Baptist 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: 25370 Based on reviews of patient medical records, Transfer Center logs form, Hospital Bed Census, Specialty MD (Medical Doctor) On-Call List, Policies and Procedures, and staff interviews it was determined the facility failed to accept from a Transferring Hospital (TH) within the boundaries of the United States an appropriate transfer of 1 (one) Patient #1 of 5 (five) sampled patients. Baptist Hospital (RH- Receiving Hospital) had the specialized capabilities of Cardiology services (specialized medical care for diagnosing, treating, and managing diseases of the heart and blood vessels), and the capacity to treat Patient #1 on 10/30/2025. The findings include: Cross Refer to findings in Tag A 2411.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 41185 Based on reviews of patient medical records, transfer center logs, hospital bed census, Specialty MD On-Call List, policies and procedures, and staff interviews, it was determined the facility failed to accept from a Transferring Hospital (TH) within the boundaries of the United States an appropriate transfer of 1 (one) Patient #1 of 5 (five) sampled transfer patients. Baptist Hospital had the specialized capabilities of Cardiology services (specialized medical care for diagnosing, treating, and managing diseases of the heart and blood vessels), and the capacity to treat Patient #1 on 10/30/2025. The findings include: A review of the facility’s policy and procedure entitled “Transfers To and From the Emergency Department”, effective date May 2025, indicates on page 5 : “6. Transfers to a BHC (Baptist Health Care)Hospital: a. Except in specific circumstances described in this Policy, all BHC Hospitals with specialized capabilities or facilities (including, but not limited to trauma units or behavioral health units) shall accept from a transferring hospital a individual with an EMC who requires specialized capabilities if the Receiving Hospital has the Capacity to treat the individual ....” The medical record for Patient #1 from the Transferring Hospital (TH) was reviewed. The section of the medical record titled “ED Provider Note” revealed in part,”Time seen:.. 21:58 (9:58 PM) ... Chief Complaint: Pt. (patient) was in sleep lab for sleep study, pt became dizzy, diaphoretic (sweating), and asked to lay down when pt laid down, sleep lab tech states became unresponsive foaming at the mouth, with pt eyes rolled back in head. History of Present illness: This 81 year old -lady who came for sleep study ...bought in asking her to go to the sleep lab ...she felt lightheaded and asked to be laid down which was done immediately ...while the attendant stepped out to pick up something and found her completely passed out and called for help as well as CODE BLUE ( hospital emergency announcement indicating a patient is experiencing a critical, life threatening situation-cardiac or respiratory arrest) ...brought her to the emergency room.” The evaluation completed by the ED Physician at the TH documented the patient to have an elevated WBC (white blood count), significant elevated D-dimer (a test suggestive of active, abnormal blood clotting) and a CTA (Computed Tomography Angiography) which indicated bilateral pulmonary embolisms (life threatening condition where blood clots block both arteries in both lungs) with some degree of right heart strain (Right ventricle of the heart is struggling to pump blood effectively to the lungs). The TH ED requested a transfer of Patient #1, to a higher level of care, to the RH (Receiving Hospital). A review of the RH’s Transfer Center call logs form dated 10/30/2025, identified the following timeline regarding Patient #1: - 2:40 AM Staff A (time Received call at RH), Registered Nurse (RN), Direct Admit (INBOUND TO): BH (Baptist Hospital was checked off) Primary Diagnosis /Admit Symptoms/Patients current condition and specific need/Reason (Pulmonary Embolus) with right sided heart strain Current Level of care at Transferring Facility ED Room 16 ED physician paged at 2:43 AM, 3:36 AM and 4:05 AM. DOES THE PATIENT NEED FURTHER STABILIZING CARE IN OUR ED? YES (CHECKED OFF) SEND CALL TO ED. Hospitalist paged at 3:41 AM returned call at 3:47 AM. Intensivist paged at 4:52 AM and returned call at 5:02 AM. Staff A, RH Transfer Center Nurse, notes: - 2:43 AM tried to transfer call to ED but ED physician is busy with pediatric patient. Informed TH would have ED physician call when he is out of patients room. - 3:30 AM Called TH discussed about possibly doing a direct admit, connected RH Nurse to ED physician at TH, “and he said we could try.” - 3:41 AM paged Hospitalist -0347- Hospitalist returned call phone call and explained that the RH ED was tied up in ED and wanted to see if (hospitalist) could speak the TH ED physician. The hospitalist “stated that if the patient is unstable need to be ED to ED.” - 3:48 AM Called TH informed that the hospitalist at RH “said the patient needed to go ED-to-ED.” - 4:00 AM Called ED (RH) and ED staff said that the ED physician “is in emergencies and he can call when he is done or the patient can go to another facility if unstable and can’t wait for call back.” - 4:17 AM Called ED (TH) informed of update as physician unable to come to the phone and may want to try another facility if patient is unstable. Informed that Patient #1 requesting transfer as her physicians are there at the RH. - 4:25 AM Called ED and informed by ED staff member that the