HCA Florida Aventura Hospital

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 33988 Based on the review of records and interviews, the facility failed to transfer 1 out of 7 sampled patients’ necessary medical information pertaining to post discharge goal of care to the appropriate post-acute care service provider which was the skilled nursing facility where the patient was residing prior to hospitalization. This deficient practice has the potential to affect all patients who are being discharged to a post-acute care service provider. Patient #1 The findings included: Review of Patient #1’s physician note dated 06/13/2025 at 12:26 revealed: “Patient seen by Psychiatry and discharge history of bipolar disorder with psychiatric diagnosis adjustment disorder. Patient has psychiatrically cleared by Psychiatry return to the nursing facility. BH staff psychiatry called nursing facility who accepts patient back. Follow up to be seen next few days and return to ER precautions discussed. Patient is medically and psychiatrically stable for discharge with a close follow up. MD at nursing facility needs to see patient next few days and psychiatry needs to see patient next few days.” Review of the Nurses’ Notes dated 06/13/2025 at 1130 revealed : “BAKER ACT LIFTED. PT SEEN BY PSYCH TEAM. DISCHARGE ORDER PLACED. PT HAS BEEN ADVISED OF DISCHARGE, VERBALIZED UNDERSTANDING AND HAD NO FURTHER QUESTIONS.” Another Nurses Note dated 06/13/2025 at 113 revealed: “PATIENT WILL GO BACK TO NURSING HOME USING ALL SEASONS TRANSPORT. WAITING ON TRANSPORT.” Further review of Patient #1’s medical record revealed no documentation showing that the skilled nursing facility was made aware of Patient #1’s discharge on 06/13/2025. During an interview with Staff A, Registered Nurse (RN), on 04/01/2026 at 4:53 PM, he stated that he worked in behavioral health. Staff A stated that he received a call from the nursing facility on 06/13/2025 and the caller from the transport company stated that the nursing facility did not want to accept the patient, so he notified his Director of Nursing (DON). Staff A added that Patient #1 was already in front of the facility. Staff A also revealed that when a patient has been discharged by the psychiatrist, the psych nurse would notify the medical charge nurse that the patient has been cleared by the psychiatrist and the medical staff would arrange for transport, coordinate with the receiving facility, and give report to the staff. During an interview with the DON for Behavioral Health on 04/02/2026 at 11:19 AM, she stated that If the Baker act was lifted, then the patient was no longer a psych patient; psych would sign off, then the patient would go back to the Emergency Department (ED) for the discharge instructions. The DON revealed that they were not responsible to arrange transportation once the Baker act was lifted. Interview with the RN Interim ED Director on 04/02/2026 at 11:48 AM, she stated that when a patient has been discharged from the ED, the ED nurse is responsible to follow the hospital protocol and call the nursing facility to give report. The RN Interim ED Director also stated that the nurse who discharged Patient #1 documented that the patient was going back to the nursing home but the note did not specify who the nurse spoke to or gave report to. The RN Interim ED Director confirmed that the nurse was supposed to call the nursing facility to give report. During an Interview with the Vice President of Quality (VPQ ) on 04/02/2026 at 11:49 AM, she confirmed that Patient #1’s medical record did not contain any nurse’s documentation showing that report was given to the nursing facility. Additionally, the RN Interim ED Director confirmed that the nurse who discharged the patient should have written a note documenting that report was given to the nursing home staff. Review of the facility’s Policy on “Plan for the provision of care -Facility and Patient Care services “effective date 04/2025, last revised 01/2024 revealed it included but was not limited to: “Exit:2-The discharge process provides for continuing care based upon the patient’s assessed needs at the time of discharge including discharge prescriptions. The facility facilitates the continuum of care by communicating appropriate patient information to the receiving facility and/or outside resource.”

