HCA Florida South Shore Hospital

“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 facility policy, video footage, electronic central log, and interviews, the facility failed to maintain an accurate central log for any individual seeking treatment or assistance for 1 (Patient #21) of 21 patients reviewed. Findings: Review of facility policy “Emergency Department (ED) Patient Registration” last revised 12/2025 states it is the policy of the patient access department to adhere to the EMTALA standards and the state law when performing Emergency Department (ED) patient registration. Every patient presenting to the Emergency Department is entitled to a medical screening examination and stabilizing treatment for an emergency medical condition, regardless of his /her ability to pay. Individuals and unscheduled pregnant patients presenting to the dedicated emergency department or dedicated labor and delivery department assessment area, shall be registered, triaged by a nurse, medically screened, and stabilized as necessary by a physician or qualified medical person.... the patient is entered as a new patient or as Jane Doe if necessary. Review of exterior video footage from 02/23/26 revealed: 00:00- fire rescue walk to back of the rescue truck 00:31- fire rescue inside ER 00:35- back doors of fire rescue open 1:07- fire rescue and patient walk toward ER 1:26- patient walk away from ER and camera 2:10- fire rescue walk out of ER 4:00- fire rescue x2 walk into ER 5:57- fire rescue and RN walkout of ER 6:54- RN with a wheelchair walks in ER 9:10- fire rescue walk out ER 20:28- Fire rescue truck pulling away from ER Review of interior video footage from 02/23/26 revealed: 00:43 LEO (law enforcement officer) x2 walk in with patient 00:50- LEO speaking with CNC (clinical nurse coordinator) *Patient noticed swaying back and forth while LEO x2 is holding him up* 2:00- CNC speaking with LEO 2:26- LEO x2 leaving with patient while CNC speaking with other LEO 2:35- LEO #3 leaving the ER 2:40- CNC speaking with another staff member Review of facility EMTALA (Emergency Medical Treatment And Labor Act) log dated 02/23/2026, no entry for Patient #21 was noted. During an interview on 03/12/2026 at 11:04 AM, the CNO (Chief Nursing Officer) stated it was brought to our attention when the [hospital name] called us. [Hospital name] stated a deputy attempted to bring the patient here, but we said we do not do trauma, so they took the patient there, [hospital name]. We looked into it immediately. The relief charge stated EMS called in a patient was found walking in traffic with laceration on head and possibly hit in face with pipe. EMS arrived without the patient and stated the patient ran away while on hospital property. The EMS RN (nurse) then went to grab a wheelchair to go outside to retrieve the patient but did not see him and returned to the ED. The CNC (clinical nurse coordinator) was is another patients room during this time. The patient then arrived with law enforcement in handcuffs; the patient’s face was swollen including the eye. The deputy spoke with the charge, and she stated we can take the patient but if it is a trauma we will have to transfer out. Law enforcement said ok we will go another hospital then. The patient was not logged on the ED log. During an interview on 03/12/2026 at approximately 2:30 PM, the CNC stated I was in another patient’s room when the situation occurred. By the time I was made aware of what happened, I was very confused due to many conflicting stories that were being told to me. Then law enforcement showed up with a patient. The patient was not logged on the ED log. The violation related to the ED Log was identified by the hospital as a possible EMTALA violation on 02/24/2026 and reported on 03/09/2026. The violation occurred on 02/23/2026. The facility started their corrective action plan related to the ED log on 02/24/2026. This plan included the following: 1. Immediate EMTALA re-education to all emergency room staff. The education provided to all staff included the definition of EMTALA, EMTALA policies and EMTALA case studies. Attestations obtained. 2. Security officers, emergency room front desk staff/volunteers, and main entrance staff/ volunteers re-educated on EMTALA and sign in logs. Attestations continued to be obtained. 3. The lobby (Main and ER) logs are filled out and placed in a red binder. All volunteers, concierge and security officers will be signed off on this new process. The red binder will be reviewed daily by ED CNC/ED Director and the administrator. The ED director will keep track all logs and audit for completion. There will also be EMS radio logs that will be filled out and incorporated into the audits. All audits will continue until 100% x4months then quarterly check ins.”

