HCA Florida Lawnwood 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: 29151 Based on record review, transfer center transcripts and recordings, and staff interview, it was determined, the hospital failed to adopt and enforce a policy to ensure compliance with the EMTALA requirements at 42 CFR 489.24 as evidenced by failure to accept a transfer from another hospital despite having the specialized capability and capacity to manage the patient. The failure affected 1 of 21 sampled patients (Patient #21). The findings included: Review of the transfer center transcript and the audio recording, and staff interviews conducted on 05/05/25 (at Hospital A) and 05/29/25 (at Hospital B), revealed Hospital B failed to accept a transfer from another Emergency Department (ED) from Hospital A. Hospital B had the capacity and capability of accepting and treating the patient, and the process in place to review potential refusals failed to identify the root cause of the denial. The failure affected 1 of 21 sampled patients (Patient #21) as detailed in citation A2411. The survey initiated at the transferring hospital, Hospital A, conducted on 05/05/25, validated the potential violation. Hospital B self-reported the event to the State Agency on 05/06/25 as a possible EMTALA violation. Corrective actions reviewed during the investigation included the following: The Chief Medical Officer and Chief Executive Officer provided education to the on-call provider involved in the event and to the entire Otolaryngology (ENT) group on 04/30/25. The Administrators On Call (AOC) received EMTALA education with goal completion date of 05/30/25, completion rate of 90% due to staff on medical leave and vacation. Education on EMTALA was emailed to all clinical staff and transfer center staff on 05/29/25. The corporation has initiated quality monthly tracers. For the month of May 2025, Hospital B completed the EMTALA module with 100% compliance.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 29151 Based on record review, transfer center transcripts and audio recordings, and staff interview, it was determined, Hospital B failed to accept a transfer from another emergency department (Hospital A) despite having the specialized capability and capacity to accept and treat the patient. The failure affected 1 of 21 sampled patients (Patient #21). The findings included: Review of the facility policy titled “Florida EMTALA Transfer Policy”, last revised 01/2025 documents as follows: “Recipient Hospital Responsibilities. a. A participating hospital that has specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units, dedicated behavioral health units, or regional referral centers in rural areas) may not refuse to accept an appropriate transfer from a transferring hospital within the boundaries of the United States, of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. b. The requirement to accept an appropriate EMTALA transfer applies to any Medicare participating hospital with specialized capabilities, regardless of whether the hospital has a DED c. The recipient hospital’s EMTALA obligations do not extend to individuals who are inpatients at another hospital. d. If an individual arrives through the DED as a transfer from another hospital or health care facility, the hospital has a duty to have a physician or QMP, not a triage nurse, perform an appropriate MSE to determine whether the patient’s condition deteriorated during the transport. The MSE must be documented in the medical record. e. A recipient hospital with specialized capabilities that delays the treatment of an individual with an EMC who arrives as a transfer from another facility could be in violation of EMTALA, depending on the circumstances of the delay. g. The receiving hospital may handle the receipt and subsequent assessment of the transferred emergency patient in a number of ways, including: iii. If a facility’s transfer coordinator receives a request from a transferring hospital and no specialty bed is available but the DED has capacity and capability to further treat and stabilize the individual and an on-call physician is available, the receiving facility should accept the transfer as an ED to ED transfer. If the Emergency Department of the receiving hospital has exceeded its capacity and capability with individuals waiting to be seen and patients being held on stretchers in the hallways because no beds are available, then the receiving ED can refuse the transfer based upon no capacity and capability if that has been their practice in the past based on the same capacity. Each specialty unit shall be responsible for entering the transferred patient’s name and pertinent data into the appropriate log as per hospital policy. 