“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: 45329 Based on the review of records, and interviews, it was determined that the facility failed to ensure an appropriate medical screening examination that was within the capability of the hospital’s Emergency Department (ED), including ancillary services routinely available to the ED, was conducted to determine whether or not an emergency medical condition existed for 1 (Patient #1) out of 20 sampled patients. ( Cross Refer to findings in tag A 2406). Based on Interview, record review and policy review, the facility failed to provide medical treatment within its capacity to minimize the risks to the individual’s health and consult with the receiving facility to accept the transfer of 1 (Patient #1) out of 20 sampled patients to provide appropriate medical treatment. (Cross Refer to findings in tag A 2409)”

“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: 45329 Based on interviews, record reviews and policy reviews for maintaining a central log on each individual who comes to the emergency department, the facility failed to identify the legal names and ages for 2 (Patient #1 and Patient #7) out of 20 sampled patients seeking assistance whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. Findings Include: Review of Policy Emergency Medical Treatment and Labor Act (EMTALA) - Central Log Policy - Florida, LL.EM.002, Effective 08/2024 documented: PROCEDURE: (3) The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core of information. The logs must contain at a minimum, the name of the individual and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged, or expired. Review of the History and Physical Note dated 09/04/2024 at 2:43 PM signed by Staff F (ED Physician) documented Patient #1 is a 37-year-old who presented as a level 1 trauma, after a motorcycle accident. Per history from emergency medical services (EMS), Patient #1 was not wearing a helmet, at a high rate of speed, hit a car at an intersection and was ejected forward. Patent #1 was transferred from the facility as an unknown. The legal name and date of birth was not established prior to transferring Patient #1 to Hospital B. Review of the Central Log dated 09/04/2024 does not identify Patient #1’s legal name or date of birth and currently all Patient #1’s medical records remain with an alias identifier. Review of the History of Present Illness dated 10/14/2024 at 8:30 PM documented Patient #7 is a 19-month-old who suffered burns to the anterior thorax and left shoulder prior to admission secondary to hot water. It was decided that Patient #7 would benefit from transfer to a burn center for further evaluation and management. Patient #7 was transferred to a sister facility as an unknown pediatric burn. The legal name and date of birth was not established prior to Patient #7 leaving the facility. Review of the Central Log dated 10/14/2024 does not identify Patient #7’s legal name or date of birth and currently all Patient #7’s medical records remain with an alias identifier. An interview was conducted with Staff E (Trauma Nursing Program Director) on 10/17/2024 at 11:50 AM regarding the identification process for patients arriving at the ED unidentified. Patient #1 was registered as an alias on 09/04/2024. Patent #1’s legal name and date of birth have not been updated and remains an alias at the time of survey. Staff E (Trauma Nursing/Program Director) stated the registration department is responsible for updating the patient’s information.”

“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: 45329 Based on record review and interview and policy review, the facility failed to ensure that an appropriate medical screening examination was conducted that was 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 existed for 1 (Patient #1) out of 20 sampled patients. Findings Include: Review of the facility’s Policy Stat ID 13752542, Emergency Medical Treatment and Labor Act (EMTALA) - Medical Screening Examination and Stabilization Policy, LL.EM.0033, Last Revised 11/2021 documented: (1) When an MSE is Required. A hospital must provide an appropriate medical screening examination (MSE) within the capability of the hospital’s emergency department, including ancillary services routinely available to the dedicated emergency department (DED). An MSE shall be provided to determine whether or not the individual is experiencing an emergency medical condition (EMC) or a pregnant woman is in labor. An MSE is required when: (d) An individual is in a ground or air ambulance for purposes of examination and treatment for a medical condition, and EMS has requested emergency services and care on behalf of the individual; (e) A community-wide plan exists for specific hospitals to treat certain EMCs (e.g., psychiatric, trauma, physical or sexual abuse). Prior to transferring the individual to the community