Homestead Hospital

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 33162 Based on record review and staff interviews, the Hospital failed to follow its own medical staff rules and regulations that were approved by the governing body to ensure physicians are in charge of Codes Blue and Codes Rescue, but has implemented a policy for Advanced Practice Registered Nurses (APRNs) to be in charge of those codes instead of physicians. This has the potential to affect the safety of any patient who experiences an emergent event requiring a Code Blue or Code Rescue response. This affected Patient #4, for whom the responding APRN identified an anaphylaxis (severe allergic reaction) but did not timely administer epinephrine, instead administering other medications he incorrectly reported as “first line treatment” for allergic reactions, resulting in a delay of over an hour for Patient #4 to receive the first line treatment of anaphylaxis, epinephrine, and which likely contributed to the inability to prevent Patient #4’s death. The findings included: The Hospital’s Medical Staff Rules and Regulations, approved and adopted by signatures of the President of Medical Staff, Hospital Chief Executive Officer (CEO), and the Chairperson of the Board of Directors dated 06/01/2017 to 06/09/2017, documents under Code Blue/Code Rescue, “The first physician on the scene of a Code Blue or Code Rescue is in charge unless that physician decides to direct it to some other physician who is more experienced than himself/herself. The responsibility of the physician is to direct the administration of medication, IV [intravenous] fluids, and defibrillation or any other procedures deemed necessary,” and under Physician Substitute, “A physician, who is unable to attend to his or her patients, is to designate a substitute physician who is a member of the Medical Staff with suitable privileges. In the event the attending physician fails to do so, the Clinical Service Chief or Medical Staff President or either of their designees shall have the authority to call any appropriate member of the Medical Staff.” During an interview on 02/20/2026 at 9:33 AM, the Supervisor of Medical Staff provided the Definitions Manual and stated physicians are defined as Medical Doctors or Doctors of Osteopath, and that APRNs are Allied Health Professionals. Review of the Hospital’s Definitions Manual, approved and adopted by signatures of the President of Medical Staff on 05/04/2015, the Hospital Chief Executive Officer on 05/27/2015, and Chairperson of Board of Directors on 05/27/2015, documents, “”Physician(s)” means doctors of medicine licensed under chapter 458 of the Florida Statutes, as amended or doctors of osteopathy licensed under chapter 459 of the Florida Statutes, as amended.” During an interview on 02/20/2026 at 1:33 PM, the Assistant Vice-President of Nursing confirmed the Medical Staff Rules and Regulations manual approved in 2017 and Definitions Manual approved in 2015 are the most current versions of those documents but that according to the Delineation of Privileges and Code Blue policy, APRNs (rather than physicians) can run the “Codes.” The hospital’s Policy titled Code Blue Response, approved 12/02/25 and released 01/06/26, documents under definitions, “The Code Blue team includes but is not limited to the following: Patient Care House Supervisor; Critical Care (ICU) Team: ICU Patient Care Supervisor [and] ICU Advanced Practice Registered Nurse (APRN); Patient’s Nurse; Patient Care Supervisor (PCS)/Relief charge from patient’s unit; Respiratory Therapist; Nursing Unit designee; (and) Emergency Department ED Team: ED Charge Nurse and/ or designee when code is called in areas on the first floor” and does not include a physician. A Memorandum to HH [Homestead Hospital] Staff from Medical Staff/Administration, with the subject ICU APRNs, dated 12/28/22 documents, “Effective Monday January 2, 2023, Homestead Hospital will have 24/7 ICU APRN coverage. They will be responsible for attending Code Rescues and Code Blues, in addition to managing the ICU patients. Part of their scope of responsibility will include intubations and central lines insertions for ICU patients. ED physicians, Hospitalists and e-ICU (electronic (virtual) ICU) will be available for additional support if needed. The ICU APRN’s can be contacted directly via...” Review of the record revealed Patient #4 was 23 years old and was admitted to the hospital on 01/16/2026 for sickle cell crisis