Central Florida Lake Monroe Hospital

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 21084 Based on interview and record review the facility failed to document accurate and complete patient records for 2 (#1,3) of 8 selected patient records . Findings: 1. Record review of Patient #1 ‘s record revealed she was admitted to the hospital on 2/9/25 through the Emergency department. Diagnosis included a right open bimalleolar fracture and right ankle laceration. On 2/10/25 her surgeries included Irrigation/exicsional debridement of skin, subcutaneous tissue, muscle, fat and bone of right ankle fracture, open ankle traumatic areotomy and an Open Reduction Internal fixation right, open type IIIA PA-III bimalleolar ankle fracture, operative stabilization of right syndesmosis and repair in multilayered fashion of right ankle traumatic laceration, 10 centimeters in total length. Pt. # 1’s discharge disposition documented by the physician on the Discharge Summary read: “...Per physical therapy recommendations, patient is independently ambulating with durable medical equipment (DME) and is cleared for discharge home. DME and home health care Physical Therapy ordered. Plan for discharge home today. “ Review of the Case Management notes documented on 2/12/25 documented discussion with patient and caregiver regarding the necessary DME and what was already in the home. There was no further documentation regarding patient needs or ordered home health physical therapy. There was no choice letter found in the record for selection of home care. In an interview with the Quality Manager, Risk Manager and the Case Manager Manger at 12:30 on 4/2/25, they confirmed there was a physician order for home health care, for patient #1, however no documentation was in the record that documented the referral for home care had been made. 2. Record review reveled Patient # 3 was a 35 year old male admitted to the hospital on 1/29/25 through the Emergency department (ED.) Documentation revealed the patient was recently discharged from an acute care hospital in Charlotte North Carolina and arrived by a private ambulance company transportation. The patient was discharged from the hospital to go home and stay with family in Florida, however upon arrival they were not home and the ambulance company brought the patient to the hospital ED. Past medical history and present diagnosis was T-cell Lymphoma , pain, anemia, and failure to thrive. Documentation revealed the patient was bedbound and had chronic contractures of both lower extremities. The record reflected pertinent diagnostics and attempted medical care and treatment that was frequently refused by the patient, along with refusals of medications, and physical and occupational therapies. The patient accepted and received continued pain medications as ordered. The History and physical documented by the physician ordered and recommended a Case Management (CM) consult for placement. The physician discharge summary documented discharge instructions as: “Home Health with Plan of Care.” Documentation revealed the patient was discharged from the hospital, transported to a homeless shelter in another city, and refused entrance due to his disabilities and inability to walk or care for self. In a group interview which included the Vice President of Quality/Risk Manager, the facility Medical Director, and the Director of Case Management at 12:30 PM on 4/2/25 revealed the case manager had spoken to the patient regarding the discharge to the homeless shelter and he was in agreement. They were informed there was no documentation in the legal record that supported the discussion with the patient or the agreement by the patient to be transferred to another city to a homeless shelter. They confirmed and agreed that the case management conversation with #3 regarding his discharge disposition was not documented.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 21084 Based on interview, record review, and review of hospital documents, the facility failed to ensure a safe and appropriate discharge plan was arranged and accomplished for 2 (#1, 3) of 8 sampled patients. Findings: 1. Record review of Patient #1 ‘s record revealed she was admitted to the hospital on 2/9/25 through the Emergency department. Diagnosis included a right open bimalleolar fracture and right ankle laceration. On 2/10/25 her surgeries included Irrigation/exicsional debridement of skin, subcutaneous tissue, muscle, fat and bone of right ankle fracture, open ankle traumatic areotomy and an Open Reduction Internal fixation right, open type IIIA PA-III bimalleolar ankle fracture, operative stabilization of