CMS-HCA-Florida-JFK-Hospital

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Based on record review, video surveillance review, policy review and interview, it was determined, the facility failed to ensure the central log included all individuals who presented to the Emergency Department (ED) seeking treatment. This failure affected 1 of 21 sample patients (Patient #21).

The findings included:

Facility policy titled EMTALA Central Log last reviewed on April 2021 documents This policy reflects guidance under the Emergency Medical Treatment and Labor Act (EMTALA) and associated state laws only. It does not reflect any requirements of the Joint Commission or other regulatory entities. Each facility should ensure it has policies and procedures to address such additional requirements. No facility may edit this policy in a manner that would remove existing language in order to indicate additional facility procedures or requirements necessary to carry out the provisions of the policy within the facility.

Policy: 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 needs examination or treatment, whether he or she left before a medical screening examination could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred admitted or 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 dedicated emergency department's or where an individual may present for emergency services or receive a medical screening exam, such as labor and delivery.

Procedure:

All hospitals must maintain the Central Log in an electronic format. An electronic template that includes all federal requirements for EMTALA is available on Medictech for each market or division to customize.

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 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.

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. Further.

The Central Log of individuals who have come to the hospital seeking medical attention or who appear to need medical attention will be available within a reasonable amount of time for surveyor review and must be retained for a minimum of five years from the disposition of the individual.

Review of the surveillance video conducted on 05/17/21 at 3:48 PM while accompanied by the Director of the ED and The Director of Patient Safety revealed on 05/02/21 at approximately 6:07 PM, a police officer enters the facility with a patient (Patient #21) thru the ambulance entrance. The video shows the officer and Patient #21 going to the nurses' station and talking to the staff with paperwork on hand. Then the officer is seen escorting the patient to a sitting area in the hallway. The officer and patient remained in the area until approximately 6:43 PM, then the officer and patient are seen going back to the nurses' station and talking to a nurse. At approximately 6:57 PM, the officer is seeing grabbing the paperwork from the desk and leaving the facility with Patient #21.

Review of the facility Emergency Department Central Logs dated 05/02/21 revealed the facility failed to maintain a record of every patient presenting to the emergency department, there is no record of Patient #21.

Phone interview with Staff A, a Registered Nurse, conducted on 05/18/21 at 9:38 AM revealed her recollection of the events on 05/02/21. Staff A recalls the police officer brought in Patient #21, they were very busy, there was no room to place the patient at the time and the officer did not want to wait. Staff A stated they did not turn anyone away, she did explain to the officer they were on diversion, the officer was not aware of that, and they were trying to make room while maintaining patient safety.

Interview with Staff C, a Registered Nurse, conducted on 05/18/21 at 10:21 AM revealed on 05/02/21, she was working as the charge nurse. Staff C recalls a police officer bringing in Patient #21. The charge nurse asked the officer if the patient was violent and he replied yes, she glanced at the paperwork, gave the paperwork back to the officer and advised the officer to wait in the designated area. This day was extremely busy, there was no room for this patient and repeatedly asked the officer to wait until they made room. The patient was not safe out of handcuffs, and she could not take the patient until there was a room available. Staff C stated the officer was uncooperative, and later heard he had removed the handcuffs. During this time, another patient was dropped off, an overdose, this patient was unresponsive, and her efforts were to assist with this situation. When that was taken care of, the officer and the patient were gone.

Staff C elaborated that at one point the officer uncuffed the patient, and the officer was told that he needed to hold on to this patient, and that he needed to wait. The officer came back to the desk and dropped off the paperwork. Staff C kept telling him that he needed to hold on to the paperwork until they make room for the patient. Staff C was not aware when the officer left with Patient #21 and reiterated, she did not refuse the patient, they just asked the officer to wait until they could safely accommodate the patient.

Staff C was then asked at what point she registers the patient in the system and explained that she did not accept Patient #21, the patient is logged in the ED registry when is safe, after the handoff between the police and the hospital.

Interview with the ED Director conducted on 05/18/21 at 10:35 AM revealed the scheduled charge nurse called off and Staff C was put on that position by default. This is her first shift as the charge nurse and it is the charge nurse responsibility to ensure all patients coming into the ED with police are registered in the central log.

Violation Name: MEDICAL SCREENING EXAM(A-2406)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, Video surveillance review, Central log 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 existed for 1 (#21) of 21 sampled patients.

The findings included:

Facility policy titled Emtala-Medical Screening Examination and Stabilization Policy last reviewed 04/21 documents An EMTALA obligation is triggered when an individual comes to a dedicated emergency department and the individual or a representative acting on the individual behalf requests an examination or treatment for a medical condition.... A hospital must provide an appropriate medical screening exam within the capabilities of the hospital emergency department, including ancillary services routinely available to determine whether or not an emergency medical condition exist; to any individual who request such examination, an individual who has such a request made on his or her behalf... an medical screening exam shall be provided to determine whether or not the individual is experiencing an emergency medical condition.

