all individuals presenting to the hospital’s emergency department with presenting signs and symptoms (altered mental status, hallucinations, chest pain, weakness, blistered possibly infected leg ulcers, chest pain/shortness of breath, left eye blurred and gray vision, high blood pressure/dizziness, syncope/chest pain, urinary catheter with pain/bloody urine in drainage bag) received an appropriate medical screening examination (MSE) within the capability of the hospital’s Emergency Department (ED) determine whether or not an emergency medical condition existed for 15 (fifteen) Patients (Pt) #1, Pt #2, Pt #3, Pt #6, Pt #8, Pt #9, Pt #12, Pt #13, Pt #14, Pt #15, Pt #16, Pt #17, Pt #18, Pt #19, and Pt #20 out of 20 (twenty) sampled patients medical records reviewed. Additionally, the facility’s Medical Staff Bylaws and Medical Staff Rules, Regulations and Policy Manual failed to identify individuals qualified (Qualified Medical Personnel - QMP) to conduct medical screening examinations for all patients presenting to the hospital’s emergency department seeking emergency services. The facility failed to have an effective system in place to ensure that patients in the hospital’s ED lobby received an appropriate medical screening examination by Qualified Physicians or Qualified Medical Person or Personnel. Refer to findings in 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: 49777 Based on medical record reviews, Medical Staff Bylaw review, Medical Staff Rules, Regulations and Policy Manual review, Hourly Rounding Log review, Ambulance Run Sheet review , Policy and Procedure review, and staff interviews, it was determined the facility failed to provide all individuals presenting to the hospital’s emergency department with presenting signs and symptoms (altered mental status, hallucinations, chest pain, weakness, blistered possibly infected leg ulcers, chest pain/shortness of breath, left eye blurred and gray vision, high blood pressure/dizziness, syncope, chest pain, and indwelling urinary catheter with pain/bloody urine received an appropriate Medical Screening Examination (MSE) within the capability of the hospital’s Emergency Department (ED) to determine whether or not an emergency medical condition existed for 15 (fifteen) Patients, (Pt) #1, Pt #2, Pt #3, Pt #6, Pt #8, Pt #9, Pt #12, Pt #13, Pt #14, Pt #15, Pt #16, Pt #17, Pt #18, Pt #19, and Pt #20, out of 20 (twenty) sampled patients, whose medical records were reviewed. Additionally, the facility’s Medical Staff Bylaws and Medical Staff Rules, Regulations and Policy Manual failed to identify individuals qualified to conduct medical screening examinations for all patients presenting to the hospital’s emergency department seeking emergency services. The facility failed to have an effective system in place to ensure that patients in the hospital’s ED lobby received an appropriate medical screening examination by Qualified Physicians or Other Qualified Medical Person or Personnel. Findings include: The facility’s Policy and Procedure titled “Medical Screening Policy” Policy # 4666 , Effective Date: 01/22/2024, Last Revision Date: 01/22/2024 was reviewed. The Policy read in part, , “ ... Policy: The hospital with an emergency department must provide to an individual that is not a patient who “comes to the emergency department” an appropriate MSE, 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 (EMC) exists, ... The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual requests emergency care on hospital property, other than in a DED or when a person is involuntarily brought to a DED after being placed under a Baker Act by law enforcement ... PROCEDURE: Definitions: ... Comes to the Emergency Department means with respect to an individual who is not a patient, the individual: 1. Has presented at a hospital’s DED and requests examination or treatment for a medical condition , or has such a request made on his or her behalf In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual’s appearance or behavior, that the individual needs examination or treatment for a medical condition ...4. Is in a ground or air non-hospital -owned ambulance on hospital property for presentation for examination and treatment for a medical condition at a hospital’s DED. Emergency Medical Condition (EMC) means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: 1. Placing the health of the individual ... in serious jeopardy; ... Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part; ... Such screening must be done within the facility’s capability and available personnel, including on-call physicians, and be applied in a non-discriminatory manner (i.e., a different level of care must not exist based on payment status, race, national origin, etc.) Screening is to be conducted to the extent necessary, by physicians and/or other qualified medical personnel to determine whether an EMC exists ...The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the individual’s needs and must continue until the individual is either stabilized or appropriately transferred. Qualified Medical Person (QMP) or Personnel means an individual in addition to a licensed physician who is licensed or certified and who has demonstrated current competence in the performance of MSEs (Medical Screening Examinations.” Further review of the policy revealed in part, “Quality Medical Person or Personnel means an individual in addition to a licensed physician who is licensed or certified and who has demonstrated current competencies in the performance of MSEs, for example: Registered Nurse in Perinatal Services, Psychiatric Social Worker, Registered Nurse