Cape Coral Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 25370 Based on staff interviews, review of facility policy and procedures, Obstetrical physician on-call schedule review, Facility self- report letter review it was determined the facility failed to ensure 1 (Patient #20) of 3 patients seeking emergency care in the Obstetrics (OB) triage unit had an appropriate medical screening examination (MSE) 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. 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: 25370 Based on the facility’s Emergency Department (ED) Registration Log review, Policy and Procedure review and staff interviews it was determined the facility failed to maintain a central log on each individual who comes to the hospital’s emergency department, seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 (#20) of 3 sampled obstetrical medical records reviewed for patients who presented to the hospital’s emergency department seeking medical assistance for obstetrical complaints. The findings include: The facility’s Central Log Policy #118 with a last revised date of 2/2024 was reviewed. The facility’s policy revealed in part, ...”each hospital offering emergency services will maintain a computerized central log on each individual who comes to the emergency department, which includes individuals presenting to Obstetrics (OB) triage seeking assistance for a medical condition, patients who are refusing treatment prior to registration, and those who leave without being seen. The log must contain the name, age, and se of the individual seeking assistance. The date, time and means of arrival, and the nature of the complaint. The disposition including whether or not he or she refused treatment, was transferred, was admitted and treated, was stabilized and transferred or was discharged.” Review of the hospital’s ED l Registration Log dated October 4, 2024, was reviewed. Review of the hospital’s ED registration log revealed that Patient #20 was not registered in the hospital’s ED log when the patient presented to the hospital’s ED on October 4, 2024. During an interview on 11/4/2024 at 12:38 p.m., with the Risk Manager (RM) II she stated their investigation, revealed that Staff A had assessed Patient #20 to include the baby’s heartbeat but when she went to document her medical screening assessment into Patient #20’s medical record was when she discovered Patient #20 was not registered, meaning an electronic medical record was not created as required seeking medical assistance for an obstetrical complaint. The facility failed to ensure that their own policy and procedures were not followed as evidenced by failing to enter Patient # 20 on 10/4/2025 in the facility’s ED Registration as stated in the facility’s policies.”

“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: 25618 Based on staff interviews, review of facility policy and procedures, Obstetrical physician on-call schedule review, Facility self- report letter review it was determined the facility failed to ensure 1 (Patient #20) of 3 patients seeking emergency care in the Obstetrics (OB) triage unit had an appropriate medical screening examination (MSE) 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. The findings included: Review of the Obstetrics Medical Screening Examination Policy #655 with a last revised date of 3/2024 stated a pregnant women, greater than 20 weeks gestation, who comes to the hospital requesting an evaluation of her obstetrical condition should receive an appropriate medical screening examination within the capability of the hospital’s obstetrical department, including ancillary services routinely available to the obstetrical department, to determine wither or not an emergency medical condition existed. Under the Documentation section, the policy stated staff were required to record all information obtained from the medical screening exam in the electronic health record. Obstetrical triage units were to enter patient data into the Labor and Delivery Outpatient Logbook to include the patient’s name, medical record number, date and time of arrival, presenting complaint or diagnosis, medical screening exam provided and by whom, disposition of the patient, and the date and time of discharge/transfer from the unit. Review of the Medical Screening Examination Policy #561 with a last revised date of 4/2016 stated all individuals coming to the hospital requesting emergency services received an appropriate medical screening examination as required by law. An individual who comes to the emergency department requesting emergency services or had presented on hospital property should receive an appropriate medical screening examination within the capability of the hospital’s emergency department, to determine whether or not an emergency medical condition existed. Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition existed. The facility’s Physician Obstetrical/Gynecology on-call schedule dated 10/4/2024 was reviewed. The Physician Obstetrical/Gynecology schedule revealed that when Patient #20 presented to the hospital’s ED 10/4/2024, verified that an Obstetrical/Gynecology physician (ancillary services) was on call and available Review of the (facility Self- Report ) letter dated 10/14/24 addressed to the Agency Health Care Administration (AHCA) Field Office Manager (FOM) from the hospital Risk Manager wanted to advise the FOM of a possible Emergency Medical Treatment and Labor Act (EMTALA)/Florida access to care violation. On 10/4/24 sometime in the early afternoon a patient presented to the hospital Obstetrics (OB) triage department with a complaint that she thought her water had broken that morning. The patient was 33 weeks pregnant at the time of the visit. OB triage was at capacity, two patients were waiting to check in and one patient waiting in PACU (post-anesthesia care) to be seen. The triage nurse conducted an evaluation of the fetal heart