HCA Florida Oak Hill 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 interviews, medical record reviews, video footage review, Fire Rescue Pre Hospital Care Report, Personnel Record review, and Policy and Procedure review, the facility failed to ensure that when an individual comes to the emergency department is provided an appropriate medical screening examination within the capability of the hospital’s emergency department including ancillary services routinely services available to the emergency department to determine whether or not emergency medical condition exists for 1 (#1) of 22 sampled patients. Patient #1 presented to the hospital’s property seeking medical assistance for an evaluation status post a fall and complaining of hip pain. A family member acting on her behalf requested hospital staff assistance to get the patient out of the vehicle, and was informed by hospital staff to take the patient home and call 911 and have EMS bring her back to HCA Florida Oak Hill Hospital for evaluation and treatment for a medical condition. 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: 29257 Based on staff interview, Emergency Department Log review, Fire Rescue Pre-Hospital Care Report, Roles and Responsibilities of the GREETER, and video footage review the facility failed to maintain a central log of each individual who comes to the emergency department for treatment for 1 of 22 patients reviewed, Patient #1. Findings include: Review of the emergency room (ED) video footage dated 04/14/2024 beginning at 5:48 PM showed Patient #1 was a passenger of a privately owned vehicle that arrived to the emergency room entrance and parked in the roundabout at the entrance of the emergency room. The driver of the vehicle (later identified as Patient #1’s daughter) approached the Greeter (Staff A), and they were involved in a discussion. (The video did not provide audio). Staff A, who was sitting in a chair, got up, placed gloves on both hands, and walked out of the emergency room to where the car was parked, pushing a wheelchair. Staff A, Patient #1, and the driver were involved in a discussion. At 5:52 PM, the driver of the vehicle shut the doors to the vehicle and drove away with the patient in the vehicle. Staff A returned to the Greeter desk. Review of the ED log dated 04/14/2024 for the time on and about 5:48 PM did not document Patient #1 presenting to the ED. Review of the “[Name of County] Fire Rescue Pre-Hospital Care Report” documented on Page 6 under the Narrative section, “Narrative: SUBJECTIVE: Called for a reported Fall [Patient #1’s home address]. On arrival, found 80 year Female patient weighting 59 KG [kilograms]. Chief complaint of Hip pain secondary to a fall. Events surrounding incident: Rescue 2 arrived on scene and found the patient sitting in the passenger seat of the car in the driveway. It was stated that the patient fell at a local restaurant and attempted to go to Oak Hill Hospital and was turned away by staff because they had no one to assist the patient out of the vehicle.” During an interview on 05/29/2024 at 12:45 PM, the Director of the ED stated, “On 04/14/2024 at approximately 5:48 PM, [Patient #1’s name] presented to this facility. The patient sustained a ground fall at a nearby restaurant. The patient was accompanied by her daughter. The patient’s daughter had parked her private car adjacent to the entrance of the facility’s ED and requested assistance getting [Patient #1’s name] out of the car. A clinical staff member, who was identified as an Emergency Medical Technician (EMT), went outside, and instructed the patient to go to her residence and call 911 from her residence, so she could be moved from her vehicle. [Patient #1’s name] and her daughter left the facility and went home and then called 911, who brought her back to this facility at 6:38 PM. [Patient #1’s name] was admitted. [Patient #1’s name] did not have a medical screening exam and was not put on the log in the ED when she first arrived [04/14/2024 at 5:48 PM]. [Patient #1’s name] required surgery. The patient’s name should have been on the ED log, even if she does not give a name. It is then written on the log as a Jane Doe. The second time the patient presented to the ED via EMS, the patient’s name was on the ED log. In speaking with the daughter, I was told she had come to the ED earlier and someone came out to the car and basically told the daughter to go home and call 911. The greeter at the desk places the name and chief complaint into the central log for all patients presenting to the ED. I was notified of the event on 04/14/2024 at 6:15 PM by [Clinical Nurse Coordinator’s name]. I immediately notified the AOC [Administrator on Call]. Review of the “Roles and Responsibilities for the GREETER, Just In Time Training. Every Patient, Every Time” read, “Responsibilities: Greet each patient kindly. Utilize Kiosk and/or timestamp when indicated. Utilize key pad to input SS# [Social Security number] for patient privacy. Always confirm patient identity with 2 patient identifiers. Any stroke like symptoms call CNC prior to recepting [Sic.] patient. Communicate with triage RN for all chest pains. Insert chief complaint, heart rate and O2 [oxygen] in the chief complaint box. Re-vitalize patients q2 [every 2] hours. Review of the policy and procedure titled “Policy Name: LL.EM.001.05 Florida EMTALA - Central Log Policy” with a revision date of 06/2024 read, “Purpose: To establish guidelines for tracking the care provided to each individual seeking care in a dedicated emergency department (“DED”) for a medical condition or seeking care in areas on hospital property other than a DED for an emergency medical condition (“EMC”) as required of any hospital with an emergency department by EMTALA, 42 U.S.C. §1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder, as well as section 395.1041, Florida Statues, and all related administrative rules. The hospital will maintain a Central Log containing information on each individual who requests emergency services or care or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination (“MSE”) could be performed, whether he or she refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. The Central Log includes the patient logs from the traditional ED and, either by direct or indirect reference, patient logs from any other areas of the hospital that may be considered DEDs or where an individual may present for emergency services or receive an MSE, such as Labor and Delivery. 