in Psychiatric Services, Psychologist, Physician Assistant, Advanced Registered Nurse Practitioner , Certified Registered Nurse Midwife. The above-referenced categories are examples of professional that may be approved by a hospital’s governing board as qualified to administer one or more types of initial MSEs ...The hospital’s governing board must be make such determination on behalf of the hospital through the hospital’s bylaws or rules and regulations.” The facility’s Medical Center Medical Staff Bylaws, adopted by the Medical Staff of the Medical Center on December 3, 2020, and ratified and adopted by the Board of Directors of the Medical Center on January 5, 2021, was reviewed. The facility’s Medical Staff Rules, Regulations and Policies Manual, last revised 2/2025 was reviewed. The Medical Staff Bylaws and the Medical Staff Rules, Regulations and Policy Manual failed to identify individuals who were determined qualified to conduct medical screening examinations in the hospital’s emergency department. During an interview on 06/22/2026 at 1:42 PM via telephone with Staff C, Risk Manager, when asked according to the Medical Staff Bylaws and the Medical Staff Rules and Regulations, and Policy Manual who is deemed competent to conduct MSEs in the emergency department, Staff C stated, “We are aware that the Medical Staff Bylaws and Medical Staff Rules and Regulations do not clearly specify who is responsible for performing medical screening exams. We added this to our plan of correction.” 1. Review of the Emergency Department (ED) medical record for Patient #1 documented the patient arrived in the emergency department on 1/20/2026 at 10:25 AM. Review of the ED note read, “Brought in by wife for concerns of altered mental status, fatigue, confusion, hallucinations x 2 days. History includes Parkinson’s disease (disorder or the nervous system that affects movement), CABG [coronary artery bypass grafting - surgical procedure to improve blood flow to heart muscle], prostate cancer. No anticoagulation use.” Vitals Signs completed at 10:30 AM, temperature 98.1 Fahrenheit, pulse: 92 (normal pulse rate 60-100), respirations 20, blood pressure 144/88 (normal blood pressure less than 120/80). Chief Complaint: Altered mental status (a sudden of significant change is a person’s level of awareness or consciousness). Further review revealed the patient as triaged (medical and nursing process of rapidly assessing, sorting and prioritizing patients based on the severity of their condition) as “Patient Acuity (a measurement of the severity of a patient’s illness or condition) Emergent (2) [Emergent high-risk conditions that can worsen quickly]. Review of the medical record also revealed the triage nurse used Adult Weakness and Fatigue/Syncope/Dizziness standing orders to place orders at 10:43 AM. The triage nurse obtained a verbal order from the ED physician for a CT [computed tomography a 3-dimensional image] head/brain and documented the verbal order. EKG [electrocardiogram - used to test the electrical activity of the heart] completed at 10:43 AM. EKG reads Sinus Tachycardia (Adult heart rate over 100 beats per minute) Heart rate was 101). There was no documentation in Patient #1’s record the EKG was presented to and read by the physician. Labs were collected at 10:47 AM with all lab tests and results completed by 11:09 AM. The urinalysis with reflex [a two-step diagnostic test] was referred for urine culture. Urine dark yellow with trace ketones and protein. Chest x-ray impression at 11:01 AM read, “No acute cardiopulmonary [heart/lung] abnormality”. CT head without contrast [no dye was injected into the vein] impression at 12:44 PM read, “No acute intracranial (the skull) abnormality. Prominent paranasal sinus disease [inflammation of the sinus mucosal tissue lining].” Vital signs were documented as completed on 1/20/2026 at 1:02 PM, 3:41 PM, 6:41 PM and 9:14 PM. Review of Patient #1’s “ED Disposition” read, “LWBS [left without being seen] at 10:23 PM.” Review of the policy and procedures titled “Emergency Department Standing Orders, Adult Care (18 years old and above)” read, “Weakness and Fatigue/Syncope: 1. Place IV [intravenous line-flexible tube placed directly into a vein to deliver medicine, fluid into the blood stream] saline lock. 2. Draw and send CBC with diff [complete blood count that measures red and white blood cells, and platelets], BMP [basic metabolic panel used to diagnose conditions], and Hepatic Function [liver function test]. 3. Obtain urine and send for urinalysis with reflex CS [culture and sensitivity]. 4. Order CXR [chest x-ray], 2 views. Patient signs/symptoms or known diagnosis: Weakness and Fatigue. 5. Perform 12 lead EKG. Have EKG interpreted by ED attending within 10 minutes.” Review of the “Refusal of Medical Care” form dated and signed by Patient #1’s spouse on 01/20/2026 read, “C. Refusal on Behalf of patient (To be used for minors and incapacitated adults), [name of Patient #1’s spouse], the spouse of the above-named patient, refuse emergency examination and treatment because excessive wait of 12 hours.” Review of the ED medical record for Patient #1 did not show documentation of a physical examination or MSE having been performed by a Physician or Qualified Medical Personnel (QMP) on 1/20/2026 for Patient #1 to determine whether or not an EMC existed. During an interview on 4/16/2026 at 12:03 PM, the ER Manager stated, “There is no doctor note or that an MSE was completed for this patient [Patient #1] in the record. The physician notes would be under the “All notes” in the medical record. There are no physician notes because the