Review of the surveillance video conducted on 05/17/21 at 3:48 PM while accompanied by the Director of the ED (Emergency Department) and the Director of Patient Safety revealed on 05/02/21 at approximately 6:07 PM, a police officer enters the facility with a patient (Patient #21) through the ambulance entrance. The video shows the officer and Patient #21 going to the nurses' station and talking to the staff with paperwork on hand. Then the officer is seen escorting the patient to a sitting area in the hallway. The officer and patient remained in the area until approximately 6:43 PM, then the officer and patient are seen going back to the nurses' station and talking to a nurse. At approximately 6:57 PM, the officer is seeing grabbing the paperwork from the desk and leaving the facility with Patient #21.

Review of the facility emergency department central logs and electronic medical records conducted on 05/17/21 revealed the facility failed to perform a medical screening exam for patient #21 on 5/2/2021, arriving to the facility with the police officer.

The Certificate of Professional Initiating Examination dated 5/2/2021 (4:54 p.m.) for patient #21 was reviewed. The document revealed a social worker from Hospital B filled out the form indicating patient #21's Diagnosis of Mental Illness : Opioid use disorder. Further documentation revealed because of the Mental Illness, b. Individual is unable to determine for himself/herself whether examination is necessary AND . . .b. There is substantial likelihood that without care or treatment the individual will cause serious bodily harm to ...self and others or the near future, as evidenced by recent behavior....Section II Supporting evidence... Pt. is reporting that he is suicidal -wants to leave treatment. Reports he does not care if he overdoses and dies. He states he wants to harm himself now. The Medical Record from Hospital B where Patient #21 was taken by the Police Officer was reviewed. Hospital B's medical record revealed that patient #21 (MDS) dated [DATE] at 7:17 PM, and received an appropriate medical screening examination . Patient #21 was appropriately transferred to an in-patient psychiatric facility on 5/2/2021 to receive psychiatric care and treatment.

Phone interview with Staff A, a Registered Nurse, conducted on 05/18/21 at 9:38 AM, revealed her recollection of the events on 05/02/21. Staff A recalls the police officer brought in Patient #21, they were very busy, there was no room to place the patient at the time and the officer did not want to wait. Staff A stated they did not turn anyone away, she did explain to the officer they were on diversion, the officer was not aware of that, and they were trying to make room while maintaining patient safety.

During this time, another patient was dropped off, an overdose, this patient was unresponsive, and her efforts were to assist with this situation. When that was taken care of, the officer and the patient were gone.

Staff C was then asked at what point she registers the patient in the system and explained that she did not accept Patient #21, the patient is logged in the ED registry when it is safe, after the handout between the police and the hospital.

Interview with the ED Director conducted on 05/18/21 at 10:35 AM revealed the scheduled charge nurse 'called off' and Staff C was put on that position by default. This is her first shift as the charge nurse and is the charge nurse responsibility to ensure all patients coming into the ED with police are registered in the central log and will subsequently receive a medical screening exam. The facility failed to ensure that there Policy was followed as evidenced by failing to provide an appropriate medical screening examination was provided for Patient #21 on May 2, 2021 as stated in their EMTALA policy

Violation Name: DISCHARGE PLANNING EVALUATION(A-0808)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the hospital failed to have an appropriate discharge plan in the patient's medical record, including the need for the patient to be discharged to a locked Assisted Living Facility, and these results of the evaluation were not discussed, in detail, with the patient's representative in 1 of 3 records reviewed (#2).

The findings Included:

Review of the Policy & Procedure for Patient Transportation to Facilitate a Safe Discharge, Extended Care Facility Transfer, and Discharge Planning revealed there is no Policy and Procedure regarding discharging patients to Boarding or Group Homes.

During the interview with the Director of Case Management, on 01/28/2020 at 1:53 PM, she agreed the hospital does not have a Policy & Procedure regarding discharging patients to boarding/group homes. She did confirm they do discharge patients to boarding/group homes.

During the interview with the Discharge Planner, on 01/28/2020 at 2:28 PM, she agreed that she discharges patients to boarding/group homes.

On 01/28/20 at 5:30 PM, the Vice President of Quality, stated the Policy & Procedure stops at Assisted Living Facilities because they do not discharge patients to Boarding or Group Homes.

Review of Patient #2's medical record, along with the Senior Risk Manager A, revealed, a [AGE] year old patient, arrived at the Emergency Department, via Emergency Medical Services, on 08/09/2019 at 05:58 AM. The chief complaint was altered mental status and possible Cerebrovascular Accident (CVA). The patient was admitted on the neuro unit and later transferred to a medical/surgical floor. His discharge diagnosis included acute bilateral frontal infarcts, toxic metabolic [DIAGNOSES REDACTED], alcohol abuse and acute embolic cerebrovascular accident (CVA).

