Tampa General 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: 36678 Based on facility policy and Procedure review, facility electronic document review, medical record review and staff interviews, the hospital failed to provide an appropriate medical screening examination within the capability of the hospital’s satellite emergency center department, including ancillary services routinely available to the emergency department, to determine, whether or not an emergency medical condition existed for 1 (Patient #3) of 20 sampled patients. Refer to findings in Tag A-2406”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 36678 Based on facility policy and Procedure review, ED (Emergency Department) Central Log review, and staff interview, the hospital failed to maintain a central log of individuals who come to the hospital’s satellite emergency center department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 (Patient#3) of 20 sampled patients Patient #3 was not entered on facility’s central log. Findings Included: The facility’s Policy and Procedure titled, “ ...Patient Transfers in and Out of Tampa General Hospital (TGH). PolicyIDStat20272846, Original issue: 7/1/2002; Last Review: 4/7/2026 was reviewed. The Policy revealed in part, “II. GENERAL OBLIGATIONS TO PROVIDE EMERGENCY SERVICES AND CARE. A. Obligation. ..B. Under EMTALA Hospitals are requires to take the following measures ...7. Maintain a central log of individuals who come to the ED.” A review of the ED log dated 3/11/26 reflected no entry for Patient #3. During an interview on 05/18/26 at 12:08 AM, Staff A, Financial Counselor said a minor brought her sister to the emergency department. “We asked for the parents. She said they were not available. I asked her to call mom. She called but mom did not answer. I asked for someone in the back. He did not know what to do. I started to check the patient in. I entered the name, date of birth, and sex. I was about to check ‘arrive’ when the CN (Charge Nurse) came to my side and started talking to the sister, and I never hit arrive. He said we could not take her because she is a minor and have to have consent from the parents to treat her. They left. They came back about 30 minutes later. She did not get logged in because I did not hit ‘arrive’.” The facility failed to follow their policy and procedure as evidenced by failing to maintain a Central Log for patient #3 ( a minor) on 3/11/2026 , when she presented to the hospital’s ED accompanied with her sister seeking medical assistance for 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: 36678 Based on facility policy and Procedure review, facility electronic document review, medical record review and staff interviews, the hospital failed to provide an appropriate medical screening examination within the capability of the hospital’s satellite emergency center department, including ancillary services routinely available to the emergency department, to determine, whether or not an emergency medical condition existed for 1 (Patient #3) of 20 sampled patients. Findings included: The facility’s Policy and Procedure titled, “ ...Patient Transfers in and Out of Tampa General Hospital (TGH). PolicyStatID 20272846, Original issue: 7/1/2002; Last Review: 4/7/2026 was reviewed. The facility’s Policy and procedure revealed in part, “VI. MEDICAL SCREENING EXAMINATION (MSE) A. Duty to provide a Medical Screening Examination to determine whether an Emergency Medical Condition Exists. 1. A medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition exists ...Such screening must be done within the facility’s capabilities and available personnel, including on call providers. The medical screening examination is an ongoing process, and the medical records must reflect continued monitoring based on the patient’s needs; ...2. A medical screening examination must be provided by a qualified medical provider, whenever a person request emergency services and care on their own behalf, or whenever emergency services and care are requested on behalf of an individual by (1) Any Individual ...” The facility’s Policy and Procedure titled “ ...ECC (Emergency Car Center) Psychiatric Patient Protocol, PolicyStatID 18663141, Original Issue : 8/1/2002, Last Review: 9/30/2026 was reviewed. The facility policy revealed in part, “ PURPOSE; To outline the care and management of the patients presenting with a psychiatric emergency ...” CONTENT: ASSESSMENT: 1. Assess patient’s potential for danger for self/staff environment a. Inform ED Security of patient location. 