ED physician was still tied up with emergencies, and ED MD will call back when he is available. - 4:52 AM Intensivist paged. - 5:02 AM Intensivist returned call and Staff A attempted to connect Intensivist with the TH Hospital ED but was informed by staff member at the TH that Patient #1 was accepted for transfer at another facility. - 5:12 AM ED physician now available to speak with TH and informed of Patient #1 being transferred to another facility. The facility’s Specialty MD On-Call Schedule dated October 29, 2025, was reviewed. The schedule revealed that a cardiologist was on call. Baptist Hospital (RH -receiving Hospital) had the specialized capability to accept Patient #1 from the TH on October 30, 2025, when the request was made. On 10/30/2025 the RH bed census report capacity was 242 with a total of 36 ICU (Intensive Care Unit) beds and an ICU census of 34. Baptist Hospital had the capacity to treat Patient #1 on 10/30/2025. On 11/24/2025 an interview was conducted at approximately 10:00 AM with Staff J, Director of Emergency Department. Staff J recalled on 10/29/2025 from 6:00 PM through 10/30/2025 6:00 AM, there were no code blues that shift, but the emergency department had 2 critical patients, a pediatric patient who was being sent out to another facility when the first call came in from the TH regarding Patient #1. Staff J further recalled there was another critical patient the facility was treating in the ED who was needing admission to an ICU bed. On 11/24/2025 an interview was conducted at approximately 11:52 AM with the Assistant Chief Nursing Officer (ACNO). The ACNO was aware of the patient at the TH who was trying to transfer to this facility. The attending physician had a critical pediatric patient he had to stabilize and transfer out and then another critical patient arrived within that window of time. The Transfer Call Center did have other physicians contacted to see if they could help with the transfer. “By the time we called the TH back with a physician to talk with them they had contacted another facility who accepted the transfer”. On 11/24/2025 an interview was conducted at approximately 2:00 PM with the Staff K, Risk Manager (RM). Staff K added, “it is very rare that we don’t accept a patient, we did not refuse to take the patient, our intensivist did accept the patient, but the TH had already arranged her transfer with another facility”. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to accept Patient #1 on October 30, 2025, from a transferring hospital with an identified emergency medical condition, as Patient #1 required specialized capabilities, and Baptist Hospital had the capacity to treat the patient.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44730 Based on interviews and record reviews, the facility failed to comply with the Condition of Participation by failing to provide care in a safe setting by failing to secure the safety of patient #1, a vulnerable adult, who was transferred to the Emergency Department (ED) for care of a foot wound, from a local Assisted Living Facility, (ALF) and was not identified as a vulnerable adult by the ED staff, and subsequently was allowed to leave the hospital 7/25/25 without the hospital notifying the ALF facility or the patient’s legal court appointed guardian, for 1 of 3 patients reviewed for emergency care which resulted in Patient #1 being reported as missing by the ALF/Guardian on 7/28/25 and subsequently found by Emergency Medical Services (EMS) on the railroad tracks, 0.8 miles from the hospital, unresponsive and septic three days later (Refer to A0144).”

“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: 44730 Based on interviews, patient medical record reviews and reviews of the hospital’s policies and procedures, the facility failed to provide care in a safe setting by failing to secure the safety of patient #1, a vulnerable adult, who was transferred to the Emergency Department (ED) for care of a foot wound, from a local Assisted Living Facility, (ALF). The ED staff failed to identify the patient as a vulnerable adult and subsequently allowed the patient to leave the hospital without the hospital notifying the ALF facility or the patient’s legal court appointed guardian, for 1 of 3 patients reviewed for emergency care. (Patient #1) This standard is not met as evidenced by: The findings include: On 8/6/25, a review of patient #1’s electronic medical record was conducted. The electronic record revealed a consent for treatment form signed by patient #1 on 7/25/25 at 3:25 PM. A Physician assessment conducted on 7/25/25 at 3:38 PM, and physician orders were placed for a venous doppler study on left foot, laboratory testing and intravenous (IV) insertion. Vital signs were last recorded on 7/26/25 at 1:41 AM. A form titled ED Release and Refusal of Screening/treatment indicating the patient left the ED without notifying staff was dated 7/26/25 at 5:40 AM. There was no further clinical documentation for this visit after this time. A review of the ED log revealed Patient #1 arrived on 7/25/25 at 3:25 PM, via Emergency Medical Services (EMS), ambulance. Further review of the electronic medical record revealed the patient returned (a second time) to the ED on 7/26/25 at 5:55 PM, per the ED log. Patient #1 was not assessed during this visit as patient #1 walked out of the ED. Interview with Staff A, Risk Manager Director, who was assisting with the electronic record review, indicated by ED protocol, staff would