physician did not see the patient. The medical refusal form is no longer in use. We quit using the form on the record and I pulled the form about two weeks ago.” During an interview on 4/16/2026 at 12:03 PM, the ER Manager stated, “There was a large number of holds in the department [emergency] on 1/20/2026 which contributed to delays in being seen.” The ER Manager provided the hourly tracking data. The Hourly Rounding Log was reviewed with the ED Manager and showed the hourly rounding log is completed by the unit secretary that outlines the number of patients in the ED, the number of patients in the waiting room, the number of emergency medical services [EMS-ambulances], the number of patient holds [patients waiting for a bed in the hospital] and the number of patients in fast/track. For the day shift on 1/20/2026 from 7:00 AM to 7: PM, the range of ED patients was 35 to 52 patients. The waiting room ranged from 1-16 patients, EMS was 1-4, holds were 22-30, fast track had 1-6 patients. For the night shift on 1/20/2026 from 7:00 PM to 7:00 AM the range of ED patients was 13 to 50 patients, the waiting room ranged from 0 to 12 patients, EMS was 1-4, holds were 7 to 28, and fast track had 0 to 6 patients. The ER Manager stated, “It took 24 hours to decrease the number of holds. The physician and nursing staff coverage is staggered. There was no decision made to divert. We have safety huddle at 8:30 PM and report the ED census and number of holds. Four RNs were brought to the ED to care for the patients on hold. Our normal census runs about 128 patients in a 24-hour period and our LWBS rate for 1/20/26 was 9%.” During an interview on 4/16/2026 at 4:00 PM, the Medical Director of Emergency Department stated, “All patients presenting to the emergency room need to have a medical screening exam unless they sign out AMA [against medical advice].” During an interview on 4/17/2026 at 3:30 PM, the Assistant Vice President Nursing stated, “The wife of [Patient #1’s name] did contact patient relations. In summary of the feedback; the wife brought [Patient #1’s name] to Leesburg ED at approximately 10:30 AM on Tuesday 1/20/2026. [Patient #1] has Parkinson’s, previously had a heart surgery here on 8/2025 and on this day was experiencing hallucinations, was delusional which is abnormal for him. His wife says all the testing was completed in the ED by 2:30 PM and they were still waiting with no care or resolution by 10:30 PM. They left without him being seen by a physician and had follow-up with the PCP [primary care physician] the next day. His wife said she’s very distraught over having spent over 12 hours here without being seen. The former ED Director and Manager on February 5, 2026, spoke to the wife over the telephone. The Patient was unhappy with the wait time in the lobby.” During an interview on 4/17/2026 at 5:45 PM, the CRM was asked, “What is the facility’s protocol as it relates to care of patients who are sitting in the ED’s lobby and the laboratory tests come back positive for a urinary tract infection and the patient presented with signs and symptoms indicating a possible UTI?” The CRM stated she would like to review the information prior to answering. On 4/18/2026 at 10:00 AM, the CRM provided email from the ER Manager dated 4/17/2026 at 9:30 PM that read, “For patients that present with that type of complaint [possible UTI], RNs have the ability to order standing orders for Adult Weakness and Fatigue/Syncope/Dizziness Standing Orders Approved by MEC [Medical Executive Committee] December 19, 2023. If imaging results are critical or positive, the radiologist will call the ER [emergency room] provider to communicate the findings via telephone. This is followed up by communication between the provider, the triage nurse, and charge nurse to ensure the patient is brought back to a room for prompt evaluation. For critical laboratory results, the process is to immediately notify the ER provider and inform the charge nurse so the patient can be brought back to a bed for prompt provider evaluation. There is also a policy for this it falls under #911.” During an interview on 4/18/2026 at 10:20 AM, Staff A, RN, stated, “When the triage nurse has a patient presenting with a change in mental status and weakness, she would use the standing order set for weakness and fatigue. If there is a change in the patient’s condition or a lab value indicating a possible UTI with a change in mental status while they are waiting in the emergency department waiting room, the triage nurse would notify the charge nurse so the patient can be brought to a room, and the physician would be notified.” During an interview on 4/18/2026 at 5:35 PM, the ED Advanced Practice Registered Nurse (APRN) stated, “All patients presenting to the emergency room need to have a medical screening exam as soon as possible. The MSE is performed to determine if the patient has an emergent medical condition. If we have a transfer, I will discuss it with the ED physician, and I do sign the transfer certification if the physician is not available at the time. Our medical director conducts monthly staff meetings every third Tuesday of the month via [virtual meeting software name] meetings. If a patient is wanting to leave before an MSE, I expect the nurses to let me know so I can see them before they leave and encourage them not to leave if possible”. 