6. Review Process for Any Refused Transfers for those situations in which the hospital refuses to accept a transfer from another facility, the hospital and PLC must have in place a procedure to review potential refusals and/or to monitor any refusals of transfer from other facilities. The PLC shall establish a process to notify a hospital of a potential EMTALA violation. Clinical record review conducted on 05/05/25 at Hospital A, the transferring hospital, revealed Patient #21 presented to the Emergency Department (ED) on 04/15/25 at 9:02 PM with chief complaint of dental pain and swelling. The patient was triaged as urgent and after completion of the medical screening exam (MSE), was diagnosed with a peritonsillar abscess requiring Ear Nose and Throat (ENT) services. Hospital A did not have ENT services on call and a request for a transfer was made utilizing the transfer center. The transfer center contacted the sister facility, Hospital B, as they had ENT services on call. Review of the hospital transfer center documentation conducted on 05/05/25 revealed that Hospital B declined the transfer. A review of the transfer center audio recording conducted on 05/05/25, including the interaction with the on-call provider and the transfer center staff dated 04/16/25 validates Hospital B declined the patient. The ENT on call stated he does not see patients from this particular area (Palm Beach County). Patient #21 was subsequently transferred to Hospital C for further treatment. On 05/06/25, Hospital B self-reported the event to the State Agency as a possible EMTALA violation. Record review conducted on 05/29/25 during the survey at Hospital B confirmed the hospital had ENT services on call on 04/16/25 and confirmed that Patient #21’s transfer was declined. The facility had the capacity and capability of accepting the transfer. There is no evidence that the clinical presentation was out of the ENT provider’s scope of practice. Review of the ENT providers privileges conducted on 05/29/25 confirmed the scope of practice included tonsillar abscess care. Interview with the Chief Medical Officer (CMO), conducted on 05/29/25 at 10:30 AM, revealed the facility takes EMTALA violations very seriously. The event involving Patient #21 was an isolated event. The CMO gave background information regarding the ENT coverage at the hospital and explained due to the high volume of patients looking for ENT services, they have arranged for Hospital A, their sister facility, to contact another hospital first, due to closer proximity, (Hospital D). The ENT providers for both Hospital B and Hospital D have the same privileges and scope of practice, so when the transfer center spoke to the ENT on call, he assumed they had already contacted Hospital D, and declined the patient thinking the services would be out of his scope of practice. The CMO approved the denial because he was under the impression the ENT declined due to being out of their scope. The ENT on call and the entire group has been educated on the EMTALA requirement, and the CEO made it very clear that refusing patients is not acceptable. The CMO confirmed the denial was not due to capacity or capability, it was an isolated event, missed communication. Interview conducted with the ED Medical Director (EDMD) on 05/29/25 at 1:08 PM revealed he was aware of the incident and the CMO and CEO addressed the issue with the provider and the ENT group. He is not aware of any prior events, and the corrective action was implemented by the CMO and CEO. The EDMD stated that on his own and in conjunction with the clinical ED Director, they will review every transfer that has been declined. The facility already has an escalation process and this review would be an additional measure to monitor compliance, it is not an official audit, is just something they have discussed and will implement in the near future. Interview conducted with the ENT physician conducted on 05/29/25 at 2:17 PM revealed his recollection of the events involving Patient #21. The patient was at Hospital A, in a neighboring county, requiring ENT services. The physician declined acceptance assuming that the transfer center had to refer the patient to Hospital D, and if Hospital D determined the case was out of their scope of practice, it would be out of scope for him as well, as both hospitals have the same level of credentialing. Since the event, the CMO provided him with education on EMTALA, and he received a power point presentation of EMTALA requirements for regulatory compliance. The interview conducted with the Ethics and Compliance Officer on 05/30/25 at 10:39 AM revealed she completed the investigation for the event in partnership with the CEO and CMO and subsequently the facility self-reported the event. The AOC on duty on 04/16/25 was the Chief Financial Officer (CFO), who is currently on vacation, and elaborated that the CFO initially took the call and based on the ENT denial, proceeded to contact the CMO to consult the declination of the transfer. After talking to the CMO, the hospital upheld the declination, and the CFO then called back the transfer center with the decision. The case was an isolated event and the CMO upheld the denial thinking that ENT services declined the transfer due to the case being out of his scope of practice, not geographical location.”