have called Patient #1’s name three times, and if there is “no show” for assessment after three calls, the patient would be removed from the list. Review of the ED log revealed Patient #1 arrived (a third time) at the ED on 7/26/25 at 7:04 PM. Patient #1 was triaged at 7:26 PM. Documentation signed by Staff Q, Advanced Practice Registered Nurse (APRN) revealed he was evaluated for possible left foot infection. Documentation by Staff Q, ARNP, indicated Patient #1 lived alone and that he was currently working in the area. On this visit, Patient #1 had a wound on the left foot that had clear drainage and a foul odor. IV antibiotics were given. Wound care was performed. Documentation further identified Patient#1 was discharged home. On 8/6/25 at approximately 12:35 PM an interview was conducted with Staff Registered Nurse (RN) C, Executive Director of Emergency Services. Staff RN C indicated that patient #1 came into the ED via EMS transport. Staff RN C further stated that the ED did not receive any documentation from EMS indicating that the patient was from a long-term care facility or an ALF. On 8/6/25 at approximately 12:38 PM an interview was conducted with Staff Member D, RN and ED Director, who indicated that Patient #1 came into the ED on Friday (7/25/25) and that the hospital received a telephone call from the ALF on Monday (7/28/25) asking about patient #1’s status. Staff RN D further stated that this was the moment that the hospital became aware that Patient #1 was a vulnerable adult and was “missing.” The Director of Risk Management indicated that the ALF notified the Police department and was not sure when the Guardian was notified that the patient was missing. The Police department arrived at the hospital requesting video footage which was released to them for viewing on the 28th at 2:57 PM. The patient was located, 3 days later, on 7/31/25 at 10:54 PM by EMS, on the railroad tracks at the corner of Sycamore Street and St. Johns Street. (Distance from the hospital was clocked by this surveyor’s odometer as being 0.8 tenths of a mile. The patient was unresponsive and septic, and emergency transported to Baptist Hospital. On 8/6/25 at approximately 12:44 PM, Staff L, the Lutheran Services program manager supervisor, was interviewed. She stated Lutheran Services had legal guardianship of Patient #1. She stated that the hospital did not contact Lutheran Services about Patient #1’s status. She further stated the (Assisted Living Facility) called Lutheran Services on Monday (7/28/25) to inform them that Patient #1 had been sent to the hospital on Friday (7/25/25) and that he was missing. The Hospital called Lutheran Services on 7/31/25 reporting Patient #1 had been found. On 8/6/25, a review of patient #1’s Letter of Plenary was conducted. This document was dated and signed on 3/4/2023 in the Circuit Court in and for Escambia County, Florida Probate division. The document indicated Lutheran Services Florida, INC. was declared plenary guardian (Absolute Control over all matters) for patient #1. On 8/6/25 at approximately 4:00 PM an in-person interview was conducted with the ALF’s Resident Care Coordinator (RCC) Licensed Practical Nurse (LPN). The RCC indicated that on 7/25/25 she was notified by therapy staff of patient #1-foot wounds. The RCC stated she went to look at the wound and called 911; printed out his transfer packet and gave it to EMS along with a verbal report at the transfer to the hospital. The transfer packet included his face sheet and medication list. The RCC further indicated that she documented in the patients record that she called and left a message on the guardian’s voice mail to return her call and sent an EMAIL to the Guardian notifying her of the patient’s transfer to the hospital. The RCC indicated that she had called on Monday to the hospital to follow up on his status and learned that he had been discharged, she then proceeded to notify his Guardian, who notified the police department, and when the police arrived here, I gave my statement to them of what occurred. Department of Children and Family was also notified. On 8/7/25 at approximately 1:15 PM a telephone interview was conducted with the paramedic, for Escambia County EMS. The Paramedic indicated that he remembered picking up Patient #1 from the ALF and stated that he did receive a report from the facility along with a transfer packet. The Paramedic indicated that they always give the packets to the ED during transfer of the patient and a rundown of where they are from and what happened and any information from the transfer trip. The Paramedic stated he did not remember who they gave hand off to, it was either the triage nurse or the paramedic in the lobby, however, did remember giving them the packet from the facility. The Paramedic indicated that patient #1 was very hard of hearing and remembered having to write the questions down on paper for the patient to read. The patient could read the questions and then answered appropriately. On 8/7/25 at approximately 2:05 PM a telephone interview was conducted with the Escambia County Emergency Medical Technician (EMT). The EMT indicated that she did remember transporting the patient from the ALF to the hospital’s ED and giving report that the patient was from an ALF to the charge nurse. The EMT further indicated that the patient was very hard of hearing. On 8/7/25 at 1:12 PM, an interview was conducted with Staff I, RN. She recalled pulling Patient #1 from the ED lobby area. She