2. Review of the ED medical record for Patient #2 documented the patient arrived in the emergency department on 1/20/2026 at 6:30 PM as a walk-in. Review of the ED note read, “c/o [complaint of] constant sharp, stabbing chest pain all day with nausea. Pain scale 10/10, location chest. Chief Complaint: Chest Pain.” Vital signs were documented as completed at 6:33 PM: temperature 98.1 Fahrenheit, pulse: 110, respirations 22, blood pressure 127/73. Patient #2 was triaged as “Patient Acuity Emergent (2).” The record documented standing orders were used by the triage nurse for chest pain for orders documented at 6:38 PM for an EKG - nursing to have EKG interpreted by the ED Physician within 10 minutes, medication - aspirin tablet 325 mg; lab panel - CBC and differential, Comprehensive Metabolic Panel. Troponin 1 HS [high sensitivity - a blood test used to measure amounts of protein released to indicate if there was heart muscle damage, capable of detecting very small amounts of protein], troponin 1 HS 2 hour; Chest x-ray 1 view frontal, IV Medlock (catheter inserted into vein and capped off), Protime-INR and PTT (measures how long it take the blood to clot). EKG completed at 6:44 PM EKG read Sinus Tachycardia [Adult heart rate over 100 beats per minute] Heart rate was 101. Further review of the EKG revealed, Biatrial Enlargement (both chambers of the heart are larger than normal), Probable Left Ventricular hypertrophy (thickening and enlargement of the heart’s main pumping chamber) , “Abnormal ECG”. Lab tests with results were completed by 7:11 PM. The chest x-ray impression at 7:12 PM read, “No evidence of acute pulmonary [lung] process.” Vital Signs were documented as completed on 1/20/2026 at 6:41 PM. Review of Resident #2’s “ED Disposition” read LWBS at 7:32 PM. ED notes addendum read, “Pts (Patient’s) wife came up to lobby desk and requested this ED tech take out IV because they wanted to leave. Pt informed of risks of leaving. Patient verbalizes he understands risks. IV removed. LWBS.” The form was signed at 7:25 PM. Review of the policy and procedures titled “Emergency Department Standing Orders, Adult Care (18 years old and above)” read, “Chest Pain: 1. Obtain a 12 lead ECG [electrocardiogram] and have it interpreted by the ED attending within 10 minutes of patient’s arrival to the Emergency Department.” Review of Patient #2’s ED Notes dated 1/20/2026 at 7:31 PM read, “Patient’s wife came up to lobby desk and requested this ED tech take out IV because they wanted to leave. Patient informed of risk of leaving. Patient verbalized he understands risks. IV removed. LWBS.” The form was signed at 1925 (7:25 PM). Review of ED medical record for Patient #2 did not show documentation of a physical examination or MSE for Patient #2 was performed by a Physician or QMP to determine whether or not an EMC existed. The record did not show documentation the physician ordered EKG was interpreted by the physician. During an interview on 4/16/2026 at 1:25 PM, the ER Manager checked Patient #2’s medical record “All notes” and confirmed there was no MSE noted for Patient #2. During an interview on 4/17/2026 at 3:20 PM, Staff B, Patient Care Technician, stated, “I was told that I should chart what I do. When a patient comes to the lobby desk to go home prior to being seen by the doctor, I have them sign the left without being seen form.” 3. Review of the ED medical record for Patient #3 documented the patient arrived in the emergency department on 1/20/2026 at 2:59 PM as a walk-in. Review of the ED note read, “Chief complaint: weakness, brought in by neighbor for evaluation of decreased intake, weakness, confusion, declining over the last few months. He lives alone without any family. His neighbor reports that he [Patient #3] usually eats cereal for breakfast in the morning and not much else.” Vital signs were documented as completed at 3:07 PM: temperature 97.7 Fahrenheit, blood pressure 94/61. Patient #3 was triaged as “Patient Acuity Emergent (2).” The triage nurse used standing orders for weakness to place orders at 3:20 PM consisting of an EKG, lab panel - CBC and differential, comprehensive metabolic panel, urinalysis with reflex to urine culture. A verbal order was received for a CT of the brain/head w/o contrast from ED physician and inserted an IV Medlock. The EKG was completed at 3:33 PM. The EKG read, “atrial sensed ventricular paced rhythm [pacemaker (small battery powered device prevents the heart from beating too slowly) detection].” The record does not show documentation a MSE was completed by a Physician or QMP. . All labs and results were completed by 4:10 PM. Vital signs were documented as completed on 1/20/2026 at 5:55 PM and 8:03 PM. On 1/20/2026 at 20:34 [8:34 PM] the ED notes read, “Pt. came up to lobby desk with friend and stated they wanted to leave. Educated of risk of leaving. Pt. signed LWBS from at 20:30 [8:30 PM]. Pt. left due to wait time.” Review of Patient #3’ ED Notes dated 1/20/26 at 8:34 PM authored by Staff B, Patient Care Technician (PCT), read, “Patient came to the lobby desk with friend and stated they wanted to leave. Educated of risks of leaving, patient signed LWBS form at 2030 [8:30 PM]. IV removed.” Review of the ED medical record for Patient #3 did not show documentation of a physical examination or MSE completed for Patient #3 to determine whether or not an EMC existed. The record did not show documentation the EKG was interpreted by the physician. During interview on 4/16/2026 at 2:10 PM, the ER Manager stated, “There is no doctor notes that the physician completed an MSE for this patient [Patient #3].” 