HCA Florida Trinity Hospital

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48190 Based on facility documents, policy review, medical record review, and interviews conducted, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, including a complete analysis of an adverse event and the development of an effective plan of correction involving a post operative patient. Failure to develop a complete analysis of the adverse event and plan of correction could result in injury or death to other patients in similar situations. Refer to A273, A283, A286.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 48190 Based on document review, medical record review and interviews, the hospital failed to ensure a comprehensive QAPI (Quality Assurance and Performance improvement) plan was developed and implemented using data collection, analysis, with tracking, trending, and monitoring its effectiveness after an adverse event occurred for 1 (Patient #4) of 1 patient sampled. Findings included: Review of the QAPI (Quality and Performance Improvement Plan) plan dated 2025 revealed no board approval has been completed. The QAPI Plan states the data collection is systematic and is used to identify areas for more focused data collection to sustain improvement over time. Data analysis ...[ is used] to identify variation, through the use of statistical tools and methods, helps focus the attention and resources on making improvement changes to the processes that will result in better outcomes. The purpose of the assessment process is to identify opportunities to improve systems or processes and to determine what actions should be taken for improvement. No evidence was provided of tracking, trending, and monitoring to prevent future recurrence. Review of Patient #4 medical record revealed missed opportunities when obtaining vital signs, documenting assessments and laboratory results. During an interview on 02/04/2025 at 3:10 PM, Staff M, Quality Director stated they have begun to track and trend vital signs; the charge nurses perform daily (3) charts for compliance. Quality staff members audit 1 chart per unit per day. There is no tracking or trending started for assessments or lab orders. I am not sure how to track them to prevent it from happening again. During an interview on 02/05/2025 at 3:45 PM, Staff N, 4th year Surgical Resident stated, “I usually order post-op labs after a big surgery. I did not follow-up with the patients laboratory results post operatively before I went home for the day.” During an interview on 02/06/2025 at 11:30 AM, Staff O, Registered Nurse stated “I had 7 patients so when I received the handoff by PACU ( Post Anesthesia Care Unit) I didn’t obtain any vital signs. I know I should have; I admit that. I acknowledged the order for stat labs and assumed they were done; the lab technologist was waiting in the patients’ room””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 48190 Based on facility documents, medical record review, and interviews conducted, the facility failed to identify opportunities for improvement and develop an effective plan of correction , inlcuding tracking and trending the measures to ensure changes will lead to improvment following an adverse event involving 1 (Patient #4) of 1 patient. Failure to ensure changes make improvement fails to reduce the risk that patients will encounter similar events. Findings included: Review of the QAPI (Quality and Performance Improvement Plan) plan dated 2025 revealed no board approval has been completed. The QAPI Plan states ... the data collection is systematic and is used to identify areas for more focused data collection to sustain improvement over time. Data analysis ...[ is used] to identify variation, through the use of statistical tools and methods, helps focus the attention and resources on making improvement changes to the processes that will result in better outcomes. The purpose of the assessment process is to identify opportunities to improve systems or processes and to determine what actions should be taken for improvement. No evidence was provided of tracking, trending, and monitoring to prevent future recurrence Review of the facility’s plan of correction revealed “reviewing the importance of post operative vital signs and review of the policy”. Review of Patient #4 medical record revealed missed opportunities when obtaining vital signs, documenting assessments and laboratory results, contributing to the decline of the patient. During an interview on 02/04/2025 at 3:10 PM, Staff M, Quality Director stated they had already began to track and trend vital signs prior to the incident. The charge nurses perform chart checks daily (3 charts) for compliance. Quality staff members audit 1 chart per unit per day. There is no tracking or trending started for assessments or lab orders. I am not sure how to track them to prevent it from happening again.