could not recall who gave her report. Staff I, RN stated Patient #1 answered all questions appropriately. She further stated she did not get any information indicating Patient #1 came from a facility (Assisted Living facility). She stated, remembering the paramedic telling her that he wrote down questions for him [the resident] and he could answer them. On 8/7/25 at 3:00 PM, Patients #1’s hard copy chart was requested for review. The following forms (4 pages) were a part of the hard copy record and had not yet been uploaded into the electronic record: 1. Yellow-colored EMS form dated 7/25/25 nature of call as dispatched: interfacility location of call 4916 Mobile Hwy apt 4. Chief complaint: foot edema/pain. Past medical history COPD, HOH. Alert. Left foot was swollen, skin appeared to be sloughing off toes and plantar side of foot. Foot appeared saturated, no bleeding noted, patient complaint pain 3/10. Staff stated left shoe was soaked. 2. Emergency Department Release and Refusal of Screening/treatment form dated 7/26/25 at 0540. The form was checked under “patient left the Emergency Department without notifying staff. 3. Face sheet for patient #1 identifying [the name of the Assisted Living Facility] with the address and telephone number listed. Under personal contacts noted Lutheran Services with a telephone number, duties: responsible party. Under care team read: left foot edema and weeping, several small areas open on toes. Surrounding skin white in color. Shoe was saturated. Resident stated that they had some pain and stiffness while ambulating. 4. The current Physician’s orders as of 25 July 2025 with the resident’s ALF admission date, full code status, the patient’s date of birth and list of current medications. Another order dated October 29, 2024, under treatment indicates that the Guardian or family should be notified of medication refusals. These 4 forms contained Patient #1 hospital medical record labels containing patient #1’s name, date of birth, medical record, and other coding. On the back of medication list form were hand-written questions: “What hospital? Does it hurt” “How bad 1-10?” “How did your foot get wet?” “What year is it now?” “How long has your foot been like that?” On this same page on right top is written “N/A and 0154”. The back contains the patient’s label on right upper side. Review of the following hospital’s policies and procedures revealed: “Discharge Planning”, effective date June 2025. Bullet 8. Discharge instructions shall be given to the patient/family in a manner that the patient/family can understand. 17. All discharge plans shall be reviewed with the patient and/or family member before the patient is discharged from the hospital to ensure that the discharge plan meets the needs of the patient. “Treating a Personal Representative of the Individual as the Individual”, effective date December 2024. Statement of purpose: to give standards on dealing with a personal representative of an individual to ensure BHC is compliance with applicable laws and regulations. Policy states 1. If, under applicable law, a person has authority to act on behalf of an individual who is an adult or an Emancipated Minor in making decisions related to health care, BHC will treat such person as a personal representative with respect to protected health information (PHI) relevant to such personal representative. “Triage and Emergency Medical Screening for the Non-Psychiatric Patient”, effective date May 2025. After the Medical Screening Evaluation (MSE) is completed: the Qualified Medical Personnel (QMP) will inform the patient and /or family that the patient doesn’t not have an Emergency Medical Condition.”

“ADMISSION, TRANSFER, AND DISCHARGE RIGHTS CFR(s): §482.58(b)(2) Admission, transfer, and discharge rights (§483.5 definition of transfer and discharge, §483.15(c)(1), (c)(2)(i), (c)(2)(ii), (c)(3), (c)(4), (c)(5), and (c)(7)) • §483.5: definition of transfer and discharge: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. • §483.15(c)(1): Facility requirements— (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless— (A) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii)The facility may not transfer or discharge the resident while the appeal is pending, pursuant to §431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to §431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. • §483.15(c)(2)(i) Documentation in the resident’s medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). • §483.15(c)(2)(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by— (A) The resident’s physician when transfer or discharge is necessary under paragraph (c)(1)(A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. • §483.15(c)(3): Notice before transfer. Before a facility transfers or discharges a resident, the facility must— (i) Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. • §483.15(c)(4): Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when— (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. • §483.15(c)(5): Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii)The location to which the resident is transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii)For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. • §483.15(c)(7): Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This Standard is not met as evidenced by: 44730 Based on interviews and record reviews the facility failed to ensure the safe welfare of patient #1 of 3 sampled for Emergency