right syndesmosis and repair in multilayered fashion of right ankle traumatic laceration, 10 centimeters in total length. Pt. # 1’s discharge disposition documented by the physician on the Discharge Summary read: “...Per physical therapy recommendations, patient is independently ambulating with durable medical equipment (DME) and is cleared for discharge home. DME and home health care Physical Therapy ordered. Plan for discharge home today. “ Review of the Case Management notes documented on 2/12/25 documented discussion with patient and caregiver regarding the necessary DME and what was already in the home. There was no further documentation regarding patient needs or ordered home health physical therapy. There was no choice letter found in the record for selection of home care. In an interview with the Quality Manager, Risk Manager and the Case Manager Manger at 12:30 on 4/2/25, they confirmed there was a physician order for home health care, for patient #1, however no documentation was in the record that documented the referral for home care had been made. 2. Record review reveled Patient # 3 was a 35 year old male admitted to the hospital on 1/29/25 through the Emergency department (ED.) Documentation revealed the patient was recently discharged from an acute care hospital in Charlotte North Carolina and arrived by a private ambulance company transportation. The patient was discharged from the hospital to go home and stay with family in Florida, however upon arrival they were not home and the ambulance company brought the patient to the hospital ED. Past medical history and present diagnosis was T-cell Lymphoma , pain, anemia, and failure to thrive. Documentation revealed the patient was bedbound and had chronic contractures of both lower extremities. The record reflected pertinent diagnostics and attempted medical care and treatment that was frequently refused by the patient, along with refusals of medications, and physical and occupational therapies. The patient accepted and received continued pain medications as ordered. The History and physical documented by the physician ordered and recommended a Case Management (CM) consult for placement. The physician discharge summary documented discharge instructions as: “Home Health with Plan of Care.” Occupational therapy notes documented with assistance, the patient was able to transfer from bed to chair and the hospital provided a wheelchair for the patient. Nursing notes documented the patient was uncooperative with care and refused personal hygiene and linen changes frequently. Review of the Case management notes for patient #3 revealed he requested skilled nursing facility placement while waiting to apply for Medicaid. There were multiple telephone calls by case management to the patient’s family members, however, no family member would assist or care for him. Nearly on a daily basis case management notes documented referrals to area skilled nursing facility (SNF.) There were some accepted placements, however, upon finding results of patient’s behaviors, refusing therapy and treatment, and refusals of care, the SNFs decline to accept him. A case management note dated 2/11/25 documented “He is declined by multiple facilities for not meeting criteria...Met with patient and addressed behaviors and its impact with not having an accepted facility. Patient is aware that if no accepting facility today, he will need to be discharged to the community or to family. Patient is requesting a facility in Jacksonville because his family reside in the area...” Case management notes continued to document referrals to SNF and continued decline of acceptance. On 2/14/25 case management notes documented the patient was brought a loaner wheelchair in case he needed it on discharge. Documentation also read the patient was denied a SNF level of care as patient was at baseline and has no skilled nursing needs. A case management note dated 2/15/25 documented: ...Patient was informed we needed an address for transportation. Patient stated that “he will provide address once he can confirm placement. CM returned at 2:00 PM for address-CM received address at (address documented). CM was not provided with a name of contact nor contact # to confirm address.. . CM placed a call to (name of transport company) and spoke to (name provided) in regards to this patient, CM was informed that transportation would be $605.00. CM provided this to leadership. Per leadership due to inability to confirm address, patient to be placed in homeless shelter in St. Augustine. (address provided) No other issues to report. Nursing and patient have been mode aware of