plan hospital, an MSE must be performed and any necessary stabilizing treatment rendered. (3) Extent of the MSE (b) Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital; (c) An on-going process. The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does, until the EMC is relieved or eliminated or the individual is appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer. Record review conducted on 10/15/2024 through 10/17/2024 revealed that Patient #1 was seen and examined by Staff F (ED Attending Physician) when initially presented as a level 1 trauma, after a motorcycle accident on 09/04/2024. Per history from Emergency Medical Services (EMS), Patient #1 was not wearing a helmet, at a high rate of speed, hit a car at an intersection and was ejected forward. A second examination was conducted by Staff D (Physician/ Trauma Director) and there were differences regarding emergency care and services required. Subsequently, Patient #1 was transferred to Hospital B by Staff D (Physician/ Trauma Director) as a trauma alert via 911 for treatment of burns to the left lateral dorsal [p....], proximal left scrotum and right anterior thigh. Laboratory results were reviewed. Additional record review revealed no documentation that the facility performed any diagnostic imaging to determine if a medical emergency condition existed prior to transferring Patient#1 to Hospital B on 09/04/2024. Emergency Department (ED) Attending Physician (History & Physical #1): Review of the first Trauma History and Physical Note dated 09/04/2024 at 2:43 PM signed by Staff F (ED Physician) documented Patient #1 is a 37-year-old who presented as a level 1 trauma, after a motorcycle accident. Per history from emergency medical services (EMS) Patient #1 was not wearing a helmet, at a high rate of speed, hit a car at an intersection and was ejected forward. Assessment using the Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) approach revealed the following: Airway- Airway intact ; Breathing- Bilateral breath sounds, no crepitus, no chest tenderness; Circulation- Distal pulses present, equal in the radial, bilateral femoral, and dorsalis pedis pulses, no concern for massive bleed; Disability- GCS (Glascow Coma Scale) 14, pupils 3 millimeters (mm) and react ; Exposure- Patient was adequately exposed to determine extent of injuries and kept warm to prevent hypothermia. 4 centimeters (cm) laceration under the right eyebrow, 4 cm laceration under the chin, 3 cm laceration on the left forehead, circular 10 cm burn on the right thigh, burns over the [p....], testicles, pubic area. Vital signs reviewed: Temperature: 98.1; Pulse Rate: 67 beats per minute; Respiratory Rate: 18 breaths per minute; Blood Pressure: 131/90; Oxygenation via Pulse oximetry: 99% on room air. Primary survey performed and stable. Vital signs stable. Burns to genitals. Staff D (Physician/ Trauma Director) made the decision to have 911 called for Patient #1 to go to a higher level of care immediately, burn center. EMS transported Patient #1 out of the ED. ASSESSMENT/PLAN: Patient #1 presented with non-blanching, suspected full thickness thermal burns to dorsal left lateral [p....], , proximal left scrotum, groin, partial thickness friction burns to right anterior thigh as well as facial friction burns. Patient #1 met criteria for transferring to a burn center for management of burns. Emergency 911 call made for transfer. EMS returned; Patient #1 transferred per transfer form at 2:45 PM. An interview conducted with Staff D (Physician/ Trauma Director) on 10/15/2024 at 2:30 PM revealed that Patient #1 was transferred because of concerns related to a scrotal burn. Staff D (Physician/ Trauma Director) stated the location, degree and percentage of burn area determines whether the patient should be evaluated at a burn center. The scrotum has a high risk for complications. If the patient is not a trauma patient, they will not be seen in trauma. Patient #1 was not sent because of the other injuries. Patient #1 was otherwise stable. The concern was related to the burn. Staff D (Physician/ Trauma Director) stated if the patient was unstable, they would have to be stabilized prior to transfer. EMS stated they kind of saw the wound but were not thinking about bringing Patient #1 to a burn center. Burns, pediatrics or obstetrical trauma are not treated at this facility. Staff D (Physician/ Trauma Director) stated the transfer center was called. An interview was conducted with Staff F (ED Attending Physician) on 10/18/2024 at 11:15 AM. Staff F (ED Attending Physician) stated Patient #1 was involved in a motorcycle accident, un-helmeted and there were differences regarding the transfer of Patient #1 to another facility based on the information available. Staff F (ED Attending Physician) stated a call was placed to the immediate supervisor, Staff L (ED Medical Director). When asked if any