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48190 Based on facility documents, medical record review and interviews conducted, the facility failed to identify opportunities for improvement and develop an effective plan of correction for an adverse event involving a post operative patient without prompt intervention to seek effective preventive measures to protect in 1 of 1 QAPI program. Finding included: During the facility review process, the Council meets on a bi-weekly basis with the CMO (Chief Medical Officer), the physician involved and other members of the council. A meeting request was implemented however, the date is still undetermined. Review of the QAPI (Quality and Performance Improvement Plan) plan dated 2025 revealed no board approval has been completed. The QAPI Plan states the data collection is systematic and is used to identify areas for more focused data collection to sustain improvement over time. Data analysis ...[ is used] to identify variation, through the use of statistical tools and methods, helps focus the attention and resources on making improvement changes to the processes that will result in better outcomes. The purpose of the assessment process is to identify opportunities to improve systems or processes and to determine what actions should be taken for improvement. No evidence was provided of tracking, trending, and monitoring to prevent future recurrence. Review of Patient #4 medical record revealed missed opportunities when obtaining vital signs, documenting assessments and laboratory results. During an interview on 02/04/2025 at 3:10 PM, Staff M, Quality Director stated they had already begun to track and trend vital signs prior to the incident. The charge nurses perform chart checks daily (3 charts) for compliance. Quality staff members audit 1 chart per unit per day. There is no tracking or trending started for assessments or lab orders. I am not sure how to track them to prevent it from happening again.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 36678 Based on staffing grid, staffing assignments, and interviews, the hospital failed to adhere to facility staffing grid on 2 (Medical Surgical) of 6 nursing units. Findings included: A review of the Nursing Grid Guidelines revealed Medical Surgical (Med Surg) and Specialty Med Surg nurses should have a maximum of 6 patients. Review of the last 30 days of staffing assignment sheets for 4 East Med Surg and 4 West Med Surg revealed: 4 West: 01/02/2025 7 PM 1 CN (Charge Nurse) both sides (East and West) for total of 58 patients 3 RN’s with 7 patients each 01/05/2025 7 AM 1 CN 5 RN’s with 7 patients each 01/06/2025 7 AM 1 CN 5 RN’s with 7 patiets each 01/10/2025 7 PM 1 CN both units (4E and 4W) for total of 67 patiemts 3 RNs with 7 patients 01/12/2025 7 AM 1 CN 3 RNs with 7 patients 01/14/2025 7 AM 1 CN 5 RNs with 7 patients 01/16/2025 7 AM 1 CN 5 RNs with 7 patients 01/17/2025 7 AM 1 CN 5 RNs with 7 patients 01/22/2025 7 AM 1 CN with 1 patient 5 RNs with 7 patients 01/24/2025 7 AM 1 CN 5 RNs with 7 patients 01/25/2025 7 AM 1 CNC 2 RNs with 7 patients 01/26/2025 7 AM 1 CNC with 4 patients 4 RNs with 7 patients 01/27/2025 7 PM 1 CNC both units (4 East and 4 West) for a total of 69 patients 4 RNs with 7 patients 01/31/2025 7 AM 1 CNC with 1 patient 4 RNs with 7 patients 4 East: 01/02/2025 7 PM 1 CN both for nursing units (East and West) for a total of 58 patients 5 RNs with 7 patients 01/05/2025 7AM 1 CNC 5 RN with 7 patients 01/6/2025 7 AM 1 CNC 5 RNs with 7 patients 01/09/2025 7 AM 1 CNC with 1 patient 5 RNs with 7 patients 01/10/2025 7 PM 1 CNC with both nursing units (4 East and 4West) for a total of 67 patients 1 RN with 7 patients 01/11/2025 7 PM 1 CNC for both nursing units (4 East and 4 West) 4 RNs with 7 patients 01/12/2025 7 AM 1 CNC 4 RNs with 7 patients 01/19/2025 7 AM 1 CNC with 1 patient 5 RNs with 7 patients 01/22/2025 7 AM 1 CNC 5 RNs with 7 patients 01/23/2025 7 AM 1 CNC 5 RNs with 7 patients 01/24/2025 7 AM 1 CNC 5 RNs with 7 patients 01/26/2025 7 AM No CNC 5 RNs with 7 patients 01/27/2025 7 AM 1 CNC 5 RNs with 7 patients 01/27/2025 7 PM 1 CNC for both nursing units (4 East and 4 West) for a total of 69 patients 5 RNs with 7 patients 01/28/2025 7 AM 1 CNC 5 RNs with 7 patients 01/31/2025 7 AM 1 CNC 5 RNs with 7 patients 02/02/2025 7 PM 1 CNC for both nursing units (4 East and 4 West) During an interview on 02/03/2025 at 1:15 PM, Staff A, RN CN (Charge Nurse) of 4 West stated we were short that day (01/26/2025). “I had 4 patients and the nurse all had 7 each. We follow the grid. It goes by the census. We have had 7 quite a bit lately. 