4. Review of the ED medical record for Patient #6 documented the patient is a 93-year-old female who presents to the urgent care with blood blister to left lower leg with edema. The patient referred to the emergency room for further evaluation and testing. The patient left without being seen. The patient arrived in the emergency department on 1/20/2026 at 3:40 PM as a walk-in. Review of the ED note read, “Chief complaint: Blisters, possible infections. Arrived through triage ambulatory with walker for left ankle edema x [times] a few days with ulcer on left lower extremity, reports has had ulcers present for approx. [approximately] 2 weeks. Currently on warfarin [blood thinning medication] for afib [atrial fibrillation]. Denies history of DM [diabetes mellitus]. Reports increased pain in left lower extremity when leg is in downward position and has some relief with elevation. Denies fever. History of anemia, arthritis, colorectal cancer, colostomy in place, glaucoma, lung cancer, and stroke.” Vital signs were documented as completed at 3:45 PM, temperature - not documented, blood pressure 147/84. Patient #6 was triaged as “Patient Acuity Urgent (3) [Urgent - stable but require prompt medical attention].” The triage nurse completed orders per standing orders for a PTT and INR, x 1 time, CBC and differential and comprehensive metabolic panel. A verbal order was obtained from the provider for an ultrasound of the lower extremity venous duplex left, and x-ray left foot complete 3 views. Lab test and results were completed by 4:10 PM. Impression for the ultrasound lower extremity read, “No sonographic evidence for DVT [deep vein thrombosis - blood clot] in the left lower extremity. Xray left foot (three views) Indications: wound assessment/osteo [bone], chronic wound, blisters Lt [left] foot that sometimes bleed and won’t heal. impression: No acute bony abnormality. No bony destruction.” Blood pressure vital signs were documented as completed on 1/20/2026 at 3:45 PM, 6:58 PM, and 9:24 PM. The ED Notes read, “LWBS at 2255 [10:55 PM]. Pt. left due to wait time/educated can return to ER at anytime if needed.” Review of the ED medical record for Patient #6 did not show documentation of a physical examination or MSE was performed by a physician or QMP for Patient #6 to determine whether or not an EMC existed. During an interview on 4/18/2026 at 11:30 AM, Staff A, RN, stated, “There is no additional nursing notes for [Patient #6’s name] of the physician being notified that the patient is leaving AMA and there is no provider MSE.” During an interview on 4/18/2026 at 12:25 PM, the Manager of Patient Safety and Accreditation reviewed the witness signature on the refusal of medical care form and confirmed the signature to be that of Staff B, PCT. 5. Review of the ED medical record for Patient #8 documented the patient arrived in the emergency department on 1/19/2026 at 10:51 PM as a walk-in. Review of the ED note read, “Chief complaint: Shortness of breath, chest pain x 3 weeks states history of 3 vessel heart bypass in 2014 and heart stents [tube placed in narrow heart artery to prop it open and improve blood flow]. Triage/Acuity Emergent (2).” The triage nurse used standing orders mode for chest pain. Labs for troponin, CBC, BMP, chest x-ray, BNP [B-type natriuretic peptide - protein hormone secreted by the heat ventricles in response to high pressure and fluid overload] Chest x-ray 2 views Impression: No acute pulmonary process. Electrocardiogram (EKG) completed on 1/19/2026 at 10:59 AM. Vital signs were documented as completed at 10:51 PM. Temperature - none documented, blood pressure 140/83 Pulse 84 Respirations 17. Additional blood pressure documented at 1:23 PM, 1:56 PM, and 5:14 PM. Review of Resident #8’s “ED Disposition” read, “LWBS on 1/19/2026 at 6:29 PM.” Review of the ED medical record for Patient #8 did not show documentation of a physical examination or MSE being completed by a Physician or a QMP for Patient #8 to determine whether or not an EMC existed. The record did not show documentation of the EKG being interpreted by the ED physician. During an interview on 4/18/2026 at 2:00 PM, Staff A, RN/Medical Record Navigator, stated, “There is no documentation of a medical screening exam or of a nursing note that the MD was notified the patient was leaving.” Review of the “Consents - Scan on 1/23/2026 1515 [3:15 PM]: Against Medical Advice” form read, “B. Patient’s Refusal (To be used for patients 18 years-of-age or older; ... I, [Patient #8’s name].” There is no information documented. The form was signed by Patient #8 and undated. 6. Review of the ED medical record for Patient #9 documented the patient arrived in the emergency department on 1/19/2026 at 1:21 PM as a walk-in. Review of the ED note read, “Chief complaint: c/o left eye blurred, grey vision since Friday, denies any pain, was seen by retinal specialist and told to come to ER.” Vital signs at 1:29 PM: temperature 98.2 Fahrenheit, pulse 66, respirations 18, and blood pressure 151/66. Standing orders were documented by the triage nurse for labs to consist of a CBC, CMP, Protime, and PTT. A verbal order for a CT Head w/ (without) contrast was obtained from the ED provider. Impression: No intracranial hemorrhage, mass or acute territorial infarcts. Electrocardiogram (EKG) was completed on 1/19/2026 at 1:52 PM. Further review documented the patient was triaged as “Patient Acuity Emergent (2).” Vital signs were documented as completed on 1/19/2026 at 4:57 PM. Review of Resident #9’s “ED Disposition” read, “LWBS on 1/19/2026 at 628 PM.” Review of the ED medical record for Patient #9 did not show documentation of a physical examination or MSE being completed by a Physician or QMP for Patient #9 to determine whether or not an EMC existed. The record did not show documentation of the EKG being interpreted by the ED physician. During an interview on 4/18/2026 at 2:33 PM, Staff A, RN, stated, “There is no nursing note for [Patient #9’s name] besides triage and no medical screening exam documentation by a provider in the medical record.” 