arrangements.” Information provided revealed the patient was discharged from the hospital, transported to a homeless shelter in another city, and refused entrance due to his disabilities and inability to walk or care for self. In a interview with the patient’s Phrygian who documented the discharge order at 3:30 PM on 4/2/25 revealed upon patient #3’s discharge she was unaware of where the patient was discharged to and was not contacted or called by a case manager to inform her that the parameter was not met or where the patient was discharged to. A physician discharge order for patient #3 dated 2/8/25 documented: Discharge/Parameters:2/8/25 SNF (skilled nursing facility) bed. Also documented , was to notify attending when discharge parameter met. Call if parameters not met. The physicians name and telephone number were included. The order also read: “Discharge to: Home Health with Plan of Care.” In a group interview which included the Vice President of Quality/Risk Manager, the facility Medical Director, and the Director of Case Management at 12:30 PM on 4/2/25 revealed the case manager had spoken to the patient regarding the discharge to the homeless shelter and he was in agreement. They were informed there was no documentation in the legal record that supported the discussion with the patient or the agreement by the patient to be transferred to another city to a homeless shelter. They confirmed and agreed that the case management conversation with #3 was not documented. They were also informed that the transfer to a homeless shelter was an inappropriate level of care for patient #3 as he was unable to ambulate or care for himself, and he was refused entrance/admission to the homeless shelter which resulted in the patient being transferred to an acute care hospital by the transportation company. Review of the hospital policy entitled “Discharge Planning #17660951, Approved 2/26/2025” documented on page 1 under “POLICY” section; (Name of hospital) provides discharge planning to promote a safe and timely discharge to an appropriate level of care.””

“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: 13640 Based on interviews, record reviews and a review of facility documentation, to include HCA Lake Monroe’s written self-report of violation, the facility failed to provide a medical screening examination for one of twenty-one sampled patients (#1) who presented to the ED. Findings: Medical Record Review: A review of the medical record for patient #1 was performed. The patient initially presented to the Emergency Department (ED) at a sister hospital (Hospital AA) in a nearby town. Review of the ED physician note, from hospital AA with an “initial greet date/time” of 9:33 AM on 3/24/24 (signed on 3/29/24) by Physician- A, noted Chief complaint to include Left side weakness, other balance problems, confusion, dizziness, mental status change, and slurred speech. Record noted reason for ED visit to include acute stroke evaluation for AMS (altered mental status) and left side weakness noting new onset at 8 AM. Review of a Neurology consult note from hospital AA dated 3/24/24 at 11:04 AM by Physician-B read: “Will need to admit for post Thrombolytic care. . . but symptoms are worrisome so will emergently transfer to thrombectomy capable hospital and they can repeat the scan there.” Also noted in consult note the ED MD said they would call for the transfer and Physician-B gave them their cell phone number in case they wanted to talk to them. The ED physician note by Physician-A stated at 11:30 AM transfer to Lake Monroe ED was accepted by Dr. (Physician-D). The note continued to reflect at 11:50 AM: (Physician-B), Tele-neuro notified. 11:50 AM: (Physician-C - Hospitalist at Hospital AA) notified of possible admit and recommends transfer due to no available Neurosurgery and patient to have a high risk of bleeding after TPA (Tissue Plasminogen Activator) administered. Note further indicated that at 12:15 PM transport arrived for patient transfer and the AOC (Administrator-on-Call at HCA Florida Lake Monroe Hospital) approved the hospital transfer despite there being a lack of LVO (large vessel occlusion) intervention and patient had been declined by stroke neuro-interventionalist. The note also continued with the mention of an event that took place after the patient had arrived at HCA Florida Lake Monroe Hospital when it read at 1:30 PM Patient #1 was transferred to another sister facility about an hour away (hospital BB) due to there being no available ICU (intensive care unit) beds at Florida Lake Monroe Hospital. This entry indicated an expectation for a direct admission to the ICU at HCA