and bilateral knee pain. Patient #4’s medication record documents he was given the first dose of ceftriaxone on 01/17/26 at 6:14 PM. During a telephonic interview on 02/18/26 at 4:18 PM, Registered Nurse, Staff B stated after she gave Patient #4 the IV push antibiotic on 01/17/26, she was about to start the next antibiotic but he started screaming that he was burning, that his whole body was burning, and she called a Code Rescue; that a couple minutes later, before the Code Team arrived, he started gasping for air and she called a Code Blue; and that she believed it to be a reaction to the antibiotic. Patient #4’s Code Blue Resuscitation Report documents a Code Blue was started on 01/17/2026 at 6:24 PM, Patient #4 was administered Solumedrol IV (intravenous) at 6:27 PM, Benadryl IV at 6:28 PM, and Pepcid 20 mg IV at 6:30 PM; was intubated at 6:34 PM; had a chest x-ray to confirm successful intubation on 6:36 PM; was taken to CT at 6:40 PM; and Patient #4 arrived in the ICU at 6:59 PM; but no evidence of epinephrine administration. Further review of the record reveals APRN C ordered epinephrine 0.3 mg (milligrams) IM on 01/17/2026 at 7:23 PM and it was administered on 01/17/2026 at 7:30 PM, over an hour after the Code Blue response started. Patient #4’s Critical Care Consultation note by APRN C for service date/time of 01/17/2026 at 7:31 PM documents after antibiotic the patient reported feeling hot and had a syncopal episode; that a Code Blue was called; that on arrival the patient was foaming at the mouth and unresponsive to any painful stimuli; that with concerns for allergic reaction secondary to IV antibiotic administration, the decision was made to emergently intubate him for airway protection; that he was “quickly treated with Benadryl, Solumedrol, Pepcid and epinephrine IM (intramuscular injection);” and will be sent to the ICU. During a telephonic interview with APRN C on 02/19/2026 at 3:21 PM, he stated after some of Patient #4’s notes were read to him that he remembered Patient #4 and the Code Rescue and Code Blue on 01/17/26 and explained Code Blues are either for CPR (cardiopulmonary resuscitation) or intubation and Patient #4 was not cardiac, he needed intubation; that he thought it was anaphylaxis and treated it with solumedrol, Benadryl, and Pepcid, which he claimed are the first line treatment for anaphylaxis; that he was sure he ordered epinephrine during the code but someone handed him the wrong concentration and he said it was the wrong one; that the patient was not responsive and foaming at the mouth so he proceeded with intubation; that after intubation the patient went to CT (Computed Tomography); that when he saw the radiologist’s CT report that the back of the throat was completely closed except for the tube, he ordered epinephrine and went upstairs and gave it himself. During this interview when asked if epinephrine, rather than solumedrol, Benadryl, and Pepcid, is the first line treatment for anaphylaxis, APRN C stated he was not sure if those medications could reverse anaphylaxis but he decided to transfer the patient to the ICU, where he knew where the correct epinephrine was, rather than to wait for it and give it first; he stated he was been on the Code Blue Team since he started working at this hospital and has treated allergic reactions with solumedrol, Benadryl, and Pepcid before and they always resolved without needing to intubate those patients but that he never saw a case like this before, which was really severe. During an interview on 02/19/26 at 11:25 AM, Clinical Pharmacist, Staff D confirmed she remembered Patient #4’s Code Blue, that during the code she asked what medications Patient #4 had already received and if it was anaphylaxis; that they said they already gave solumedrol and Benadryl, and did not think it was anaphylaxis; that APRN C asked for racemic epinephrine, which relaxes the throat for intubation and is not for anaphylaxis; that Staff D got the racemic epinephrine for APRN C but does not know if it was used; and denied awareness of an order or request for IM epinephrine.