Care Services. Patient #1, a vulnerable adult, who was transferred to the Emergency Department (ED) for care of a foot wound, from a local Assisted Living Facility, (ALF) was not identified as a vulnerable adult by the ED staff, and subsequently was allowed to leave the hospital 7/25/25 without the hospital notifying the ALF facility or the patient’s legal court appointed guardian, which resulted in Patient #1 being reported as missing by the ALF/Guardian on 7/28/25 and subsequently found by Emergency Medical Services (EMS) on the railroad tracks, 0.8 miles from the hospital, unresponsive and septic three days later. The findings include: On 8/6/25, a review of patient #1’s electronic medical record was conducted. The electronic record revealed a consent for treatment form signed by patient #1 on 7/25/25 at 3:25 PM. A Physician assessment conducted on 7/25/25 at 3:38 PM, and physician orders were placed for a venous doppler study on left foot, laboratory testing and intravenous (IV) insertion. Vital signs were last recorded on 7/26/25 at 1:41 AM. A form titled ED Release and Refusal of Screening/treatment indicating the patient left the ED without notifying staff was dated 7/26/25 at 5:40 AM. There was no further clinical documentation for this visit after this time. A review of the ED log revealed Patient #1 arrived on 7/25/25 at 3:25 PM, via Emergency Medical Services (EMS), ambulance. Further review of the electronic medical record revealed the patient returned (a second time) to the ED on 7/26/25 at 5:55 PM, per the ED log. Patient #1 was not assessed during this visit as patient #1 walked out of the ED. Interview with Staff A, Risk Manager Director, who was assisting with the electronic record review, indicated by ED protocol, staff would have called Patient #1’s name three times, and if there is “no show” for assessment after three calls, the patient would be removed from the list. Review of the ED log revealed Patient #1 arrived (a third time) at the ED on 7/26/25 at 7:04 PM. Patient #1 was triaged at 7:26 PM. Documentation signed by Staff Q, Advanced Practice Registered Nurse (APRN) revealed he was evaluated for possible left foot infection. Documentation by Staff Q, ARNP, indicated Patient #1 lived alone and that he was currently working in the area. On this visit, Patient #1 had a wound on the left foot that had clear drainage and a foul odor. IV antibiotics were given. Wound care was performed. Documentation further identified Patient#1 was discharged home. On 8/6/25 at approximately 12:35 PM an interview was conducted with Staff Registered Nurse (RN) C, Executive Director of Emergency Services. Staff RN C indicated that patient #1 came into the ED via EMS transport. Staff RN C further stated that the ED did not receive any documentation from EMS indicating that the patient was from a long-term care facility or an ALF. On 8/6/25 at approximately 12:38 PM an interview was conducted with Staff Member D, RN and ED Director, who indicated that Patient #1 came into the ED on Friday (7/25/25) and that the hospital received a telephone call from the ALF on Monday (7/28/25) asking about patient #1’s status. Staff RN D further stated that this was the moment that the hospital became aware that Patient #1 was a vulnerable adult and was “missing.” The Director of Risk Management indicated that the ALF notified the Police department and was not sure when the Guardian was notified that the patient was missing. The Police department arrived at the hospital requesting video footage which was released to them for viewing on the 28th at 2:57 PM. The patient was located, 3 days later, on 7/31/25 at 10:54 PM by EMS, on the railroad tracks at the corner of Sycamore Street and St. Johns Street. (Distance from the hospital was clocked by this surveyor’s odometer as being 0.8 tenths of a mile. The patient was unresponsive and septic, and emergency transported to Baptist Hospital. On 8/6/25 at approximately 12:44 PM, Staff L, the Lutheran Services program manager supervisor, was interviewed. She stated Lutheran Services had legal guardianship of Patient #1. She stated that the hospital did not contact Lutheran Services about Patient #1’s status. She further stated the (Assisted Living Facility) called Lutheran Services on Monday (7/28/25) to inform them that Patient #1 had been sent to the hospital on Friday (7/25/25) and that he was missing. The Hospital called Lutheran Services on 7/31/25 reporting Patient #1 had been found. On 8/6/25, a review of patient #1’s Letter of Plenary was conducted. This document was dated and signed on 3/4/2023 in the Circuit Court in and for Escambia County, Florida Probate division. The document indicated Lutheran Services Florida, INC. was declared plenary guardian (Absolute Control over all matters) for patient #1. On 8/6/25 at approximately 4:00 PM an in-person interview was conducted with the ALF’s Resident Care Coordinator (RCC) Licensed Practical Nurse (LPN). The RCC indicated that on 7/25/25 she was notified by therapy staff of patient #1-foot wounds. The RCC stated she went to look at the wound and called 911; printed out his transfer packet and gave it to EMS along with a verbal report at the transfer to the hospital. The transfer packet included his face sheet and medication list. The RCC further indicated that she documented in the patients record that she called and left a message on the guardian’s voice mail to return her call and sent an EMAIL to the Guardian notifying her