7 is too many. I take assignments once in a while.” During an interview on 02/03/2025 at 1:32 PM on 2/3/25, Staff B, RN of 4 West stated it’s 6 to 7 patients to 1 (nurse). It should be 5, although not sure what the ratio is supposed to be exactly. “I can take care of 7. It’s not what I envisioned as a nurse, it’s too much. I have 7 patients at least 2 out of every 3 shifts a week and the charge takes patients not often.” During an interview on 02/03/2025 at 1:58 PM, Staff C, RN of 4 West stated i am a contract/travel RN it’s 1 (nurse) to 6 or 7 (patients). “It’s not safe.” During an interview on 02/03/2025 at 10:41 AM, Staff D, RN of 4 Wes stated “As of lately we have had 7 patients for 2 weeks. 6 is supposed to be our max. RN A, CNC had 4. She took care of her 4 and was trying to do charge duties also. There is not enough staff. I do not feel I can provide quality care with 7 patients.” During an interview on 02/03/2025 at 11:33 AM, Staff E, MT (monitor tech) stated “I used to work on the floor. I know what it’s like.That unit was very chaotic. It’s a busy floor. If they’re short staffed, then it’s chaos. We have to call the nurses, not the techs (CNAs-certified nursing assistants). A lot of times they are short on the weekends. They’re full and have 5 nurses and 2 techs. But then the charge will take a team.” During an interview on 02/03/2025 at 11:53 AM, the Director of Med-Surg-Tele (telemetry) stated “the grid is 6 patients and then they flex up to 7. Without a grid I don’t know what it is. I don’t know that I would make anyone primary with 5 patients. We still have positions open. We lost a lot of people in the beginning when I came. I think we may lose some more. We have always had a staffing challenge, but it seems a little different. I think we could do more. I don’t think we are as proactive as we could be. We own Agency Name. It’s the largest staffing agency in the country. They all do the best they can. It’s not their decision. It’s over our heads. It’s over the CNO (chief nursing officer) and CEO’s (chief executive officer) heads. We don’t want them to have 7. The new grads are struggling. I have not had the challenges with staffing that I have had here. We try to staff to grid. We are making an effort. We are trying to come up with a plan where we never have to go up to 7 patients again. We have been approved for contracts. Not as many as we need. The charges rarely take patients. We had some people go to PCU (progressive care unit). It’s difficult to have 7 patients and precept a new nurse too.” During an interview on 02/03/2025 at 10:43 AM, Staff F, House Supervisor stated “I look at staffing the minute I walk through the door. I am constantly looking at it to tweak it and balance it throughout the facility. We can do 1 to 7 in the evenings. I do staffing for nights. If we need to we can use CNCs or balance from other floors. 72 beds combined (4 east and west). Ideally, we would like 3 PCTs on each side.” There have been times a CN had to oversee both 4 east and 4 west. During an interview on 02/03/2025 at 10:54 AM, 5th floor Nurse Manager stated around 50% of the time they are staffed to grid on his floor. They do contracts, but it’s hard to get them approved. During an interview on 02/03/2025 at 11:11 AM, Staff G, CN of 4 East stated I am a house supervisor also.The charge takes patients 1 to 2 times a month. “Usually if we’re waiting for discharges I take 1 patient if they’re busy, until they’re caught up, and then I give it back. Day shift charge does not have both sides. Night shift charge has both units (4 east and 4 west) at least a couple of times in the last month. We get as many from agency as they will allow us to have. We have to take care of the patients, so we have to put a CN on an assignment.” It is not reasonable to have one charge for both sides. “The night shift is not as bad. They shouldn’t have 7. There has been a lot of sickness and a lot of call-offs. This floor has the highest number of admissions and discharges. It’s a fast turnovee; we discharge and then get admissions. We have 3 PCTs (patient care technicians-CNAs) today, but they get pulled to sit for one to ones. Sitters have also been calling off like crazy, we have to have the sitters. 