2. Medical evaluation provided by the ECC Attending Physician/designee. a . Medical clearance/stability is determined and documented by ECC Attending Physician ...b. The voluntary/involuntary status of a patient is determined as a result of the criteria met upon the Attending Physician’s evaluation ...4 Patient is to be assigned a room and paled under continuous Video observation or one on one sitter for suicidal precautions and patient safety 5. Gather Data- Information received from patient, person(s) accompanying patient.” A review of facility electronic documentation dated 3/12/26 at 9:55 AM revealed a document was sent to Staff B, RN from Staff C, ED Nurse Manager, regarding Patient #3. The document stated “A minor was brought in by her 18-year-old sister on 3/11/26 at 11:45 PM with concern about 12 200 mg Ibuprofen (a nonsteroidal anti-inflammatory drug (NSAID) used to relieve mild to moderate pain, reduce fever, and decrease inflammation) tablets ingestion. I called patients mother, but she did not answer the phone. Patient’s sister also tried to contact her but she did not answer. I went to the back to try to talk to the Charge Nurse, but he was busy at the moment. Not long after the Charge Nurse showed up to the front desk at 11:55 PM. He proceeded to ask the sister why the mother was not present and told her that legally we were not allowed to see a minor without the parent or legal guardian consent. They left shortly after at 11:57 PM.” Review of the medical record for Patient #3 reflected a return to the ED on 3/12/26 12:32 AM, accompanied by her mother. Further review of the record revealed “Reason for Visit; Chief Complaint Ingestion (patient’s mother states that one of patient’s friends stated she took approximately 12 Motrin tablets two hours ago.” Review of the ED Provider Note dated 3/12/2026 at 1:32 AM revealed in part, “HPI (history of Present illness) 12 year-ole female who presents s/p (Status/post) suicide attempt ...Physical Exam: ...Psychiatric: Comments: Flat affect, endorses SI (suicidal ideation-thoughts, ideas about ending one’s life) ...ED Course & Medical Decision Making:. Will B52 (Baker Act- Florida Mental Health Act- is a law that allows for the involuntary examination and temporary psychiatric hold of individuals who are experiencing a mental health crisis. It provides a way to get emergency care for someone who is a danger to themselves or others) She needs medical clearance for ingestion ....Social work and poison control; consult. ...Clinical Impressions: Medically cleared for psych.” Review of the Social Work Psychosocial Progress Note date 3/12/2026 at 2:33 AM was reviewed. The LCSW (Licensed Clinical Social Worker) revealed in part, “INTERVENTION & CARE PLAN OF CARE: Patient and/or safety needs identified: awaiting medical clearance for pediatric baker act placement. Patient #3 was admitted, treated and transferred to inpatient behavioral health hospital. During an interview on 05/18/2026 at 11:18 AM, the ED Director stated the nurse manager emailed after the incident occurred. The email stated it happened on night shift and the charge nurse sent it in the end of shift report. Registration emailed their director who contacted me. We started the investigation and I knew it was an issue. A minor was brought in by her sister and left after speaking to the charge nurse. But they returned an hour later with her mother. During an interview on 5/18/26 at 2:28 PM, the Medical Director of the ED said “we don’t delay the patient’s care. We make an effort to make sure the parent or guardian is aware.” The MSE and care proceed and are not delayed in an emergency. If it’s not emergent, we will wait until we can contact the parent or guardian. They have parental rights. We would engage a mental health professional. We may need to get DCF (Department of Children and Families) involved. Something in our process was not followed. During an interview on 5/18/26 at 4:02 PM, Staff B, RN (Registered Nurse) said Registration approached him and said there was a patient out there who was brought in by her sister for taking a handful of ibuprofen. There were four teenagers in the lobby. They said that she wanted to hurt herself and took some ibuprofen. I asked them to call the mom. They said she didn’t want to come in. He said he doesn’t recall saying that she couldn’t be seen. He did say it was necessary to have the mom there. They walked out and left and returned about twenty minutes later with the mom. The facility failed to follow their policy and procedure as evidenced by failing to provide an appropriate medical screening medical screening examination for Patient #3 a minor who presented to the hospital ‘s ECC on 3/11/2026, accompanied by her sister (18 years old); who requested emergency services and care on behalf of the patient , who ingested about 12 (twelve) 200 mg Ibuprofen tablets.