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 33162 Based on record review and interviews, the governing body failed to ensure radiology services were furnished in a manner to comply with standards for radiological services. This affected 3 of 3 patients sampled for MRI (Magnetic Resonance Imaging) STAT (immediate or without delay) orders resulting in undue delays of STAT MRIs for Patient #1, whose condition deteriorated during this delay until an MRI could no longer be completed because he then required continuous IV (intravenous) medication and the hospital did not have a functioning MRI-safe intravenous pump, as well as Patients# 2 and 3. Cross refer to A 529. The findings included: Review of the Hospital’s Policy and Procedure for the Imaging Department titled Scope of Care and Services, revision date 05/23/2023, released 07/11/2023, documents, “The department provides the following imaging services 24 hours a day to Emergency and in-house patients ranging from newborn to aging adult. ... e. MRI;” and “Elective outpatient procedures are available at the hospital Monday through Friday from 0700 until 1900 and Saturday from 0800 until 1200. Outside of these hours, the focus of the department’s resources is on emergency and inpatient needs;” “The services not provided by the Imaging Services Department at Homestead Hospital are: ...d. Stat MRI Services;” “The department of Imaging Services recommends referral to other Baptist Health facilities for imaging procedures not provided here;” and “The Imaging Services Department will provide diagnostic imaging sufficient to meet the needs of the patients and medical staff of Homestead Hospital.” During an interview with Staff A on 02/19/26 at 2:10 PM she stated she was told they do not have “STAT MRIs” because they schedule outpatient MRIs for the MRI machines. During a virtual interview on 2/19/26 at 2:15 PM, the Director of Radiology stated “there is no timeframe” for when a STAT MRI should be completed but it depends on the necessity of orders; that the goal is within 4 hours but there is a lot of prep work that has to take place; that roughly 40% of their MRIs are for outpatients; that one machine is staffed 8 hours a day Monday through Friday and the other machine is staffed 24 hours a day 7 days a week; and denied awareness that a functioning intravenous pump was not available for Patient #1’s MRI on 12/01/2025 but stated he would not need to be informed of this because they can still do MRIs, just not patients who need continuous intravenous medication, such as in the ICU (Intensive Care Unit).”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 33162 Based on record review and staff interviews, the Hospital failed to follow its own medical staff rules and regulations that were approved by the governing body to ensure physicians are in charge of Codes Blue and Codes Rescue, but has implemented a policy for Advanced Practice Registered Nurses (APRNs) to be in charge of those codes instead of physicians. This has the potential to affect the safety of any patient who experiences an emergent event requiring a Code Blue or Code Rescue response. This affected Patient #4, for whom the responding APRN identified an anaphylaxis (severe allergic reaction) but did not timely administer epinephrine, instead administering other medications he incorrectly reported as “first line treatment” for allergic reactions, resulting in a delay of over an hour for Patient #4 to receive the first line treatment of anaphylaxis, epinephrine, and which likely contributed to the inability to prevent Patient #4’s death. Cross refer to A 048. The findings included: The Hospital’s Medical Staff Rules and Regulations, approved and adopted by signatures of the President of Medical Staff, Hospital Chief Executive Officer (CEO), and the Chairperson of the Board of Directors dated 06/01/2017 to 06/09/2017, documents under Code Blue/Code Rescue, “The first physician on the scene of a Code Blue or Code Rescue is in charge unless that physician decides to direct it to some other physician who is more experienced than himself/herself. The responsibility of the physician is to direct the administration of medication, IV [intravenous] fluids, and defibrillation or any other procedures deemed necessary,” and under Physician Substitute, “A physician, who is unable to attend to his or her patients, is to designate a substitute physician who is a member of the Medical Staff with suitable privileges. In the event the attending physician fails to do so, the Clinical Service Chief or Medical Staff President or either of their designees shall have the authority to call any appropriate member of the Medical Staff.” During an interview on 02/20/2026 at 9:33 AM, the Supervisor of Medical Staff provided the Definitions Manual and stated physicians are defined as Medical Doctors or Doctors of