of the patient’s transfer to the hospital. The RCC indicated that she had called on Monday to the hospital to follow up on his status and learned that he had been discharged, she then proceeded to notify his Guardian, who notified the police department, and when the police arrived here, I gave my statement to them of what occurred. Department of Children and Family was also notified. On 8/7/25 at approximately 1:15 PM a telephone interview was conducted with the paramedic, for Escambia County EMS. The Paramedic indicated that he remembered picking up Patient #1 from the ALF and stated that he did receive a report from the facility along with a transfer packet. The Paramedic indicated that they always give the packets to the ED during transfer of the patient and a rundown of where they are from and what happened and any information from the transfer trip. The Paramedic stated he did not remember who they gave hand off to, it was either the triage nurse or the paramedic in the lobby, however, did remember giving them the packet from the facility. The Paramedic indicated that patient #1 was very hard of hearing and remembered having to write the questions down on paper for the patient to read. The patient could read the questions and then answered appropriately. On 8/7/25 at approximately 2:05 PM a telephone interview was conducted with the Escambia County Emergency Medical Technician (EMT). The EMT indicated that she did remember transporting the patient from the ALF to the hospital’s ED and giving report that the patient was from an ALF to the charge nurse. The EMT further indicated that the patient was very hard of hearing. On 8/7/25 at 1:12 PM, an interview was conducted with Staff I, RN. She recalled pulling Patient #1 from the ED lobby area. She could not recall who gave her report. Staff I, RN stated Patient #1 answered all questions appropriately. She further stated she did not get any information indicating Patient #1 came from a facility (Assisted Living facility). She stated, remembering the paramedic telling her that he wrote down questions for him [the resident] and he could answer them. On 8/7/25 at 3:00 PM, Patients #1’s hard copy chart was requested for review. The following forms (4 pages) were a part of the hard copy record and had not yet been uploaded into the electronic record: 1. Yellow-colored EMS form dated 7/25/25 nature of call as dispatched: interfacility location of call 4916 Mobile Hwy apt 4. Chief complaint: foot edema/pain. Past medical history COPD, HOH. Alert. Left foot was swollen, skin appeared to be sloughing off toes and plantar side of foot. Foot appeared saturated, no bleeding noted, patient complaint pain 3/10. Staff stated left shoe was soaked. 2. Emergency Department Release and Refusal of Screening/treatment form dated 7/26/25 at 0540. The form was checked under “patient left the Emergency Department without notifying staff. 3. Face sheet for patient #1 identifying [the name of the Assisted Living Facility] with the address and telephone number listed. Under personal contacts noted Lutheran Services with a telephone number, duties: responsible party. Under care team read: left foot edema and weeping, several small areas open on toes. Surrounding skin white in color. Shoe was saturated. Resident stated that they had some pain and stiffness while ambulating. 4. The current Physician’s orders as of 25 July 2025 with the resident’s ALF admission date, full code status, the patient’s date of birth and list of current medications. Another order dated October 29, 2024, under treatment indicates that the Guardian or family should be notified of medication refusals. These 4 forms contained Patient #1 hospital medical record labels containing patient #1’s name, date of birth, medical record, and other coding. On the back of medication list form were hand-written questions: “What hospital? Does it hurt” “How bad 1-10?” “How did your foot get wet?” “What year is it now?” “How long has your foot been like that?” On this same page on right top is written “N/A and 0154”. The back contains the patient’s label on right upper side. Review of the following hospital’s policies and procedures revealed: “Discharge Planning”, effective date June 2025. Bullet 8. Discharge instructions shall be given to the patient/family in a manner that the patient/family can understand. 17. All discharge plans shall be reviewed with the patient and/or family member before the patient is discharged from the hospital to ensure that the discharge plan meets the needs of the patient. “Treating a Personal Representative of the Individual as the Individual”, effective date December 2024. Statement of purpose: to give standards on dealing with a personal representative of an individual to ensure BHC is compliance with applicable laws and regulations. Policy states 1. If, under applicable law, a person has authority to act on behalf of an individual who is an adult or an Emancipated Minor in making decisions related to health care, BHC will treat such person as a personal representative with respect to protected health information (PHI) relevant to such personal representative. “Triage and Emergency Medical Screening for the Non-Psychiatric Patient”, effective date May 2025. After the Medical Screening Evaluation (MSE) is completed: the Qualified Medical Personnel (QMP) will inform the patient and /or family that the patient doesn’t not have an Emergency Medical Condition.”