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 48190 Based on facility documents, policy, interviews conducted and medical record review, the facility failed to maintain an accurate central log for any individual seeking treatment or assistance for 1 (Patient #21) of 21 patients reviewed. Findings: Review of facility EMTALA (Emergency Medical Treatment And Labor Act) log, no entry for Patient #21 was noted. Review of facility policy “Emergency Medical Care Policy” last reviewed 06/2024 states “Tampa General Emergency Department will provide care, without discrimination, for Emergency Medical Conditions (EMC) (as directed under the Emergency Medical Treatment and Labor Act (EMTALA) to individual regardless of their eligibility under TGH’s (Financial Assistance Policy LD-107)”. During an interview on 08/29/2024 10:27 AM, Patient #21’s daughter stated I walked into the ER (Emergency Room) and asked the person at the front desk to help me get my mom out of the car. The person said “I’m not allowed to do that. If you want your mom checked out, then you need to bring her in yourself.” Then Staff A/RN walked out. I explained the whole situation to Staff A/RN and how my mom was just discharged from the rehab across the parking lot. My mom was crying from a lot of pain. Patient #21’s daughter asked Staff A/RN if she could come out to the car to look at my mom to see I should have mom checked out here. Staff A/RN said, “maybe you just need to go home and get your mom in her pajamas and get into her own bed”. Patient #21 daughter said “Ok” and left. During an interview on 09/03/2024 01:30 PM, Staff A/RN (Registered Nurse) stated Patient #21’s daughter came into the ER after picking her mom up from a rehab. The daughter stated I think my mom has a UTI (Urinary Tract Infection is a bacterial infection that affects the urinary tract, which includes the bladder, urethra, and kidneys). The daughter asked me if I thought her mom should get checked out here. Staff A/RN stated if you would like your mom checked out, we will get her signed into the ER. Staff A/RN then stated the daughter said she will just taker her home. Review of Patient #21’s medical record reveals Patient #21 returned to Tampa General ER the next day on 03/31/2024 and expired on 04/03/2024. The facility completed their corrective action plan on 06/30/2024. This plan included education on the EMTALA requirements, Patient transfers, general obligations for emergency services and EMTALA transfers, MSE (Medical Screening Examination), Emergency Medical Conditions, Stabilization, transfer vs discharge, and transfers requiring investigation and reporting. Employees were required to acknowledge education with a sign in sheet. Evidence of the above was reviewed on 08/29/2024 and found plan of correction in place and completed.”

“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: 48190 Based on facility documents, policy, interviews conducted and medical record review, the facility failed to provide an appropriate medical screening for 1 (Patient #21) of 21 patients reviewed. Failure to provide an appropriate medical screen resulted in Patient #21’s death. Findings: Review of facility EMTALA (Emergency Medical Treatment And Labor Act) log, no entry for Patient #21 was noted. Review of facility policy “Emergency Medical Care Policy” last reviewed 06/2024 states “Tampa General Emergency Department will provide care, without discrimination, for Emergency Medical Conditions (EMC) (as directed under the Emergency Medical Treatment and Labor Act (EMTALA) to individual regardless of their eligibility under TGH’s (Financial Assistance Policy LD-107)”. During an interview on 08/29/2024 10:27 AM, Patient #21’s daughter stated I walked into the ER (Emergency Room) and asked the person at the front desk to help me get my mom out of the car. The person said “I’m not allowed to do that. If you want your mom checked out, then you need to bring her in yourself.” Then Staff A/RN walked out. I explained the whole situation to Staff A/RN and how my mom was just discharged from the rehab across the parking lot. My mom was crying from a lot of pain. Patient #21’s daughter asked Staff A/RN if she could come out to the car to look at my mom to see I should have mom checked out here. Staff A/RN said, “maybe you just need to go home and get your mom in her pajamas and get into her own bed”. Patient #21 daughter said “Ok” and left. During an interview on 09/03/2024 01:30 PM, Staff A/RN (Registered Nurse) stated Patient #21’s daughter came into the ER after picking her mom up from a rehab. The daughter stated I think my mom has a UTI (Urinary Tract Infection is a bacterial infection that affects the urinary tract, which includes the bladder, urethra, and kidneys). The daughter asked me if I thought her mom should get checked out here. Staff A/RN stated if you would like your mom checked out, we will get her signed into the ER. Staff A/RN then stated the daughter said she will just taker her home. Review of Patient #21’s medical record reveals Patient #21 returned to Tampa General ER the next day on 03/31/2024 and expired on 04/03/2024. The facility completed their corrective action plan on 06/30/2024. This plan included education on the EMTALA requirements, Patient transfers, general obligations for emergency services and EMTALA transfers, MSE (Medical Screening Examination), Emergency Medical Conditions, Stabilization, transfer vs discharge, and transfers requiring investigation and reporting. Employees were required to acknowledge education with a sign in sheet. Evidence of the above was reviewed on 08/29/2024 and found plan of correction in place and completed.”