Florida Lake Monroe Hospital, which preceded the actual admission to the patient’s ultimate destination, Hospital BB. Although this expectation is also reflected in transfer call center notes, record review revealed the orders in place by the ED physician at Hospital AA were specifically for a transfer to the ED at HCA Florida Lake Monroe Hospital, not the ICU. This ED Physician note also read: “Request time: 11:30 AM. Request Date: 03/24/24. Call returned time: 11:30 AM. Spoke with: Emergency physician. Receiving hospital: Lake Monroe. Transfer accepted: yes. Accepted by: (Physician-D).” The document reviewed from Hospital AA, known as the EMTALA Memorandum of Transfer dated 03/24/24, with a final signature time of 12:10 PM read: “Patient stable for transfer” noting physician authorized this at 11:13 AM. The reason for transfer was stated as “Medically indicated”. The risks and benefits for transfer were stated as “Obtain level of care/service unavailable at this facility. Service: Neurosurgery.” Under the section Mode/Support during transfer as determined by physician it read: “Mode of transportation for transfer: ALWS (advanced life support).” The receiving facility and individual was stated as: Receiving MD: (Physician-D).” This had been indicated at 10:58 AM. The time of transfer was stated as 12:20 PM on 3/24/24. This indicates acceptance by the ED physician at FL Lake Monroe Hospital. Throughout the medical record there was no mention of what was stated in the EMTALA Memorandum of Transfer or of it being rescinded and changed by the ED physician at Hospital AA to any another destination besides the ED at HCA Florida Lake Monroe Hospital. A nurse’s note at 12:30 PM on 3/24/24 read: the reason for transfer to HCA Florida Lake Monroe ED to include a Specialist was not available and the services required for transfer being Neurology with transferring facility to be Lake Monroe. Patient was to be transferred via ambulance. Transfer Center Call/Records Review of Transfer Center Notes revealed a form that was created at 10:58 AM on 03/24/24. It also indicated a destination of HCA Florida Lake Monroe Hospital with the requested service of neurology, reflecting communication with Physician G and Physician D. It also indicated that HCA Florida Lake Monroe Hospital accepted the patient at 11:10 AM. An entry in transfer center documentation at 03/24/24 at 11:04 AM reflected a conversation between Physician-A and Physician-D, which read “We would like to TX (transfer) for Neuro IR (Interventional Radiology)” and asking if they had reached the stroke IT (interventional). Entry ended with confirmation that they would take the patient at Florida Lake Monroe ED. This documentation also indicated there was an agreement by the ED physician at HCA Florida Lake Monroe Hospital to accept the patient from the ED at hospital AA. An entry in transfer center documentation at 11:35 AM on 3/24/24 reflected a conversation between “Dr. (Physician-A) and Dr. (Physician-E) Neuro IR (interventional radiology) Lake Monroe.” The entry continued with a discussion of the case and read: “I do not know that transferring would be beneficial. . . . He already has some disability and this would be more significant change in his morbidity. I understand that he is outside the criteria for intervention.” Note also reflected Dr. E to say Please document that he did not think he would be a good candidate for transfer for the purpose of intervention as patient was not a good candidate. Although the Neurologist indicated in this entry that it was unlikely that he could help the patient, the previously approved transfer orders were not cancelled. An entry in transfer center documentation at 11:42 AM on 3/24/24 read: “Called (hospital AA) ED . . . SW (spoke with) (a Registered Nurse). Request next steps in the transfer. States Dr. (Physician-A) is going to SW (speak with) his hospitalist and see if they can keep the patient at (hospital AA) since Dr. (Physician-E) is no longer accepting the patient. Requests we put NHT (National Health Transport) on will call.” During an interview of the Director of Quality on 4/3/24 at 3:10 PM, she stated that “will call” is a wait status, stating In other words, a request was made to hold the transport. However, documentation indicated NHT transport came anyway. An entry in transfer center documentation at 11:46 AM on 3/24/24 indicated NHT (transport) was called and spoke with (staff member) and they placed Transport on “will call”. An entry in transfer center documentation at 11:53 AM on 3/24/24 read a call was placed to a Registered Nurse (RN) at hospital AA ED and requested date