Osteopath, and that APRNs are Allied Health Professionals. Review of the Hospital’s Definitions Manual, approved and adopted by signatures of the President of Medical Staff on 05/04/2015, the Hospital Chief Executive Officer on 05/27/2015, and Chairperson of Board of Directors on 05/27/2015, documents, “”Physician(s)” means doctors of medicine licensed under chapter 458 of the Florida Statutes, as amended or doctors of osteopathy licensed under chapter 459 of the Florida Statutes, as amended.” During an interview on 02/20/2026 at 1:33 PM, the Assistant Vice-President of Nursing confirmed the Medical Staff Rules and Regulations manual approved in 2017 and Definitions Manual approved in 2015 are the most current versions of those documents but that according to the Delineation of Privileges and Code Blue policy, APRNs (rather than physicians) can run the “Codes.” The hospital’s Policy titled Code Blue Response, approved 12/02/25 and released 01/06/26, documents under definitions, “The Code Blue team includes but is not limited to the following: Patient Care House Supervisor; Critical Care (ICU) Team: ICU Patient Care Supervisor [and] ICU Advanced Practice Registered Nurse (APRN); Patient’s Nurse; Patient Care Supervisor (PCS)/Relief charge from patient’s unit; Respiratory Therapist; Nursing Unit designee; (and) Emergency Department ED Team: ED Charge Nurse and/ or designee when code is called in areas on the first floor” and does not include a physician. A Memorandum to HH [Homestead Hospital] Staff from Medical Staff/Administration, with the subject ICU APRNs, dated 12/28/22 documents, “Effective Monday January 2, 2023, Homestead Hospital will have 24/7 ICU APRN coverage. They will be responsible for attending Code Rescues and Code Blues, in addition to managing the ICU patients. Part of their scope of responsibility will include intubations and central lines insertions for ICU patients. ED physicians, Hospitalists and e-ICU (electronic (virtual) ICU) will be available for additional support if needed. The ICU APRN’s can be contacted directly via...” Review of the record revealed Patient #4 was 23 years old and was admitted to the hospital on 01/16/2026 for sickle cell crisis and bilateral knee pain. Patient #4’s medication record documents he was given the first dose of ceftriaxone on 01/17/26 at 6:14 PM. During a telephonic interview on 02/18/26 at 4:18 PM, Registered Nurse, Staff B stated after she gave Patient #4 the IV push antibiotic on 01/17/26, she was about to start the next antibiotic but he started screaming that he was burning, that his whole body was burning, and she called a Code Rescue; that a couple minutes later, before the Code Team arrived, he started gasping for air and she called a Code Blue; and that she believed it to be a reaction to the antibiotic. Patient #4’s Code Blue Resuscitation Report documents a Code Blue was started on 01/17/2026 at 6:24 PM, Patient #4 was administered Solumedrol IV (intravenous) at 6:27 PM, Benadryl IV at 6:28 PM, and Pepcid 20 mg IV at 6:30 PM; was intubated at 6:34 PM; had a chest x-ray to confirm successful intubation on 6:36 PM; was taken to CT at 6:40 PM; and Patient #4 arrived in the ICU at 6:59 PM; but no evidence of epinephrine administration. Further review of the record reveals APRN C ordered epinephrine 0.3 mg (milligrams) IM on 01/17/2026 at 7:23 PM and it was administered on 01/17/2026 at 7:30 PM, over an hour after the Code Blue response started. Patient #4’s Critical Care Consultation note by APRN C for service date/time of 01/17/2026 at 7:31 PM documents after antibiotic the patient reported feeling hot and had a syncopal episode; that a Code Blue was called; that on arrival the patient was foaming at the mouth and unresponsive to any painful stimuli; that with concerns for allergic reaction secondary to IV antibiotic administration, the decision was made to emergently intubate him for airway protection; that he was “quickly treated with Benadryl, Solumedrol, Pepcid and epinephrine IM (intramuscular injection);” and will be sent to the ICU. During a telephonic interview with APRN C on 02/19/2026 at 3:21 PM, he stated after some of Patient #4’s notes were read to him that he remembered Patient #4 and the Code Rescue and Code Blue on 01/17/26 and explained Code Blues are either for CPR (cardiopulmonary resuscitation) or intubation and Patient #4 was not cardiac, he needed intubation; that he thought it was anaphylaxis and treated it with solumedrol, Benadryl, and