imaging was done, Staff F (ED Attending Physician) could not confirm that the facility performed any diagnostic imaging prior to transferring Patient #1 to Hospital B on 09/04/2024. An interview conducted with Staff L (ED Medical Director) on 10/17/2024 at 12:15 PM revealed Staff L (ED Medical Director) walked into the ED after the events had occurred and the environment was very tense. Staff L (ED Medical Director) stated the information received was that a trauma alert was called for an emergent burn. The ED Charge Nurse and Staff F (ED Attending Physician) was not comfortable with the transfer and asked for administrative guidance. Administration (Chief Medical Officer) came down and an MSE was done, and Patient #1 was transferred. Staff L (ED Medical Director) stated Staff F (ED Attending Physician) was very upset regarding the transfer.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45329 Based on Interview, record review and policy review, the facility failed to provide medical treatment within its capacity to minimize the risks to the individual’s health and consult with the receiving facility to accept the transfer of 1 (Patient #1) out of 20 sampled patients to provide appropriate medical treatment. Findings Include: Review of of the facility’s Policy Stat ID 15414004, Transfer of the Trauma Patient, TR:5.02, Last Revised 04/2024 documented: SCOPE: Trauma Services. PURPOSE: The purpose of this guideline is to support the facility’s compliance with Florida Department of Health (FDOH) accreditation standard outlined in FDOH Pamphlet DHP 150-9, Trauma Center Standards, and the American College of Surgeon’s Resources for Optimal Care of the Injured Patient. GUIDELINE: (1). Patients will be transferred from Hospital A to other facilities only if the services needed are not provided. (a) before any transfer the trauma medical director or designee must approve the transfer. PROCEDURE: (1) Transfers require acceptance by the physician at the receiving facility. The primary responsibility with the transferring physician and accepting physician is discussing the care in the trauma room, exchanging pertinent details, and determining any potential treatments the patient may require prior to transfer. (2) The Trauma Center nurse will call report to the receiving facility nurse. (3) The patient’s condition must be stable, and the patient must be capable of being transported. (4) Copies of all medical information must accompany the patient in a sealed envelope. Review of the Miami-Dade County Uniform Trauma Transport Protocols, June 26, 2023 documented Adult trauma alert criteria: Injured persons with anatomical and physiological characteristics of a person 16 years of age or older meeting any one of the parameters in Category 1, or any two parameters in Category 2, are considered trauma transport criteria (TIC} patients and will be transported to the nearest State Approved Trauma Center (SATC). FRACTURE Category 1: 2 or more long bone fracture sites (humerus, radius/ulna , femur, tibia/fibula. FRACTURE Category 2: Any long bone fracture sustained in a MVC or fall greater than 10 feet. CUTANEOUS Category 1: 2nd or 3rd degree burns to greater than 15% total body surface area (TBSA), or proximal to wrist or ankle or penetrating injury to head, neck, or torso CUTANEOUS Category 2: major degloving injury, or major flap avulsion > 5 inches,or GSW to the extremities Notification of the presence of a “Trauma Alert”. Any patient who meets any of the above adult or pediatric trauma criteria will be termed a “Trauma Alert” patient. Patient meets trauma alert criteria: When any non-trauma center hospital determines that a trauma patient, they have received meets trauma criteria as described in the Florida Department of Health Trauma Scorecards, they will immediately activate the Emergency Medical Services System(EMS) by dialing 9-1-1. Review of the second Trauma History and Physical Note dated 09/04/2024 at 2:52 PM signed by Staff D (Physician, Trauma Director) documented Motorcycle driver: collision with /car/truck/van. Chief Complaint: Level 1 trauma alert status post motorcycle collision (MCC). Assessment using the Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) approach revealed the following: Airway - intact, phonating (speaking); Breathing - Bilateral breath sounds, symmetric chest rise; Circulation - HDS (Hemodynamically Stable), pulses all extremities; Disability - GCS (Glasgow Coma Scale) 15, Pupils Equal Round Reactive to Light (PERRL); Exposure - facial friction burns, right eyebrow 4 (centimeters) cm laceration, 4 cm chin laceration, left forehead 6 cm laceration. Suspected full thickness burns to dorsal left [p....], proximal left scrotum. Partial possible full thickness burns to the right distal anterior thigh. Patient #1 is a 37-year-old with a history of HTN (high blood pressure) presented as a level 1 trauma