on transfer. RN stated her ED MD spoke with the hospitalist and they are hesitant to care for the patient at hospital AA since the patient received TNK (Tenecteplase) and may bleed and they do not have the services to care for that patient if they do start to bleed. Another transfer center entry at 11:57 AM on 3/24/24 read they called Lake Monroe AOC (Administrator on Call) and TCC (transfer call center) was informed of the case and the decline in taking patient by Dr. (Physician-E) to consult on the case stating they could still send the pt to the ED, stating even if patient may not be an LVO (large vessel occlusion) candidate there were other services they could offer at Lake Monroe that Hospital AA does not have. Stated they can go ahead and send to Lake Monroe ED, noting an understanding that the transfer to the ED could continue. An entry on 3/24/24 at 12:00 PM read: “Called (hospital AA) ED. SW (spoke with) (Registered Nurse) . . . . States the admitted MD (physician at hospital AA) is not comfortable with caring for the PT D/T (due to) the risk of bleeding. Requests we continue with transfer to Lake Monroe. TCC (transfer call center) informed after SW the AOC at Lake Monroe we can send the pt to the ED at Lake Monroe.” indicating the transfer request Documentation from NHT (National Health Transport) transport indicated they were with the patient at 12:06 PM on 3/24/24. An entry at 12:33 PM by a transfer center staff member on 3/24/24 read: “. . . AOC Lake Monroe called about pt (#1) at (hospital AA) ED. DX (diagnosis) stroke which is old. Per AOC at LMH (Lake Monroe Hospital) this pt will go from (Hospital AA) ED to LMH ICU (Intensive Care Unit). No additional ED workup needed and holding 2 ICU pts in ED at LMH.” This entry indicated a planned direct admission to the ICU, and not an ED to ED transfer. However, there was no physician statement or physician order specifically countering the directive in the EMTALA Memorandum of patient transfer and having the ED physician at HCA Florida Lake Monroe Hospital receive the patient. Interviews: During an interview with the CEO/AOC, on 4/4/24 at 11:40 AM, he showed the surveyor a call on his cell phone which indicated he communicated with the transfer call center at 11:57 AM (incoming, one minute). During an interview of the CEO/Administrator on Call, on 4/4/24 at 11:40 AM, he showed surveyor a call on his cell phone which noted he had communicated with the transfer call center at 12:26 PM (outgoing call of 4 minutes). Continued interview with the CEO/AOC on 4/4/24 at 11:15 AM, noted he stated that an admission to the ICU would not have involved entry through the ED. Later text revealed that this desired change to an ICU admission, authorized or not, was not relayed to the transport company. A text from transfer center documentation at 12:52 PM on 3/24/24 indicated that the patient left (hospital AA) ED at 12:35 PM (documentation from the transport company indicated departure at 12:47 PM). An entry at 12:40 PM by a transfer center staff member on 3/24/24 read: SW (Registered Nurse at hospital AA) ED and asked if patient #1 was still there and nurse stated, “leaving on stretcher now.” This entry did not indicate awareness by the Administrator on Call of the patient being in the hands of transporters. Continued review of documentation through 12:40 PM indicated that a transfer was to proceed. The Facility’s AOC indicated that the patient needed to go to the ICU, but the physician had not changed the orders from the patient being received in the ED. Also, the patient was leaving around 12:40 PM. Documentation noted a sudden change of plans and an intent to stop the transfer. The plan had been changed at 12:33 PM to a direct admission, but that plan was not authorized by the physician and the patient was already on the way out of the (hospital AA) ED at this time. An entry by transfer center staff at 12:41 PM on 3/24/24, read: “SW. . . AOC LMH . . . Informed we (HCA Florida Lake Monroe Hospital) cannot take the pt right now. . . “tap the brakes” noting they need to wait for ICU, indicating they could send nurses, but would need to redirect to (hospital BB) in Osceola County, noting they had 3 ICU holds in ED and did not have the staff. Due to this, the CEO/AOC at HCA Florida Lake Monroe requested that the transfer to the ICU be stopped. During an interview of the CEO/Administrator on Call on 4/4/24 at 11:40 AM, he showed the surveyor a call on his cell phone which showed his communication with the transfer call center at 12:41 PM for two minutes. Documentation from National Health Transport indicated departure from hospital AA to