Pepcid, which he claimed are the first line treatment for anaphylaxis; that he was sure he ordered epinephrine during the code but someone handed him the wrong concentration and he said it was the wrong one; that the patient was not responsive and foaming at the mouth so he proceeded with intubation; that after intubation the patient went to CT (Computed Tomography); that when he saw the radiologist’s CT report that the back of the throat was completely closed except for the tube, he ordered epinephrine and went upstairs and gave it himself. During this interview when asked if epinephrine, rather than solumedrol, Benadryl, and Pepcid, is the first line treatment for anaphylaxis, APRN C stated he was not sure if those medications could reverse anaphylaxis but he decided to transfer the patient to the ICU, where he knew where the correct epinephrine was, rather than to wait for it and give it first; he stated he was been on the Code Blue Team since he started working at this hospital and has treated allergic reactions with solumedrol, Benadryl, and Pepcid before and they always resolved without needing to intubate those patients but that he never saw a case like this before, which was really severe. During an interview on 02/19/26 at 11:25 AM, Clinical Pharmacist, Staff D confirmed she remembered Patient #4’s Code Blue, that during the code she asked what medications Patient #4 had already received and if it was anaphylaxis; that they said they already gave solumedrol and Benadryl, and did not think it was anaphylaxis; that APRN C asked for racemic epinephrine, which relaxes the throat for intubation and is not for anaphylaxis; that Staff D got the racemic epinephrine for APRN C but does not know if it was used; and denied awareness of an order or request for IM epinephrine. Review of APRN C’s credentialing files reveals privileges for his appointment as a member of Allied Health Staff for 02/22/2023 to 06/30/2025 included under Core Privileges “Airway management, cardioversion, defribillation, and cardiopulmonary resuscitation (must have current ACLS (Advanced Care Life Support certification).” However, APRN C’s reappointment for 09/30/2025 to 09/30/2028 (gap in credentialing noted in retrospect and not explained), date stamped for Credentials Committee action and “Medical action Executive Committee” (sic) on 08/04/2025 and for Board of Directors action on 08/08/2025, documents Core Privileges that now include, “Management of Codes Rescue and Codes Blue (must have current ACLS)” as “current” (renewal of that privilege) rather than “new.””

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 33162 Based on record review and interviews, the facility failed to complete STAT (immediately or without delay) Magnetic Resonance Imagings (MRIs) in a timely manner for 3 out of 4 patients (Patients# 1, 2, and 3) sampled for STAT MRI orders. The findings included: Review of the Hospital’s Policy and Procedure for the Imaging Department titled Scope of Care and Services, revision date 05/23/2023, released 07/11/2023, documents, “The department provides the following imaging services 24 hours a day to Emergency and in-house patients ranging from newborn to aging adult. ... e. MRI;” and “Elective outpatient procedures are available at the hospital Monday through Friday from 0700 until 1900 and Saturday from 0800 until 1200. Outside of these hours, the focus of the department’s resources is on emergency and inpatient needs;” “The services not provided by the Imaging Services Department at Homestead Hospital are: ...d. Stat MRI Services;” “The department of Imaging Services recommends referral to other Baptist Health facilities for imaging procedures not provided here;” and “The Imaging Services Department will provide diagnostic imaging sufficient to meet the needs of the patients and medical staff of Homestead Hospital.” 