1. All hospitals must maintain the Central Log in an electronic format. An electronic template that includes all federal requirements for EMTALA is available on Meditech for each market or division to customize. 2. All ancillary logs maintained by all hospital departments, including the DEDs, labor & delivery, behavioral health, pediatric EDs, and catheterization labs, are incorporated by reference and become part of the facility’s EMTALA Central Log. 3. The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core of information. The logs must contain at a minimum, the name of the individual and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged, or expired. 4. A log entry for all individuals who have come to the hospital seeking medical attention or who appear to need medical attention must be made by the appropriate individual.” The facility failed to ensure that their policy and procedure was followed as evidenced by failing to maintain a Central Log on Patient #1, when a request was made by a prudent layperson (family member) believed patient #1 needed examination and treatment on 4/14/2024.”

“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: 29257 Based on interviews, medical record reviews, video footage review, Fire Rescue Pre Hospital Care Report, Personnel Record review, and Policy and Procedure review, the facility failed to ensure that when an individual comes to the emergency department is provided an appropriate medical screening examination within the capability of the hospital’s emergency department including ancillary services routinely services available to the emergency department to determine whether or not emergency medical condition exists for 1 (#1) of 22 sampled patients. Patient #1 presented to the hospital’s property seeking medical assistance for an evaluation status post a fall and complaining of hip pain. A family member acting on her behalf requested hospital staff assistance to get the patient out of the vehicle, and was informed by hospital staff to take the patient home and call 911 and have EMS bring her back to HCA Florida Oak Hill Hospital for evaluation and treatment for a medical condition. Findings include: Review of the emergency department (ED) video footage dated 04/14/2024 beginning at 5:48 PM showed Patient #1 was a passenger of a privately owned vehicle that arrived to the emergency room entrance and parked in the roundabout at the entrance of the emergency room. The driver of the vehicle (later identified as Patient #1’s daughter) approached the Greeter (Staff A), and they were involved in a discussion. (The video did not provide audio). Staff A, who was sitting in a chair, got up, placed gloves on both hands, and walked out of the emergency room to where the car was parked, pushing a wheelchair. Staff A, Patient #1, and the driver were involved in a discussion. At 5:52 PM, the driver of the vehicle shut the doors to the vehicle and drove away with the patient in the vehicle. Staff A returned to the Greeter desk. Review of the “[Name of County] Fire Rescue Pre-Hospital Care Report” documented on Page 6 under the Narrative section, “Narrative: SUBJECTIVE: Called for a reported Fall [Patient #1’s home address]. On arrival, found 80 year Female patient weighting 59 KG [kilograms]. Chief complaint of Hip pain secondary to a fall. Events surrounding incident: Rescue 2 arrived on scene and found the patient sitting in the passenger seat of the car in the driveway. It was stated that the patient fell at a local restaurant and attempted to go to Oak Hill Hospital and was turned away by staff because they had no one to assist the patient out of the vehicle.” The medical record for patient #1 was rviewed when the patient returned to the hospital via EMS. The medical record revaled in the section titlted “Free Text HP”I (History of Present Illness) Notes dated 04/14/24 at 1902 [7:02 PM] read, “80/F presents to OHH ED [Oak Hill Hospital Emergency Department] with right hip pain after a ground level fall. Patient was leaving a [name of restaurant] when she tripped over a wheelstop in the parking lot. Patient states that she drove to the hospital was unable to get out of her car and nobody with his sister {sic} so she drove home and then called EMS [Emergency Medical Services]. EMS found her severe pain {sic} with her right hip externally rotated. They gave her 100 mcg [micrograms] fentanyl. She is unable to bear weight move her leg in any meaningful way, she does however remain neurovascular intact distal to the injury. General: Initial Greet Date/Time: 04/14/24 1835 [6:35 PM]. ED course: Patient present to the ED with externally rotated right hip and pain after a ground level fall in a parking lot. X-ray of the right hip shows a fracture. Patient’s orthopedic surgeon office was contacted, who states that patient will