“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 facility policy review, video footage review, electronic central log, medical record review and interviews, the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for 1 (Patient #21) of 21 patients reviewed. Findings included: Review of facility policy “EMTALA- Medical Screening Examination and Stabilization” approved 11/2024 states “An EMTALA obligation is triggered when an individual or a representative acting on the individual’s behalf, including EMS or a transferring hospital, requests emergency services and care; or a prudent layperson observer observing an individual who comes to the dedicated emergency department (DED) would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition.” Review of exterior video footage from 02/23/26 revealed: 00:00- fire rescue walk to back of the rescue truck 00:31- fire rescue inside ER 00:35- back doors of fire rescue open 1:07- fire rescue and patient walk toward ER 1:26- patient walk away from ER and camera 2:10- fire rescue walk out of ER 4:00- fire rescue x2 walk into ER 5:57- fire rescue and RN walkout of ER 6:54- RN with a wheelchair walks in ER 9:10- fire rescue walk out ER 20:28- Fire rescue truck pulling away from ER Review of interior hospital video footage from 02/23/26 revealed: 00:43 LEO (law enforcement officer) x2 walk in with patient 00:50- LEO speaking with CNC *Patient noticed swaying back and forth while LEO x2 is holding him up* 2:00- CNC speaking with LEO 2:26- LEO x2 leaving with patient while CNC speaking with other LEO 2:35- LEO #3 leaving the ER 2:40- CNC speaking with another staff member Review of facility EMTALA (Emergency Medical Treatment And Labor Act) log dated 02/23/2026, no entry for Patient #21 was noted. Review of Patient #21’s medical record from [hospital name] revealed, per Emergency Department document “Patient is a 31 years old male brought in by EMS (Emergency Medical Services) under Baker Act (allows for involuntary, emergency detention and examination of individuals in a mental health crisis for up to 72 hours) by law enforcement. Apparently he was involved in altercation at a bar and Sheriff’s officer came to the scene. Details of the altercation are unclear, but the patient apparently suffered facial injuries. Is unclear what the mechanism was. Apparently, the patient was running in front of the police cruiser in an attempt to harm himself. He told the officers that he was suicidal. Given the apparent imminent self harm that the patient was in, Sheriff’s deputy placed the patient under Baker act and brought him here. Patient is here under Baker act for medical clearance. He did suffer head trauma. The history is unclear. Unsure if the patient lost consciousness. As such we will screen with CT scan of the head. Will obtain baseline medical screening labs and continue to monitor closely. Consult with telepsychiatrist who was able to speak with the patient and recommends upholding the Baker act for inpatient psychiatric treatment. Patient #21 medically cleared and admitted.” During an interview on 03/12/2026 at 11:04 AM, the CNO (Chief Nursing Officer) stated it was brought to our attention when the [hospital name] called us. [Hospital name] stated a deputy attempted to bring the patient here, but we said we do not do trauma, so they took the patient there, [hospital name]. We looked into it immediately. The relief charge stated EMS called in a patient was found walking in traffic with laceration on head and possibly hit in face with pipe. EMS arrived without the patient and stated the patient ran away while on property. The EMS RN (nurse) then went to grab a wheelchair to go outside to retrieve the patient but did not see him and returned to the ED. The CNC (clinical nurse coordinator) was is another patients room during this time. The patient then arrived with law enforcement in handcuffs; the patient’s face was swollen including the eye. The deputy spoke with the charge, and she stated we can take the patient but if it is a trauma we will have to transfer out. Law enforcement said ok we will go another hospital then. The patient was not logged on the ED log and no medical screening exam was completed. During an interview on 03/12/2026 at approximately 2:30 PM, the CNC stated I was in another patient’s room when the situation occurred. By the time I was made aware of what happened, I was very confused due to many conflicting stories that were being told to me. Then law enforcement showed up a patient. I received report and stated if this is a trauma patient, we will transfer out since we are not a trauma center. Law enforcement then said they would go to another hospital; I did not refuse the patient. Hospital staff failed to provide an appropriate medical screening exam or document an attempt to explain the risk and benefits of remaining in the DED for Patient #21.”