alert via EMS ground status post motorcycle collision (MCC) with car. +HS (head strike), +LOC (Level of consciousness) GCS 15. Patient #1 t-boned a car and fell onto motorcycle exhaust pipe. Injuries: Suspected full thickness gas/thermal burn to left lateral dorsal [p....], proximal left scrotum, right anterior thigh~ 4% TBSA (total body surface area) 4 cm right eyebrow. ASSESSMENT/PLAN: Patient presented with non-blanching, suspected full thickness thermal burns to dorsal left lateral [p....], proximal left scrotum, groin, partial thickness friction burns to right anterior thigh as well as facial friction burns. Patient #1 met criteria for transferring to a burn center for management of burns. Emergency 911 call made for transfer. EMS returned; Patient #1 transferred per transfer form at 2:45 PM. Transfer center was notified and made aware. Hospital B trauma center made aware of patient transfer. An interview conducted with Staff D (Physician/ Trauma Director) on 10/15/2024 at 2:30 PM revealed that Patient #1 was transferred because of concerns related to a scrotal burn. Staff D (Physician/ Trauma Director) stated the location, degree and percentage of burn area determines whether the patient should be evaluated at a burn center. The scrotum has a high risk for complications. If the patient is not a trauma patient, we will not see them. Patient #1 was not sent because of the other injuries. Patient #1 was otherwise stable. The concern was related to the burn. Staff D (Physician/ Trauma Director) stated if the patient was unstable, we would have to ensure they were stable prior to transfer. EMS stated they kind of saw the wound but were not thinking about bringing Patient #1 to a burn center. Burns, pediatrics or obstetrical trauma are not treated at this facility. Staff D (Physician/Trauma Director) stated the transfer center was called. The transfer form documented Receiving Facility: “Hospital B”; Person Accepting Transfer: “Hospital B Attending (unnamed)”; Date:”09/11/24”; Time: “2:47 PM”. The date and time of the actual transfer is blank on the transfer form. Transfer Center Communication According to the documented information provided by the transfer center, they received a call from Staff D (Physician Trauma Director) as the referring physician at 2:35 PM for a transfer for Patient #1 with a primary diagnosis of burn. Reason for Transfer - ED Notification. The service specialty requested was Burn. Destination Facility, Hospital B. Transfer center notes dated 09/04/2024 at 2:39 PM documented, “Staff D (Physician, Trauma Director) - Sending doctor stated that the people did not know the process. Staff D (Physician, Trauma Director) stated that Patient #1 was 911 from their facility (Hospital A) ED, barely got information on the patient. Transfer center notes dated 09/04/2024 at 2:50 PM documented, “Transfer Coordinator (TC) at Hospital B was informed that Patient #1 was on the way to Hospital B via 911 from Hospital A ED. The TC confirmed that this is not a transfer at this time.” An Interview was conducted with Staff I (Trauma Nurse) on 10/17/2024 at 11:39 AM. Staff I (Trauma Nurse) was the primary nurse assigned to Patient #1 on 09/04/2024 and stated report was not called because Staff D (Physician, Trauma Director) wanted to transfer Patient #1 emergently. An interview was conducted with Staff F (ED Attending Physician) on 10/18/2024 at 11:15 AM. Staff F (ED Attending Physician) stated Patient #1 was involved in a motorcycle accident, un-helmeted and there were differences regarding the transfer of Patient #1 to another facility based on the information available. Staff F (ED Attending Physician) stated a call was placed to the immediate supervisor, Staff L (ED Medical Director). When asked if any imaging was done for Patient #1, Staff F (ED Attending Physician) could not confirm that the facility performed any diagnostic imaging prior to transferring Patient #1 to Hospital B on 09/04/2024. An interview conducted with Staff L (ED Medical Director) on 10/17/2024 at 12:15 PM revealed Staff L (ED Medical Director) walked into the ED after the events had occurred and the environment was very tense. Staff L (ED Medical Director) stated the information received was that a trauma alert was called for an emergent burn. The ED Charge Nurse and Staff F (ED Attending Physician) was not comfortable with the transfer and asked for administrative guidance. Administration (Chief Medical Officer) came down and a medical screening exam (MSE) was done, and Patient #1 was transferred. Staff L (ED Medical Director) stated Staff F (ED Attending Physician) was very upset regarding the transfer. An interview was conducted with the Chief Medical Officer (CMO) on 10/17/2024 at 4:30 PM regarding the transfer process. The CMO stated the physician’s judgement could not be questioned. The CMO was informed that the physician’s judgement