3 PCTs isn’t even enough and 6 patients is too many on this floor. The patients are sicker and the acuity is higher. They really need to reconsider the ratio.” During an interview on 02/03/2025 at 11:29 AM, Staff H, RN of 4 East stated this is a med-tele floor. I have 6 patients today. “Once in awhile it’s 7; but it’s rare. 6 is manageable. 7, not so much. If we’re short a tech, it’s tough. There’s been a few weeks with 7 and the charge also took 1 or 2. A couple times a month the charge has both units. It happens more often on nights. I have to stay late and don’t get a full break. You do what you have to.” During an interview on 02/03/2025 at 11:35 AM , Staff I, RN of 4 East stated “it’s 6 patients. 7 is not very often maybe a couple times a month. It happens on nights a lot more. Most days 6 is manageable but the patients are sicker and acuity is higher; they also have multiple comorbidities. So that makes it not manageable. The ratio is supposed to be 6. The charge also takes patients but it’s not that often on days. On nights it’s a couple times a week. The charge has had both sides at least a couple times a month. I do relief charge sometimes. You become more of a resource nurse when you have both sides. It’s a lot and it’s not safe. The paperwork is neglected. They hire staff but then they leave and go to other units. There’s been codes. They use agency. They can’t always get them. They have call offs. Our director is talking about changing the grids so we don’t have 7 anymore.” During an interview on 02/03/2025 at 11:47 AM, Staff J, CN of 4 West stated “It’s been rougher lately. Last week I had 1 to 2 patients 4 days in a row and one day I had to take 7 patients. The manager did come in to be the CN. Most of the time I don’t take patients. One time I had to take both sides (4 East and 4 West) but then the manager from 4 East came in and took over CN for me. They have 7 patients most of the time. It’s been that way since August. Often times it’s one PCT. Most of the time it’s agency staff. They can’t take care of 7. Medications and assessments are done, but not always on time. They can’t be everywhere; they try. It’s not administration; it’s above them. It’s division. The standard is 6 (nurses) and 3 techs. Since mid-December the call-offs are non-stop. People are leaving. They have hired new grads. But it takes a long time to train them. We have 1 contract starting soon. We use agency, but they don’t pick up because they come here and get 7 and they can go elsewhere and get 5 plus incentives. Division has to approve incentives. They have a metrix to follow. There hasn’t been any events, but it’s a matter of time. Night shift CN doesn’t take patients often lately. Night shift nurses regularly take 7. We like them at 6. They are capping us at 35 and blocking a room. Night charge takes both sides more often than day shift. It is not manageable. That’s 72 patients. We have lost nurses because of the ratio, and not so much because of the pay. We have a resource nurse on each floor, but it’s still too much. They have considered taking away the secretary for another nurse, but then charge has to do the secretary’s work too. We don’t have secretaries on weekends so we are doing their job then also.” During an interview on 02/03/2025 at 12:10 PM, Staff K, RN stated they don’t have 7 very often. “Last week was short. I can take care of 7. I am used to it. It’s overwhelming for the new nurses. Some refuse to take 7 so the charge picks up the rest. Usually charge doesn’t take patients. It’s 2 to 3 PCTs. It’s not enough. On good days we have 3. With 7, the patient care is impacted. If you have an emergency, you can’t pay attention to your other patients.” During an interview on 02/03/2025 at 12:21 PM, Staff L, RN stated “Staffing is terrible. I think more falls are happening because no one is there. It’s hard to get nurses to the floor for sepsis alerts; the sepsis RNs come from ICU. You wait awhile to even get one person here. We have 7 all the time and only about twice a month has it been less. Today is one of them, we have 6. The charge has been taking more lately. There has been no charge at times. When there is no CNC, we help each other and the secretary helps. When it’s one shift you can get through it, but it’s back to back. Nightshift has no charge more often and mostly during the holidays. It’s not possible and it is a little bit scary. They’re not doing anything about it. They just tell us to speak more positively. We only have 4 full time nurses and 1 LPN (licensed practical nurse). No other core staff. We want the patients safe. They use agency. They use staff from other units or float pool. The acuity is high and the ratio is high. They can’t retain staff; they come then leave. There have been more falls. People leave because it’s not safe. We have a lot of near misses.” 48190”