have to undergo repair. Patient was given morphine and Dilaudid for pain control.” Review of Patient #1’s “Radiology of hip” dated 04/14/2024 at 7:32 PM read, “Impression: 1. Fracture of the right femoral neck.” Review of the History of Present Illness dated 04/15/2024 at 0639 (6:39 AM) read, Reason for consult: Orthopedic evaluation and treatment of right femoral neck fracture. Chief complaint: Right hip pain. HPI: The patient is an 80-year-old female presents to the hospital yesterday after having a ground fall. The patient reports that she was coming out across his {sic} and tripped on 1 of parking lot curb stops landing down onto her right hip. Patient had a tremendous amount of pain was taken to Oak Hill Hospital Emergency room where x-rays demonstrated the patient have {sic} a displaced right femoral neck fracture. Diagnosis, Assessment, & Plan: The patient is an 80-year-old female status post ground level fall resulting in a displaced right femoral neck fracture. This will require surgery to the right hip hemiarthroplasty (Total Hip Replacement). Placed on the surgical schedule for tomorrow. Review of the Operative Report dated 04/15/2024 (no time documented) read, “Diagnosis: Displaced right femoral neck fracture. Procedure: Right hemi hip arthroplasty. During an interview on 05/29/2024 at 12:45 PM, the Director of the ED stated, “On 04/14/2024 at approximately 5:48 PM, [Patient #1’s name] presented to this facility. The patient sustained a ground fall at a nearby restaurant. The patient was accompanied by her daughter. The patient’s daughter had parked her private car adjacent to the entrance of the facility’s ED and requested assistance getting [Patient #1’s name] out of the car. A clinical staff member, who was identified as an Emergency Medical Technician (EMT), went outside, and instructed the patient to go to her residence and call 911 from her residence, so she could be moved from her vehicle. [Patient #1’s name] and her daughter left the facility and went home and then called 911, who brought her back to this facility at 6:38 PM. [Patient #1’s name] was admitted. [Patient #1’s name] did not have a medical screening exam when she first arrived [04/14/2024 at 4:48 PM]. In speaking with the daughter, I was told she had come to the ED earlier and someone came out to the car and basically told the daughter to go home and call 911. I was notified of the event on 04/14/2024 at 6:15 PM by [Clinical Nurse Coordinator’s name]. I immediately notified the AOC [Administrator on Call] of the event after hanging up with [Clinical Nurse Coordinator’s name]. My recollection of the conversation with the CNC [Clinical Nurse Coordinator] the employee was relieved for lunch at 5:58 PM, at that time he went to the CNC to inform him that he asked a patient to go home and call 911. Just In Time training is when something occurs in the department that needs transparency and therefore an investigation will be conducted with complete follow up that includes information on how to prevent that incident to occur in the future. This was done and included education and scenarios. A mock code for EMTALA/drill [Emergency Medical Treatment and Labor Act] was conducted unannounced on 04/25/2024 at 12:15 PM. Huddles were done and the charge nurse discussed the scenarios and reviewed the binder, education and received signatures that they [the ED staff] were educated. Four scenarios were presented to the staff for discussion as to what they would do. Managers or charge RNs [Registered Nurses] facilitated the scenario discussions and awaited responses from staff.” A request was made for the training provided related to the event that occurred on 04/14/2025 at 5:48 PM and the content of the training. Review of the personnel record for Staff A documented the staff member was hired as a paramedic on 03/11/2019. Staff A no longer works for the facility as of 04/19/2024. Multiple interviews were attempted on 05/29/2024 and 05/30/2024 via telephone with Staff, A, Paramedic. Staff A did not return the calls. Review of the policy and procedure titled “EMTALA-Medical Screening Examination and Stabilization Policy” with a revision date of 06/2023 read, “Purpose: To establish guidelines for providing appropriate medical screening examinations (“MSE”) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA, 42 U.S.C. §1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder, as well as section 395.1041, Florida Statutes, and all related administrative rules. Policy: An EMTALA obligation is triggered when: 1. An individual or a representative acting on the individual’s behalf, including EMS or a transferring hospital, requests emergency services and care; or 2. 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. Procedure: When an MSE 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, to determine whether or not an EMC exists: ... (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 individual’s appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC... An MSE is required when: a. A request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition... The individual arrives on the hospital property, either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment. Extent of the MSE - a. Determine if an EMC exists. The hospital must perform an MSE to determine if an EMC exists... or not. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to provide an appropriate medical screening examination that was within the capability of the hospital emergency department for patient #1’s initial visit to the ED on 4/14/2024 at 5:48 p.m., when she presented to the hospital’s property complaining of hip pain after a fall.”