rate by doppler in the charge control office and noted the rate to be re-assuring. The patient denied having pain and reported that she was feeling fetal movement. The patient was advised that she would have to wait in the waiting room to be checked in. The patient’s husband questioned the nurse about not waiting and taking his wife to another hospital. The OB triage nurse explained that because the patient was only 33 weeks and had a history of a pre-term delivery that after she was evaluated by the physician and determined to be stable and not an imminent delivery, she would be transferred to the other hospital by ambulance to ensure that when the patient delivered the baby the NICU (neonatal intensive care unit) team would be available to attend to the birth. The patient’s husband asked if they could drive to the other hospital rather than wait to be seen in the OB triage unit. The OB triage nurse advised the patient and her husband that the hospital was required to provide for an emergency screening to ensure that the patient’s condition was stable, and she was not an imminent delivery. The patient elected to leave and go to the other hospital. Prior to the patient’s departure the OB triage nurse contacted the midwife about the patient’s decision to leave. The OB triage nurse called the OB Charge nurse at the other hospital and gave them a report of the patient coming to their facility. The hospital determined the deficiency was the patient was not registered, there was no documentation of the patient’s decision to leave, and the patient did not sign the form (Withdrawal of request for service) that is required when a patient elects to leave OB triage before the emergency screening exam was performed. On 11/4/24 at 12:38 p.m., in an interview with the hospital’s Risk Manager II (RMII), Vice President of Operations, and Chief Nursing Executive said Patient #20 was the patient in the letter dated 10/14/24 and Staff A was the OB triage nurse in the letter addressed to the FOM of a possible EMTALA and Florida access of care violation. The RMII confirmed the Obstetrics Medical Screening Examination Policy #655 with a revised date of 3/2024 stated a pregnant women, greater than 20 weeks gestation, who comes to the hospital requesting an evaluation of her obstetrical condition should receive an appropriate medical screening examination within the capability of the hospital’s obstetrical department, including ancillary services routinely available to the obstetrical department, to determine whether or not an emergency medical condition existed. The RMII said their investigation, as noted above, revealed that Staff A had assessed Patient #20 to include the baby’s heartbeat but when she went to document her medical screening assessment into Patient #20’s medical record was when she discovered Patient #20 was not registered, meaning an electronic medical record was not created as required. The RMII said because Staff A did not document Patient #20 visit to the OB triage unit on 10/4/24, they did not have documentation a medical screening examination was performed as required as noted in their OB Medical Screening Examination policy. The RMII also confirmed Patient #20’s name, date and time of her arrival, presenting complaint, medical screening exam provided and by whom and disposition of the patient was not entered on the Obstetrical Triage Units Labor and Delivery Logbook as required in their OB Medical Screening Exam policy. On 11/5/24 at 10:30 a.m., in an interview with Staff A and the Nursing Director of Women’s Care/OB Labor Unit, they confirmed Staff A was the OB triage nurse who had taken care of Patient #20 on 10/4/24. Staff A confirmed Patient #20 had presented to OB triage unit stating she thought her water had broken that morning. Staff A said the triage unit was full and she did not want to exam Patient #20 in the lobby, so she brought the patient to the Charge Nurse office, where she did an examination of Patient #20 and listened to the baby’s heartbeat. She said she had a conversation with the Charge Nurse and the Midwife about her assessment of Patient #20 and they stated Patient #20 needed to be at the other hospital which had a NICU team to attend to the birth. She said she informed Patient #20 and her husband they needed to be medically screened to ensure Patient #20 was stable, but Patient #20 and her husband decided they would drive to the other hospital to be seen by their OB triage unit. Staff A said Patient #20 was in the OB triage unit for about 40 minutes, and when she went to enter Patient #20’s information into her medical record was when she discovered Patient #20 had not completed the registration process. She said because Patient #20 was not registered she did not have an electronic medical record to document the medical screening exam assessment she had done in the charge nurse office of Patient #20 on 10/4/24. On 11/5/24 at 11:45 a.m., in an interview with Staff B Registered Nurse (RN), Critical Care Charge nurse in Women and Neonatal Service, she said when a patient comes to the OB triage with a medical condition the OB triage nurse was required to complete an appropriate medical screening examination per their policy and enter the information into the patient’s electronic medical record. She said sometimes the electronic medical system had scheduled down time, and during those times they had paper forms in the charge nurse office where the OB triage nurse could document their medical screening examination of the patient. She said when the electronic medical system comes back online, they would upload the paper documents into the patient’s medical record. On 11/5/24 at 1:00 p.m., in an interview with the Nursing Director of Women’s Care/OB Labor Unit, she confirmed Staff A did not document her medical screening assessment of Patient #20 on 10/4/24 as required per the facility’s OB Medical Screening Examination policy #655.”