“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: 48190 Based on review of video footage, Florida Highway Patrol police report, review policy and Procedure review, Incident Report review, medical record review and interviews, it was determined the facility failed to 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 for 1 (Patient #1) of 20 patients reviewed 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: 48190 Based on review of video footage, Florida Highway Patrol police report, Computerized EMTALA Log, Facility policy and procedures, and interviews, it was determined the facility failed to maintain an central log for each on each individual who comes to the emergency department, seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated for 1 (Patient #1) of 20 patients reviewed. Findings Included: Review of the Florida Highway Patrol police report dated 12/31/24 at 1:52am revealed the Highway Patrol Trooper (Law Enforcement Officer #2) stated “I was advised by the Doctor on duty that they would not accept [Patient #1] due to his aggressiveness and combativeness. I then decided to transport [Patient #1] to [Another hospital]. Review of the emergency room video footage (no sound) from 12/31/2024 at 2:51AM revealed the Law Enforcement Officer (LEO) #1 arrived at the emergency room ambulance bay and met the Staff A, DO outside. LEO #1 and Staff A, DO were in engaged in conversation when another LEO (#2) pulled into the ambulance bay with Patient #1 in his vehicle at 02:53 AM. LEO #2 is seen getting out of the patrol car and walking toward Staff A, DO. LEO #2 and Staff A, DO exchange conversation, then 6 minutes later, LEO #1 walks away and LEO #2 gets back in his patrol car and drives away. During the conversation between the LEO #2 and Staff A, DO, 2 RNs and 1 security officer are noted standing outside behind Staff A, DO. Review of facility policy “Patient Access Department” last reviewed 05/1/2024 states “HCA Florida Trinity Hospital” It is the policy of the Patient Access Department to adhere to EMTALA standards and state law when performing Emergency Department (ED) patient registration. No facility medical record was available to review for Patient #1. Review of the computerized EMTALA Log for 12/31/2024 revealed no entry for Patient #1. During an interview on 01/27/2025 at approximately 10:00 AM, Staff B, VP, ED, stated “I spoke with the physician on duty that night and he stated that he told the officer that he would see the patient and that he would never tell them that he would not treat this patient. Several statements from staff state that Staff A, DO told the officers to take him to a different hospital that can treat his needs, and stating he only had female staff on duty. During an interview on 01/27/2025 at approximately 10:00am with Staff B, Vice President (VP), Emergency Services, “I spoke with the physician on duty that night and he stated that he told the officer he would see the patient and that he would never tell them that he would not treat this patient”, however, the officer wanted to take him to [another hospital]. During an interview on 01/27/2025 at 12:10pm with Staff A, DO, he stated that while outside with the 1st Law Enforcement Officer, that officer was told by the 2nd officer (with the patient) that he was taking him to [another hospital] due to requiring multiple staff to assist due to his agitation. I was about to go back inside when the 2nd officer showed up. I’m unsure why he showed up with the patient in the back seat. I explained that I can take care of him here, but they did not let the patient out of the patrol car. They said they were taking him to [another hospital] and proceeded to leave. During an interview on 01/29/2025 at 12:31 PM, Staff D, RN stated I’m not sure if he got out or talked through the window, but I heard the patient’s yelling, and the patient never stepped foot in the ED. During an interview with Staff F, Security Officer, on 01/29/2025 at 2:50pm, Staff A, DO told the Trooper (Law Enforcement Officer) that he believed that they should take him to a bigger hospital just because he had an all-female staff, so he just wasn’t sure if we could provide what he needed since he was being so aggressive. That’s what I remember about this incident. I did think it was odd to let him just go, but I can’t tell a doctor what to do.”