1) Review of the record revealed Patient #1 was 33 years old and was alert and oriented to person, place, time and situation with no neurological deficits upon examination when he was admitted to the hospital on 11/25/2025 for a gastrointestinal problem. Patient #1’s neurology consultation for service date/time of 12/01/2025 at 9:21 AM documents Patient #1’s previous brain MRI (on 11/28/25) for headache/migraine was unremarkable, that Patient #1 had increased headache and confusion that day, was sleepy but arousable and agitated, the presence of nuchal rigidity (severe neck stiffness), and “At this point I recommend start MRI with contrast to rule out any meningeal enhancement since patient is too agitated to perform LP (lumbar puncture). Review of Patient # 1’s physician orders revealed an order for Brain MRI with contrast STAT on 12/01/2025 at 11:51 AM. A Nursing Narrative Note dated 12/01/2025 at 10:41 PM documents, “Call placed to MRI for pending order, unable to take patient at this time . Per tech only one MRI IV (intravenous) pump is working.” Further record review revealed Patient #1’s MRI order was canceled without being completed on 12/02/2025 at 8:46 PM. Patient #1’s Brain CT (Computed Tomography) without contrast, resulted on 12/02/2025 at 8:09 AM documents the Impression: “Acute intraparenchymal hemorrhage (life-threatening brain bleed) in the right frontal lobe (45 cc (cubic centimeters)). New diffuse cerebral edema (brain swelling) with slitlike ventricles and effacement of the basal cisterns (indicating swelling has displaced structures within the skull).” Patient #1’s Brain Flow study, resulted on 12/02/2025 at 2:50 PM documents “No evidence of intracerebral blood flow” (brain death). An Infectious Disease Progress Note for service date/time of 12/04/2025 at 3:44 PM documents, “This unfortunate young man did NOT had a CNS infection but obviously a intraparenchymal bleed. There is no need for any antibiotics...” During an interview on 02/19/2026 at 2:19 PM, the Imaging Services Director confirmed Patient #1 had an order for Brain MRI with contrast that was cancelled and never performed but stated he could not find who canceled the order or the reason why it was canceled. During an interview on 02/20/2026 at 11:19 AM, the Imaging Services Manager stated Patient #1’s order on 12/01/2025 at 11:51 AM was for a STAT Brain MRI with contrast but based on their protocol the order needed to be “with or without contrast;” therefore, the first order was changed to a STAT Brain MRI with and without contrast on 12/01/2026 at 1:49 PM. The Imaging Services Manager stated the technologist received the STAT order, put it in a “bin,” and proceeded with other scheduled (routine) tests, prioritizing other patients. The Imaging Services Manager added that the technologist did not get a call to prioritize the MRI and, by the time the afternoon technologist came in and triaged Patient #1, he was already in the Intensive Care Unit and could no longer be brought down to MRI because by that time Patient #1 needed an IV (intravenous) drip and the MRI-safe IV pump in the MRI suite was not working. The Imaging Services Manager confirmed the MRI was never performed and the order was discontinued without being completed on 12/02/2025, and also stated that according to the facility’s protocol, STAT orders need to be done prior to routine inpatient and outpatient orders. 33988 2)Review of Patient #3’s physician orders revealed an order for Brain MRI without contrast STAT on 02/14/2026 at 11:59 AM with a procedure reason of stroke/TIA. Review of Patient #3’s Brain MRI without contrast STAT result revealed the procedure was not performed until 02/14/2026 from 11:32 PM to 11:54 PM, nearly 12 hours later, and was resulted at 11:57 PM. During an interview on 02/20/2026 at 3:12 PM, the Imaging Services Manager confirmed that Patient #3’s STAT Brain MRI without contrast was ordered on 02/14/2026 at 11:59 AM and was not completed until 02/14/2026 at 11:54 PM. The Imaging Services Manager stated that she was aware of the delay and she spoke to the technologist who was working that day. Additionally, the Imaging Services Manager stated that a STAT MRI should be completed within 4 hours. 3) Review of Patient #2’s physician orders revealed an order for STAT Left Foot MRI without contrast on 12/02/2025 at 11:39 AM with a procedure reason of osteomyelitis. Review of Patient #2’s STAT Left Foot MRI without contrast result revealed the MRI was not performed until 12/02/2025 from 9:39 PM to 10:32 PM and was resulted the following day, on 12/03/25 at 8:48 AM. During an interview on 02/20/2026 at 3:15 PM, the Imaging Services Manager confirmed the STAT left Foot MRI without contrast ordered on 12/02/2025 at 11:39 AM was not completed until 10:32 PM. The Imaging Services Manager reported that she was aware of the delay. Additionally, the Imaging Services Manager stated that when they had a STAT order, the patient’s nurse would usually call the Imaging Department to escalate the order so the MRI could be prioritized but in that case the nurse did not call.”