Bartow Regional Medical Center

“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: 42154 Based on facility policy, facility brochure, medical record review and staff interviews, the facility failed to provide care in a safe setting by delaying a critical transfer for life-saving measures in 1 (Patient#1) of 3 medical record reviewed. Finding included: Review of facility policy Provision of Patient Rights and Responsibilities last reviewed 11/2024, states “The Patient Admission Packet containing the PRR (Patient Rights and Responsibilities) brochure is given to all inpatients (or patient representative) upon admission. Review of the facility brochure “Patient Rights and Responsibilities” provided to all patients states “As a patient, you have the right to: equal access to medical treatment, accommodations and services ...Receive treatment for any emergency medical condition that will get worse if not treated ...” Review of Patient #1 medical record revealed on 03/26/2026 at 6:04 PM patient arrived to the emergency department (ED) via EMS(emergency medical services) with respiratory difficulty. Patient #1 had been on BiPAP (Bilevel positive airway pressure- noninvasive mask based ventilation therapy that aids breathing) placed by EMS prior to arrival in the ED (emergency department). Patient #1 was placed on heated high flow oxygen by the ED staff. On 03/26/2026 at 11:58 Patient #1 was transferred to the intensive care unit (ICU). On 03/27/2026 12:44 AM Patient #1 had a cardiac arrest. Patient #1 was intubated and placed on a ventilator (machine that moves air in and out of your lungs). At 4:41 AM, a call was placed to the transfer center and at 4:55 AM the PA (Physician Assistant) initiated the transfer to main hospital for possible ECMO (extracorporeal membrane oxygenation - blood is pumped outside of the body to a heart-lung machine. The machine removes carbon dioxide and sends oxygen-rich blood back to the body). On 03/27/2026 at 6:49 AM, the nursing note revealed the county EMS was called to transfer patient to the main hospital. EMS waited at the hospital over 40 minutes for the patient to be ready for transport and informed staff to recall when patient is fully ready for transport. The nursing note revealed staff is currently waiting on a medication to be given before transport. Patient #1 was transported at 8:21 AM to a higher level of care. During an interview on 04/22/2026 at 1:54 PM, the Pharmacist stated the pharmacy is not open 24 hours a day 7 days a week; from 10 PM to 6 AM [another hospital] covers. During an interview on 04/22/2026 at 3:04 PM, the RT (respiratory therapist) stated the surgeon from the receiving hospital called asking why the patient has not left yet. He was informed they were waiting on pharmacy get get there to paralyze the patient; the pharmacists come in at 6:00 AM. The RT stated it caused a 3 or 4 hour delay in transferring the patient. During an interview on 04/22/2026 at 3:30 PM, Staff C, registered nurse (RN) stated the provider wanted the medication Rocuronium (an intermediate-acting, non-depolarizing neuromuscular blocking agent used to induce skeletal muscle relaxation during surgery or to facilitate rapid sequence intubation) started before the patient was transferred. He said the doctor put the order in and he was waiting on the medication. During an interview on 04/23/2026 at 9:39 AM, Staff A, RN stated he was the charge nurse that night and he did not have critical care background. He said he was only the charge nurse as a helping hand and he stated, “obviously I could not help him as far as ICU capacity”. He also disclosed that he spoke with EMS and EMS said to have the patient ready for transport when they arrived; he told the patients nurse. The provider then changed the paralytic from Nimbex (a potent, intermediate-acting, non-depolarizing neuromuscular blocking agent used to induce skeletal muscle relaxation during surgery, facilitate endotracheal intubation, and aid in mechanical ventilation) to Rocuronium so we had to wait for pharmacy. During an interview on 04/23/2026 at 10:58 AM, the interim CMO (Chief Medical Officer) stated the patient would have been fine with the Nimbex paralytic for the transfer and they had standing orders; they should not have waited for the Rocuronium. He stated they waited for the medication and around 8:20 AM the patient was transferred to the main hospital during morning rush hour which took longer for them to arrive to the hospital.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 42154 Based on facility policy, medial records and interviews, the facility failed to provide the intensive care unit with an experienced critical care charge nurse and caused a delay in transfer to a higher level of care in 1 (Patient #1) of 3 patients reviewed. Finding included: Review of facility policy “Assessment/Reassessment of Adult Patient” last reviewed 03/2026 states “The scope of assessments and reassessments are based on the patient’s diagnosis, the care setting, the patient’s willingness to receive treatment, and the response to and effectiveness of care and interventions.” Review of Patient #1 medical record revealed on 03/26/2026 at 6:04 PM patient arrived to the emergency department (ED) via EMS(emergency medical services) with respiratory difficulty. Patient #1 had been on BiPAP (Bilevel positive airway pressure- noninvasive mask based ventilation therapy that aids breathing) placed by EMS prior to arrival in the ED (emergency department). Patient #1 was placed on heated high flow oxygen by the ED staff. On 03/26/2026 at 11:58 Patient #1 was transferred to the intensive care unit (ICU). On 03/27/2026 12:44 AM Patient #1 had a cardiac arrest event and code blue was called. Patient #1 was intubated and placed on a ventilator (machines that act as bellows to move air in and out of your lungs). At 4:41 AM, a call was placed to the transfer center and at 4:55 AM the PA (Physician Assistant) initiated the transfer to main hospital for possible ECMO(extracorporeal membrane oxygenation - blood is pumped outside of the body to a heart-lung machine. The machine removes carbon dioxide and sends oxygen-rich blood back to the body). On 03/27/2026 at 6:49 AM, the nursing note revealed the county EMS was called to transfer patient to the main hospital. EMS waited over 40 minutes for the patient to be ready for transport and informed staff to recall when patient is fully ready for transport. The nursing note revealed staff is currently waiting on a medication to be given before transport. Patient #1 was transported at 8:21 AM to a higher level of care. During an interview on 04/22/2026 at 1:54 PM, the Pharmacist stated the pharmacy is not open 24 hours a day 7 days a week; from 10 PM to 6 AM [another hospital name] covers. During an interview on 04/22/2026 at 3:04 PM, the RT (respiratory therapist) stated the surgeon from the receiving hospital called asking why the patient has not left yet. He was informed they were waiting on pharmacy get get there to paralyze the patient; the pharmacists come in at 6:00 AM. The RT stated it caused a 3 or 4 hour delay in transferring the patient. During an interview on 04/22/2026 at 3:30 PM, Staff C, RN stated the provider wanted the medication Rocuronium (an intermediate-acting, non-depolarizing neuromuscular blocking agent used to induce skeletal muscle relaxation during surgery or to facilitate rapid sequence intubation) started before the patient was transferred. He said the doctor put the order in and he was waiting on the medication. During an interview on 04/23/2026 at 9:39 AM, Staff A, RN stated he was the charge nurse that night and he did not have critical care background. He said he was only the charge nurse as a helping hand and he stated, “obviously I could not help him as far as ICU capacity”. He also disclosed that he spoke with EMS and EMS said to have the patient ready for transport when they arrived; he told the patients nurse. The provider then changed the paralytic from Nimbex (a potent, intermediate-acting, non-depolarizing neuromuscular blocking agent used to induce skeletal muscle relaxation during surgery, facilitate endotracheal intubation, and aid in mechanical ventilation) to Rocuronium so we had to wait for pharmacy. During an interview on 04/23/2026 at 10:58 AM, the interim CMO (Chief Medical Officer) stated the patient would have been fine with the Nimbex paralytic for the transfer and they had standing orders; they should not have waited for the Rocuronium. He stated they waited for the medication and around 8:20 AM the patient was transferred to the main hospital during morning rush hour which took longer for them to arrive to the hospital.”