7. Review of the ED medical record for Patient #12 documented the patient arrived in the emergency department on 1/20/2026 at 12:50 PM. Review of the ED nursing note read, “Currently being treated for lung cancer with chemo. He missed his chemo appointment today due to his right lateral chest. Chief Complaint: Chest Pain. The Chest pain has been ongoing, but worsening.” Vital signs at 12:52 PM: Temperature 97.7 Fahrenheit, pulse 64, respirations 16, and blood pressure 140/87. The triage nurse completed orders per the standing order mode for chest pain. Labs for Troponin 1 HS: 2 Hours; CBC, CMP, Protime - INR, PTT, Chest x-ray 1 view frontal; IV Medlock, and EKG. The EKG was completed on 1/20/2026 at 12:58 PM. Patient #12 was triaged as “Patient Acuity Emergent (2).” Review of Patient #12’s “ED Disposition” read, “LWBS on 1/20/2026 at 3:41 PM.” Review of the ED medical record for Patient #12 did not show documentation of a physical examination or MSE being completed by a physician or QMP for Patient #12 to determine whether or not an EMC existed. The medical record did not show documentation of the EKG being interpreted by the ED physician. 8. Review of the ED medical record for Patient #13 documented the patient arrived in the emergency department on 1/20/2026 at 6:58 PM. Vital signs at 6:02 PM: Temperature 98.4 Fahrenheit 98.4, pulse 84, respirations 18, blood pressure 163/98. Chief Complaint: Chest tightness. Review of the ED nursing note at 7:04 PM read, “Pt reports chest tightness on exacerbation. Pt. reports she has breast ca [cancer], currently on estrogen [medication used to treat menopause symptoms (Like hot flashes)]pills, Ca dr [cancer doctor] at [Name of cancer center], advised by to come to get a cardiac w/u [work up]. Orders were initiated per standing order mode for chest pain. Troponin 1, result: 4; EKG. Orders for a CBC with differential, BMP, Magnesium, Phosphorus, and Brain Natriuretic Peptide were canceled. completed on 1/20/2026 at 7:06 PM. Chest xray 2 views discontinued. Vital signs rechecked at 9:19 PM. Patient #13 was triaged as “Patient Acuity Emergent (2)”. Review of Patient #13’s “ED Disposition” read, “LWBS on 1/20/2026 at 9:42 PM.” Review of the ED medical record for Patient #13 did not show documentation of a physical examination or an MSE being completed by a Physician or QMP for Patient #13 to determine whether or not an EMC existed. The record did not show documentation of the EKG being interpreted by a physician. Review of the “Consents - Scan on 1/26/2026 at 0843 [8:43 AM]: Against Medical Advice” form read, “B. Patient’s Refusal (To be used for patients 18 years-of-age or older; .... I, [Patient #13’s name].” There is no information documented. The form was signed by Patient #13 and dated 1/20/2026. 9. Review of the ED medical record for Patient #14 documented the patient arrived in the emergency department on 4/9/2026 at 11:52 AM. Vital signs at 11:54 AM, temperature 98.2 Fahrenheit, pulse 116, respirations 18, blood pressure 149/108; blood pressure at 1:55 AM 138/95. Chief Complaint: high blood pressure, A-fib. The triage nursed assessed the patient as “Patient Acuity Emergent (2)”. Vital signs were rechecked at 2:08 PM and 4:40 PM. Visit Diagnoses (primary) atrial fibrillation with RVR [rapid ventricular rate - the heart’s upper chambers quiver irregularly causing the lower chamber to beat too fast, usually over 100 beats per minute]. Review of the ED nursing note at 12:01 PM read “Pt arrived c/o (complaining of) hypertension, atrial fibrillation [a-fib], palpitations that started 2-3 weeks ago; past medical history of a-fib]. Pt also c/o increased shortness of breath. pmh (Past medical history) a-fib.” Continued review revealed that “Emergency Department Standing Orders” were initiated for chest pain at 12:01 PM. EKG completed at 12:06 PM. Review of the ED medical record for Patient #14 did not show documentation of a physical examination or MSE being completed by a Physician or QMP for Patient #14 to determine whether or not an EMC existed. The record did not show documentation the EKG was interpreted by a physician. Review of Patient #14’s “ED Disposition” read, “AMA. Comment: Time of departure: 1755 PM [5:55 PM]. Review of Patient #14’s “Discharge Information” read, “Date/Time: 04/09/2026 1755 [5:55 PM. Disposition: Left without being seen.” 10. Review of the ED medical record for Patient #15 documented the patient arrived in the emergency department on 1/4/2026 at 12:21 PM as a walk-in. Vital signs: temperature 98.2 Fahrenheit, pulse 63, respirations 18, blood pressure 162/86. Patient #15 was triaged as a “Patient Acuity Emergent (2).” Chief Complaint: Chest pain. Vital signs were rechecked at 2:09 PM and 3:09 PM. Review of the ED nursing note at 12:25 PM read, “Shortness of breath, epigastric pain, constipation x several months. She says she was seen here twice in 11/20/2025 for same concerns. She was told she had pneumonia, but her pain never improved. History of CHF [congestive heart failure], COPD [chronic obstructive pulmonary disease], on 2L [liters] home O2 [oxygen]. Pain location: abdomen. Rate of pain: 10. “Emergency Department Standing Orders” were initiated for chest pain. EKG, aspirin tablets 325 mg; Lab panel - CBC and differential; Lab- Troponin I HS: 2 hours; CMP; INR, PTT Imaging - XR chest 1 view frontal; IV- Medlock; EKG - EKG 12 lead; EKG 12 lead completed at 12:35 PM. Chest x- ray 2 views - Impression: right pleural effusion. Review of the ED medical record for Patient #15 did not show documentation of a physical examination or MSE being completed by a Physician or QMP for Patient #15 to determine whether or not an EMC existed. The record did not show documentation of the EKG having been interpreted by the physician. Review of Patient #15’s “ED Disposition” read, “LWBS after Triage. Date/Time: Sun [Sunday] January 4, 2026, 4:08 PM. Comment: ---.” Review of the “Consents - Operative Procedure - Scan on 1/9/2026 0803 [8:03 AM] Against Medical Advice” form read, “B. Patient’s Refusal (To be used for patients 18 years-of-age or older; emancipated minors; or for the minors, who are or have been married or who are being treated for a pregnancy related condition). I, [Patient #15’s first name only].” There is no information documented. The form was signed by Patient #15 and dated 1/4/2026. 