have occurred at 12:47 PM. Continued interview with the CEO/Administrator on Call on 4/4/24 at 1:05 PM confirmed there was no evidence that the order to send to the ED at HCA Lake Monroe was changed and there was no evidence in the medical record that the patient no longer had an emergency medical condition when he departed hospital AA. Documentation confirmed the patient ended up being transported without evidence that the request to cancel the transport had been relayed to the transport company. An entry at 12:52 PM by the transfer center staff on 3/24/24 read: “Called (hospital AA) ED . . . SW (Registered Nurse). Requested next steps in the transfer. Stated the pt left at 12:35 PM to go to the ED at Lake Monroe.” An entry at 1:00 PM on 3/24/24 read: “(Registered Nurse) Oviedo ED called request to SW (transfer center staff member). Heard pt was declined by LMH and would like to SW her to figure out what is going on.” Review of ED Log A review of the HCA Lake Monroe Hospital’s ED log revealed that the patient was registered on their log at 1:37 PM . The reason for visit stated: “Transfer from (hospital AA).” The Disposition Category was stated as: “Was transferred.” The Disposition Type / Disposition Place was stated as: Short term hospital. (hospital BB).” The last time notated on the log for the patient was 1:38 PM. There was no medical record for the patient, except for a few pages created by registration, and there was no evidence of a physician attempt to perform a medical screening examination. During an interview of Physician-A at approximately 2:15 PM on 4/4/24, he confirmed that he had accepted the patient for admission in the ED and stated that he did not subsequently retract the permission. Transfer Center notes continued after the patient had arrived at HCA Florida Lake Monroe Hospital and subsequently was turned away. An entry in transfer center documentation at 1:20 PM on 3/24/24 read: “Pt transferred from (hospital AA) to LMH ED but need to redirect to (hospital BB) and indicated patient at LMH ED in the EMS bay and waiting to transfer to the Osceola ED. . . “LMH ED MD not giving report to (hospital BB) ED. Connecting (hospital AA) ED MD Dr. (Physician-A) to (hospital BB) ED MD for MD Conf.” An entry on 3/24/24 at 1:29 PM read: “Dr. (Physician-A) to Dr. (Physician-F) - ED physician at the (hospital BB) ED . . . . They don’t have space at LMH. Came from (hospital BB). . . . We take everything send him over (this would be the ED physician at (hospital BB ED speaking). Talk with the IR guys and let them know. The other hospital (HCA Florida Lake Monroe Hospital) is our first transfer point and we got to you after they can’t take it.” An entry at 1:37 PM on 3/24/24 read: “Called LMH ED SW (Registered Nurse). . . . Asked if any changes on the pt for transport to (hospital BB). She stated they have NHT transport with the patient and waiting to be told where to take the pt. Advised pt has acceptance to (hospital BB) and they can take the patient to the ED. Provided accepting information.” A review of the medical record of the patient while at Hospital BB was performed. The History and Physical of 3/24/24 at 6:14 PM read: “. . . is a 68 year old male with a PmHx (past medical history) of AFib not on anticoagulants, CHF (congestive heart failure), unknown EF (ejection fraction - fluid ejected from a chamber in the heart), DM (Diabetes Mellitus), HTN (hypertension), CKD (chronic kidney disease), seizure disorders (resting tremor), who was transferred from (hospital AA) for ICU admission after administration of TNK . . . “ The Discharge Summary of 3/27/24 at 4:18 PM read: “Given poor functional status post stroke, patient’s family decided to proceed with hospice care. Patient is to discharge hospice at this time.” Review of Policies: Review of facility policies noted they were not in compliance with their internal policy known as Florida EMTALA Medical Screening Examination and Stabilization Policy which noted: “A MSE (medical screening examination) is required when: A request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition, including where: . . . The individual arrives as a transfer from another hospital or health care facility. Upon arrival of a transfer, a physician or qualified medical person (“QMP”) must perform an appropriate MSE.” ED Medical Record Reviews: Twenty ED medical records were reviewed. Although patient #1’s name was found on the ED log, there was no medical record and patient was found to have been kept in the ambulance bay and not brought into the ED. Interview with the VP of Quality on 4/5/24 at approximately 3:45 PM confirmed the findings.”