“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 review of video footage, Florida Highway Patrol police report, review policy and Procedure review, Incident Report review, medical record review and interviews, it was determined the facility failed to 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 for 1 (Patient #1) of 20 patients reviewed Findings Included: Review of the Florida Highway Patrol police report dated 12/31/2024 at 1:52am revealed the Highway Patrol Trooper (Law Enforcement Officer #2) stated “While the patient was escorted to booking, he then began to smash his forehead into the partition which resulted in him sustaining a small laceration to his forehead. The booking staff stated that he needed to go to the hospital for medical clearance due to a cut on his forehead bleeding and a head injury. I then traveled down to the Emergency room to which upon arrival, I was advised by the Doctor on duty that they would not accept Patient #1 due to his aggressiveness and combativeness. I then decided to transport Patient #1 to [Another hospital]. Review of the emergency room video footage (no sound) from 12/31/2024 at 2:51am revealed the Law Enforcement Officer (LEO) #1 arrived at the emergency room ambulance bay and met the Staff A, DO (Doctor of Osteopathy) outside. LEO #1 and Staff A, DO were in engaged in conversation when another LEO (#2) pulled into the ambulance bay with Patient #1 in his vehicle at 02:53am. LEO #2 is seen getting out of the patrol car and walking toward Staff A, DO. LEO #2 and Staff A, DO exchange conversation, then 6 minutes later, LEO #1 walks away and LEO #2 gets back in his patrol car and drives away. During the conversation between the LEO #2 and Staff A/ DO, 2 RNs (Registered Nurse) and 1 security officer are noted standing outside behind Staff A, DO. Review of facility policy EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening Examination and Stabilization: Policy #: ADMIN.L.D.009, last reviewed 09/2023. The policy revealed in part, “PROCEDURE: When a MSE (Medical Screening Examination ) is required” A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED (Dedicated Emergency Department), to determine whether or not an EMC (Emergency Medical Condition) exists: (i) to any individual, ...who requests an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individuals appearance or behavior needs an MSE.” Review of the Facility incident report shows that the patient was in police custody due to suspected Driving under the Influence and resisting arrest. An Officer came to ED to notify them of impending arrival of the patient. The Physician (Staff A, DO) met police outside and discussed behavior of the patient. Police arrived with patient and spoke to Staff A, DO. Police drove off with patient taking him to another hospital. No MSE was completed, and he was not on the EMTALA log. The Investigation confirmed Patient #1 was not seen or triaged. The history was given by Florida Highway Patrol of resisting arrest, kicking arresting officer in the jaw and self injury in squad car, banging head on seat resulting in bleeding from head. Patient #1 never left the car. No assessment was completed. No entry was entered into the EMTALA log. Security was present for part of the conversation and stated that Staff A, DO felt that due to combative, aggressive behavior of Patient #1, the Freestanding ED was not capable of handling patient. Staff A, DO stated that it was only him and 2 female nurses present, and he was concerned for their safety. Based on this he refused to see the patient. No facility medical record was available to review for Patient #1. Review of medical record from [Another Hospital] revealed Patient #1 presented with complaints of altered mental status today via Law Enforcement Officers (LEO) . Patient #1 had been placed under arrest, placed in a police car , and the patient became very combative and was hitting his head. The LEO attempted to take the patient to the HCA freestanding emergency department however they declined the patient due to the patient being so aggressive and out of control. The patient was brought to this facility in a very aggressive state and out of control. Patient refusing to answer any questions about anything that he may have taken. The patient also required sedation on arrival to be able to perform an evaluation and the patient was unable to answer questions. Assessment: multiply linear abrasions across the mid forehead which are superficial and needed no treatment. Laboratory tests, Computed Tomography of the Brain, and Chest X-Ray completed. The patient was also noted initially to have an elevated lactic acid which is likely secondary to the patient’s fighting his incarceration as well as dehydration. The patient was hydrated with IV (Intravenous) fluids and had improvement in his lactic acid. The patient is now medically cleared and is just awaiting to become more alert after the medications he was given and then he will be released to the custody of the police. During an interview on 01/27/2025 at approximately 10:00am with Staff B, Vice President (VP), Emergency Services, “I spoke with the physician on duty that night and he stated that he told the officer he would see the patient and that he would never tell them that he would not treat this patient”, however, the officer wanted to take him to [another hospital]. During an interview on 01/27/2025 at 12:10pm with Staff A, DO, he stated that while outside with the 1st Law Enforcement Officer, that officer was told by the 2nd officer (with the patient) that he was taking him to [another hospital] due to requiring multiple staff to assist due to his agitation. I was about to go back inside when the 2nd officer showed up. I’m unsure why he showed up with the patient in the back seat. I explained that I can take care of him here, but they did not let the patient out of the patrol car. They said they were taking him to [another hospital] and proceeded to leave. During an interview with Staff F, Security Officer, on 01/29/2025 at 2:50pm, Staff A, DO told the Trooper (Law Enforcement Officer) that he believed that they should take him to a bigger hospital just because he had an all-female staff, so he just wasn’t sure if we could provide what he needed since he was being so aggressive. That’s what I remember about this incident. I did think it was odd to let him just go, but I can’t tell a doctor what to do. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that when a request was made on Patient #1’s behalf by a LEO because it was determined due to the patient’s behavior and sustaining a laceration to his forehead he needed an evaluation. The facility failed to provide an appropriate MSE for patient #1 on 12/31/2024 that was within the capability if the hospital’s emergency department, including ancillary services routinely available to the emergency to determine whether or not an emergency medical condition existed, as stated in the facility’s policy.”