“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: 44730 Based on interviews, patient medical record reviews and reviews of the hospital’s policies and procedures, the facility failed to provide care in a safe setting by failing to secure the safety of patient #1, a vulnerable adult, who was transferred to the Emergency Department (ED) for care of a foot wound, from a local Assisted Living Facility, (ALF). The ED staff failed to identify the patient as a vulnerable adult and subsequently allowed the patient to leave the hospital without the hospital notifying the ALF facility or the patient’s legal court appointed guardian, for 1 of 3 patients reviewed for emergency care. (Patient #1) The findings include: On 8/6/25, a review of patient #1’s electronic medical record was conducted. The electronic record revealed a consent for treatment form signed by patient #1 on 7/25/25 at 3:25 PM. A Physician assessment conducted on 7/25/25 at 3:38 PM, and physician orders were placed for a venous doppler study on left foot, laboratory testing and intravenous (IV) insertion. Vital signs were last recorded on 7/26/25 at 1:41 AM. A form titled ED Release and Refusal of Screening/treatment indicating the patient left the ED without notifying staff was dated 7/26/25 at 5:40 AM. There was no further clinical documentation for this visit after this time. A review of the ED log revealed Patient #1 arrived on 7/25/25 at 3:25 PM, via Emergency Medical Services (EMS), ambulance. Further review of the electronic medical record revealed the patient returned (a second time) to the ED on 7/26/25 at 5:55 PM, per the ED log. Patient #1 was not assessed during this visit as patient #1 walked out of the ED. Interview with Staff A, Risk Manager Director, who was assisting with the electronic record review, indicated by ED protocol, staff would have called Patient #1’s name three times, and if there is “no show” for assessment after three calls, the patient would be removed from the list. Review of the ED log revealed Patient #1 arrived (a third time) at the ED on 7/26/25 at 7:04 PM. Patient #1 was triaged at 7:26 PM. Documentation signed by Staff Q, Advanced Practice Registered Nurse (APRN) revealed he was evaluated for possible left foot infection. Documentation by Staff Q, ARNP, indicated Patient #1 lived alone and that he was currently working in the area. On this visit, Patient #1 had a wound on the left foot that had clear drainage and a foul odor. IV antibiotics were given. Wound care was performed. Documentation further identified Patient#1 was discharged home. On 8/6/25 at approximately 12:35 PM an interview was conducted with Staff Registered Nurse (RN) C, Executive Director of Emergency Services. Staff RN C indicated that patient #1 came into the ED via EMS transport. Staff RN C further stated that the ED did not receive any documentation from EMS indicating that the patient was from a long-term care facility or an ALF. On 8/6/25 at approximately 12:38 PM an interview was conducted with Staff Member D, RN and ED Director, who indicated that Patient #1 came into the ED on Friday (7/25/25) and that the hospital received a telephone call from the ALF on Monday (7/28/25) asking about patient #1’s status. Staff RN D further stated that this was the moment that the hospital became aware that Patient #1 was a vulnerable adult and was “missing.” The Director of Risk Management indicated that the ALF notified the Police department and was not sure when the Guardian was notified that the patient was missing. The Police department arrived at the hospital requesting video footage which was released to them for viewing on the 28th at 2:57 PM. The patient was located, 3 days later, on 7/31/25 at 10:54 PM by EMS, on the railroad tracks at the corner of Sycamore Street and St. Johns Street. (Distance from the hospital was clocked by this surveyor’s odometer as being 0.8 tenths of a mile. The patient was unresponsive and septic, and emergency transported to Baptist Hospital. On 8/6/25 at approximately 12:44 PM, Staff L, the Lutheran Services program manager supervisor, was interviewed. She stated Lutheran Services had legal guardianship of Patient #1. She stated that the hospital did not contact Lutheran Services about Patient #1’s status. She further stated the (Assisted Living Facility) called Lutheran Services on Monday (7/28/25) to inform them that Patient #1 had been sent to the hospital on Friday (7/25/25) and that he was missing. The Hospital called Lutheran Services on 7/31/25 reporting Patient #1 had been found. On 8/6/25, a review of patient #1’s Letter of Plenary was conducted. This document was dated and signed on 3/4/2023 in the Circuit Court in and for Escambia County, Florida Probate division. The document indicated Lutheran Services Florida, INC. was declared plenary guardian (Absolute Control over all matters) for patient #1. On 8/6/25 at approximately 4:00 PM an in-person interview was conducted with the ALF’s Resident Care Coordinator (RCC) Licensed Practical Nurse (LPN). The RCC indicated that on 7/25/25 she was notified by therapy staff of patient #1-foot wounds. The RCC stated she went to look at the wound and called 911; printed out his transfer packet and gave it to EMS along with a verbal report at the transfer to the hospital. The transfer packet included his face sheet and medication list. The RCC further indicated that she documented in the patients record that she called and left a message on the guardian’s voice mail to return her call and sent