11. Review of the ED medical record for Patient #16 documented the patient arrived in the emergency department on 1/19/2026 at 4:32 PM AM by means of a wheelchair. Vital signs: temperature 97.3 Fahrenheit, pulse 79, respirations 18, blood pressure 178/90. Vital signs were rechecked at 8:12 PM. Chief Complaint: high blood pressure and dizzy. Review of the ED nursing note at 4:43 PM read, “C/o dizziness and elevated blood pressure since Saturday, denies any falls or injuries, hx [history] of CVA [cerebral vascular accident - stroke] with left sided weakness as baseline. Acuity level at Urgent (3). “Emergency Department Standing Orders” were initiated at 4:47 PM. A verbal order was received from the ED provider for a CT Brain at 4:48 PM; CT impression: Brain atrophy with chronic microvascular ischemic changes. No definite acute intracranial abnormality. Review of the ED medical record for Patient #16 did not show documentation of a physical examination or MSE being completed by a Physician or QMP for Patient #16 to determine whether or not an EMC existed. During an interview on 4/18/2026 at 2:53 PM, Staff A, RN, stated, “There is no nursing note besides a triage and no medical screening exam documentation by a provider in the medical record.” Review of Patient #16’s “ED Disposition” read, “LWBS after Triage. Date/Time Mon [Monday] January 19, 2026, 9:14 PM” 12. Review of the ED medical record for Patient #17 documented the patient arrived in the emergency department on 1/19/2026 at 10:10 AM, means of arrival: wheelchair. At 10:13 AM vital signs were completed, blood pressure 118/67; vital signs were rechecked at 12:59 PM and 3:44 PM. Review of the ED nursing note dated 1/19/2026 at 10:18 AM read, “C/o cough congestion and dizziness, states he fell this morning while walking his dog after becoming dizzy, hit head on ground, denies LOC [loss of consciousness]; Acuity level at Emergent (2), Order set initiated at 10:15 AM. Verbal order obtained for a CT brain /head, CT Cspine [cervical spine] w/o [without] contrast, x-ray ribs and chest. Impressions: CT brain/head: impression No skull fracture or acute intracranial finding. CT spine impression: reversal levoscoliosis [a left bending]; prominent cervical spondylosis, no fracture or dislocation or locked facet. X-ray ribs impression: no active cardiopulmonary disease; no left rib fractures evident; osteopenia, multiple likely chronic compression fractures thoracic and lumbar spine. Review of Patient #17’s “ED Disposition” read, “LWBS after triage. Date/Time Mon January 19, 2026, 7:53 PM. Comment: Pt. elected to leave due to wait. Educated on importance of staying or val [voluntary leaving]. Pt. declined.” Review of the ED medical record for Patient #17 did not show documentation of a physical examination or MSE being completed by a Physician or QMP for Patient #17 to determine whether or not an EMC existed. During an interview on 4/18/2026 at 3:52 PM, Staff A, RN, stated, “There is no nursing note besides triage and no medical screening exam documentation by a provider in the medical record.” 13. Review of the ED medical record for Patient #18 documented the patient arrived in the emergency department on 4/6/2026 at 5:39 PM. Means of arrival: Walk-in. Vital signs: blood pressure 1141/67, pulse 67, respirations 18. Acuity level Emergent (2). Chief Complaint: None documented. Review of the ED nursing note read, “History of myasthenia gravis [autoimmune disorder causing fluctuating weakness]. Since yesterday her legs have been weak. Denies difficulty breathing.” Emergency Department Standing orders were initiated for weakness at 5:55 PM; CBC with values of RBC 3.46 [normal range 4.2 - 6.1 - low range can indicate anemia], hematocrit 35.5 [normal range 36 - 50], MCV [mean corpuscular volume -diagnoses types of anemia] 102.6 [normal range 80 - 100], MCH [mean corpuscular hemoglobin - diagnoses types of anemia] 35 [normal range 27-330; Chest x-ray impression: no acute abnormality correlate for COPD changes. Review of Patient #18’s “ED Disposition” read, “LWBS after triage. Date/Time Mon April 6, 2026, 9:40 PM. Comment: Pt. elected to leave due to wait. Educated on importance of staying for eval [evaluation]. Pt. declined. Pt. left in no overt distress with spouse.” Review of the ED medical record for Patient #18 did not show documentation of a physical examination or MSE being completed by a Physician or QMP for Patient #18 to determine whether or not an EMC existed. During an interview on 4/18/2026 at 4:17 PM, Staff A, RN, stated, “There is no nursing note besides triage and no medical screening exam documentation by a provider in the medical record.” 