was not being questioned but the concern was related to Staff D (Physician, Trauma Director) not following the facility’s trauma transfer policy (Transfer of the Trauma Patient, TR:5.02, Last Revised 04/2024). The CMO acknowledged involvement in approving the transfer of Patient #1 to Hospital B. Patient #1 did not meet criteria for a Trauma Alert related to cutaneous Catergory 1 or 2. (1) The burns were not greater than 15% total body surface area and (2) Patient #1 was in a Trauma Center when the Trauma Alert was called. A review of the ED outgoing transfer log along with Staff C (ED Nurse Manager) revealed the Transfer Form for Patient #1 is incomplete. Information not documented includes: (1) Person/ title report given to (2) Date and time of transfer (3) Nurses’ signature (4) Patient/Responsible persons’ signature. Staff C (ED Nurse Manager) stated all transfer forms are audited and if patients are transferred from the Trauma ED, incomplete transfer forms are forwarded to Staff E (Trauma Nursing/Program Director). Review of Patient #1’s medical record from Hospital B revealed the following: Emergency/Trauma Documentation dated 09/04/2024 at 3:23 PM documented: Medical Decision Making: Trauma team; Trauma surgeon present. Rationale: 37-year-old status post motorcycle vs auto accident un-helmeted, no reported loss of consciousness (LOC). Glascow Coma Scale 15 on arrival. Airway intact, Bilateral breath sounds, pulses intact bilaterally. No neurological deficit, Patient #1 exposed with evidence of burns to genitals and bilateral thighs. Plan for pan scan, wrist x-rays, chest x-ray and pelvis, orthopedics, burn and ear, nose and throat (ENT) consult. Pain control as needed. Traumatic Findings: (1) Scout view (low-resolution radiographic images) is remarkable for acute displaced fracture of the distal left ulna and likely acute displaced comminuted fracture of the distal left radius. (2) Left frontal scalp hematoma with associated soft tissue irregularity. No acute intracranial hemorrhage. (3) Numerous acute facial fractures. No calvarial (skull) fracture. (4) Hematoma overlying the left clavicle, without underlying fracture. (5) Soft tissue swelling of the penile region and mons pubis consistent with report of soft tissue, possibly burn injury. (6) No evidence for acute fracture in the cervical, thoracic, or lumbar spine. Review of Orthopedic History and Physical Note dated 09/05/2024 at 1:16 AM documented: Patient #1 Is a 37-year-old male with a history of hypertension who presents after a motorcycle collision on September 4, 2024, resulting in a left Galeazzi fracture with left ulna abrasion down to bone. Patient #1 has no numbness or tingling to the extremity. Other injuries include multiple facial fractures and concussion. Additional review of Patient #1’s record revealed Hospital B performed the following procedures: On 09/05/2024 - Irrigation & Debridement open fracture of ulna styloid Open reduction internal fixation (ORIF) left radius Galeazzi fracture closed treatment of left open ulnar styloid fracture.”

“EMERGENCY SERVICES CFR(s): 482.12(f)(1) If emergency services are provided at the hospital, the hospital must comply with the requirements of §482.55. This Standard is not met as evidenced by: 45329 Based on interview and policy review, the facility failed to ensure that the medical staff has written policies and procedures for the appraisal of behavioral health emergencies and initial treatment in the main Emergency Department. Findings include: Review of PolicyStat ID: 14957369 - Plan for the Provision of Care - Emergency Department (ED)/Free-Standing ED, Last Revised 01/2024 documented 9 behavioral health beds. The 9 beds are no longer utilized for treating behavioral health patients. The beds are currently used as a behavioral health holding area once patients are medically cleared. Interview conducted with Staff H (ED Director of Nursing) on 05/01/2024 at 11:06 AM. Staff H (ED Director of Nursing) stated the ED staff was educated and informed that the behavioral health patients will no longer go to the ED behavioral health unit until they’re medically cleared. Staff H (ED Director of Nursing) stated that behavioral health patients are treated in Zone 23. Once medically cleared, the nurse reviews the physician orders and documentation; all medical treatments are discontinued, and the Intravenous (IV) Heparin Lock is removed. The patient is transported to the Behavioral Health Holding Area. If the patient decompensates, they are transferred back into the main ED. During an interview conducted on 05/01/2024 at 4:30 PM, the Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer, Quality Director and the Patient Safety Director acknowledged that the facility did not provide an updated documented plan for the provision of care in the Emergency Department for the treatment of behavioral health patients.”