an EMAIL to the Guardian notifying her of the patient’s transfer to the hospital. The RCC indicated that she had called on Monday to the hospital to follow up on his status and learned that he had been discharged, she then proceeded to notify his Guardian, who notified the police department, and when the police arrived here, I gave my statement to them of what occurred. Department of Children and Family was also notified. On 8/7/25 at approximately 1:15 PM a telephone interview was conducted with the paramedic, for Escambia County EMS. The Paramedic indicated that he remembered picking up Patient #1 from the ALF and stated that he did receive a report from the facility along with a transfer packet. The Paramedic indicated that they always give the packets to the ED during transfer of the patient and a rundown of where they are from and what happened and any information from the transfer trip. The Paramedic stated he did not remember who they gave hand off to, it was either the triage nurse or the paramedic in the lobby, however, did remember giving them the packet from the facility. The Paramedic indicated that patient #1 was very hard of hearing and remembered having to write the questions down on paper for the patient to read. The patient could read the questions and then answered appropriately. On 8/7/25 at approximately 2:05 PM a telephone interview was conducted with the Escambia County Emergency Medical Technician (EMT). The EMT indicated that she did remember transporting the patient from the ALF to the hospital’s ED and giving report that the patient was from an ALF to the charge nurse. The EMT further indicated that the patient was very hard of hearing. On 8/7/25 at 1:12 PM, an interview was conducted with Staff I, RN. She recalled pulling Patient #1 from the ED lobby area. She could not recall who gave her report. Staff I, RN stated Patient #1 answered all questions appropriately. She further stated she did not get any information indicating Patient #1 came from a facility (Assisted Living facility). She stated, remembering the paramedic telling her that he wrote down questions for him [the resident] and he could answer them. On 8/7/25 at 3:00 PM, Patients #1’s hard copy chart was requested for review. The following forms (4 pages) were a part of the hard copy record and had not yet been uploaded into the electronic record: 1. Yellow-colored EMS form dated 7/25/25 nature of call as dispatched: interfacility location of call 4916 Mobile Hwy apt 4. Chief complaint: foot edema/pain. Past medical history COPD, HOH. Alert. Left foot was swollen, skin appeared to be sloughing off toes and plantar side of foot. Foot appeared saturated, no bleeding noted, patient complaint pain 3/10. Staff stated left shoe was soaked. 2. Emergency Department Release and Refusal of Screening/treatment form dated 7/26/25 at 0540. The form was checked under “patient left the Emergency Department without notifying staff. 3. Face sheet for patient #1 identifying [the name of the Assisted Living Facility] with the address and telephone number listed. Under personal contacts noted Lutheran Services with a telephone number, duties: responsible party. Under care team read: left foot edema and weeping, several small areas open on toes. Surrounding skin white in color. Shoe was saturated. Resident stated that they had some pain and stiffness while ambulating. 4. The current Physician’s orders as of 25 July 2025 with the resident’s ALF admission date, full code status, the patient’s date of birth and list of current medications. Another order dated October 29, 2024, under treatment indicates that the Guardian or family should be notified of medication refusals. These 4 forms contained Patient #1 hospital medical record labels containing patient #1’s name, date of birth, medical record, and other coding. On the back of medication list form were hand-written questions: “What hospital? Does it hurt” “How bad 1-10?” “How did your foot get wet?” “What year is it now?” “How long has your foot been like that?” On this same page on right top is written “N/A and 0154”. The back contains the patient’s label on right upper side. Review of the following hospital’s policies and procedures revealed: “Discharge Planning”, effective date June 2025. Bullet 8. Discharge instructions shall be given to the patient/family in a manner that the patient/family can understand. 17. All discharge plans shall be reviewed with the patient and/or family member before the patient is discharged from the hospital to ensure that the discharge plan meets the needs of the patient. “Treating a Personal Representative of the Individual as the Individual”, effective date December 2024. Statement of purpose: to give standards on dealing with a personal representative of an individual to ensure BHC is compliance with applicable laws and regulations. Policy states 1. If, under applicable law, a person has authority to act on behalf of an individual who is an adult or an Emancipated Minor in making decisions related to health care, BHC will treat such person as a personal representative with respect to protected health information (PHI) relevant to such personal representative. “Triage and Emergency Medical Screening for the Non-Psychiatric Patient”, effective date May 2025. After the Medical Screening Evaluation (MSE) is completed: the Qualified Medical Personnel (QMP) will inform the patient and /or family that the patient doesn’t not have an Emergency Medical Condition.”