14. The Ambulance Run sheet dated 4/9/2026 for Patient #19 was reviewed. The section of the ambulance report titled “Medications/Allergies/History/Immunizations revealed medications listed as Depakote (medication used as a mood stabilizer-can help level and prevent both manic and depressive symptoms) , Xanax (medication used to, manage symptoms of Generalized Anxiety Disorder, including excessive worry, restless and tension). The patient has a history of Behavioral/Psychiatric Disorder, Schizophrenia (mental health condition, it is characterized by a combination of hallucinations, delusions and extremely disordered thinking or behavior that significantly impairs daily functioning) . The patient vital signs at 10:02 AM were listed as Blood pressure 114/74, Pulse -120 (elevated heart rate) and oxygen saturation 96%. The Assessment of the patient’s mental status revealed he was oriented to person, place and time. Further review of the Ambulance Run Sheet revealed, “Narrative ...was dispatched to reports of hallucinations(sensory experience of seeing, hearing, smelling, tasting, or feeling something that does exist in reality) at (name of Behavioral Health facility). Upon arrival contact was made with the patient outside the facility ....Pt advised they were trespassed from (name of Behavioral Health facility) and wanted to be transported to (name of Acute Care Hospital) for medical clearance prior to seeking admission at another facility. Patient denied having any symptoms or complaints ... Radio report was called in to UF Health Leesburg five minutes pta [prior to arrival] with no further questions or concerns. Upon arrival report was provided to pt’s nurse and the pt (patient) advised they were leaving the hospital AMA. The pt signed the hospital’s AMA form and left the hospital.” Review of the ED medical record for Patient #19 documented the patient arrived in the emergency department on 4/9/2026 at 10:29 AM, Means of Arrival: via Ambulance. Continued review revealed Patient #19’s “ED Disposition” dated 4/9/2026 at 10:49 AM read, “LWBS before triage”. Release for Leaving Hospital Against Medical Advice dated 4/9/2026 at 10:35 AM documented Patient #19’s signature, no witness signature documented. There is no documentation in the medical record that Patient #19 was triaged, and no evaluation or physical examination conducted by a Physician or QMP. During an interview on 4/18/2026 at 5:16 PM, Staff A, RN, stated, “There is no triage, MSE or physician documentation in the medical record that the physician spoke to the patient about leaving AMA and no documentation that nurse informed the provider patient was leaving AMA.” 15. Review of the ED medical record for Patient #20 documented the patient arrived in the emergency department on 1/3/2026 at 3:41 PM, Means of Arrival: walk-in. Reason for Visit: Chief Complaint: Hematuria (Blood in Urine). Urinary catheter insertion or check (Pt. report he began to experience bleeding form his penis at 0200 [2:00 AM] today, he went to a freestanding [name of hospital] facility where they placed a catheter and did CBI [continuous bladder irrigation], he was later sent home, reports the leg bag they left on is now straight blood for the past hour and he is having extreme bladder pressure when he drinks any water.” Vital signs blood pressure 169/76. Orders initiated. CBC with differential with abnormal results of WBC 12.4 high [white blood cell count - minor elevation often seen with common infections]. Hemoglobin 12.8 low [indicates mild anemia]. Urinalysis with reflex to urine culture (Abnormal) Color - Urine - red, Protein 2+, Ketones 1+, Blood 3+, Nitrite - positive, Leukocyte Esterase 3+, Bacteria 1+ and RBC [red blood cells] >18.00 high. [These results are highly indicative of a urinary tract infection]. Culture result: 70,000 CFU/mL Klebsiella pneumoniae subspecies pneumoniae [a significant bacterial infection in the urinary tract]. Review of the ED medical record for Patient #20 for this visit did not show documentation of the patient having been triaged, a physical examination, or MSE being completed by a Physician or QMP for Patient #20 to determine whether or not an EMC existed. Review of Patient #20’s “ED Notes” dated 1/3/2026 at 1835 [6:35 PM] read, “Does not want to wait any longer. Says he will return tomorrow.” During an interview on 4/18/2026 at 5:36 PM, Staff A, RN, stated, “There is no triage, MSE or physician documentation in the medical record, or that the physician spoke to the patient. The facility failed to follow their own policy and procedure as evidenced by failing to provide appropriate medical screening examinations within the capability of the hospital’s emergency department to by failing to ensure that physical examinations and medical screening examinations were conducted by Physicians or Qualified Medical Personnel to determine whether or not an emergency medical condition existed. This systemic failure affected #1, Pt #2, Pt #3, Pt #6, Pt #8, Pt #9, Pt #12, Pt #13, Pt #14, Pt #15, Pt #16, Pt #17, Pt #18, Pt #19, and Pt #20 out of 20 (twenty) sampled patients, who presented to the hospital’s ED with complaints of (altered mental status, hallucinations, chest pain, weakness, blistered possibly infected leg ulcers, chest pain/shortness of breath, left eye blurred and gray vision, high blood pressure/dizziness, syncope/chest pain, urinary catheter with pain/bloody urine in drainage bag). Additionally, the facility failed to identify in the hospital’s Medical Staff Bylaws or the Medical Staff Rules, Regulations and Policy individuals who were approved by the governing body or board of trustees who determined qualified to conduct medial screening examinations for individuals presenting to the hospital’s seeking medical assistance.”