During an interview with the Discharge Planner, on 01/28/2020 at 2:28 PM, she stated the patient was lethargic and when he woke up, he would say his is going home and tried to leave the hospital. Review of the record revealed the patient was then placed on a medical unit that has a psychiatric component. The nursing note revealed, a Code BERT was called, the patient was confused and trying to leave the hospital. He was not able to be re-directed.

During an interview with the Discharge Planner, on 01/28/2020 at 2:28 PM, she stated that on 11/12/19, she called the Placement Counselor and asked her to find a locked boarding home.

During the interview with the Discharge Planner, on 01/28/2020 at 2:28 PM, she stated that on 11/12/19, she called the patient's relatives and let them know that a Placement Counselor would be taking the patient to a facility in Miami. She stated the patient's family knew about the difficulty she had in placing the patient into a locked facility. She stated that she was not able to locate a locked Assisted Living Facility that would accept this patient. She further stated this is why she decided to start looking for a locked boarding home. She stated her call to the patient's relatives was sufficient notification of the patient's discharge to the family.

The Discharge Planner stated that in order to pay the facility, the Placement Counselor needed to have access to the patient's funds. The Discharge Planner told the Placement Counselor to call the patient's relatives and get the patient's ID and bank information.

The Discharge Planner notes revealed that the relative sent this information via Federal Express on 11/16/19.

On 01/28/2020, the Discharge Planner stated that the relatives knew about the Placement Counselor and her company. The Discharge Planner was reviewing her notes in the medical record and the texts that she stated both she and the Placement Counselor exchanged regularly. She stated that the Placement Counselor called her and said that she had received the patient's personal information and would be picking the patient up.

On 11/14/19, the physician wrote a discharge order to discharge the patient, to a locked Assisted Living Facility in Miami.

On 11/17/19, the physician noted the patient is medically stable for discharge to a locked Assisted Living Facility with the Placement Counselor's company.

Review of the discharge paperwork revealed the patient was unable to sign on 11/15/19 & 11/18/19, and the Placement Counselor signed as Guardian, on 11/15/19, and received the Discharge Paperwork, including discharge instructions.

During the interview with the Discharge Planner, she stated, on 11/18/19, that she had the patient discharged with the Placement Counselor, along with the patient's discharge paperwork, to what she thought was a locked group home.

Review of the patient's Discharge Papers, revealed an address where the patient was placed. Review of this address failed to reveal this place is licensed, locked, or an assisted living facility.

On 01/28/2020 at 2:28 PM, the Discharge Planner stated that she allowed the Placement Counselor to make all the arrangements for this patient's transfer to a Group Home and to take the patient from the hospital, along with the discharge instructions. She confirmed the physician had ordered the patient to be discharged to a locked Assisted Living Facility. She stated she could not locate a locked Assisted Living Facility that would accept the patient and had to resort to a group home. She admitted that she knew that the home, where the patient was admitted , was not an Assisted Living Facility, and she did not verify if the Group Home was licensed, whether the home was locked, the services they could provide, or make any attempt to contact the Group Home to determine if the home was safe for the patient. She stated that she should have Googled these homes but she didn't.

During a phone interview with the patient's sister, on 01/28/20 at 12:32 PM, she stated the Placement Counselor took the patient to the bank and tried to withdraw $3000 out of the patient's account for payment to the group home.

The patient's sister stated that the Placement Counselor called the patient's brother, in Illinois, who refused to have the bank release $3000. The Placement Counselor told the patient's brother that she would go to another bank.

The patient's sister stated the Discharge Planner gave her two addresses where the patient might be placed and a person's first name and phone number. Review of these addresses failed to reveal these places are licensed, locked, assisted living facilities or group homes.

Review of the patient's Discharge Papers, revealed a third address (group home) where the patient was placed. Review of this address failed to reveal this place is licensed, locked, or an assisted living facility or group homes.

During the interview with the patient's relative, she stated, on 11/18/19, she called the phone number the Discharge Planner had given her as the place where the Placement Counselor had taken the patient. She stated that she spoke with a person who told her the patient was at her other place. The relative further stated that, on 12/06/19, the person who was supposedly housing the patient called the family and stated that the patient had slipped out a window and she called the police, who found him, and took him to the hospital. The patient's relative confirmed he was admitted to a local hospital and stated on 12/15/19, the family found a place for the patient out of state and came down to get the patient from the hospital.

Violation Name: COMPLIANCE WITH 489.24(A-2400)

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Violation Name: EMERGENCY ROOM LOG(A-2405)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record reviews, policy review, Kiosk Registration, Central Emergency Department Log, video surveillance, and interviews it was determined, the facility failed to ensure that a central log was maintained on each individual who comes to the Emergency Department (ED) seeking treatment/assistance. This failure affected 1 of 20 sampled ED patients (Patient #1).

The findings included:

Facility policy Titled EMTALA-Central Log dated 06/2018 documents The hospital shall 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 could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged .

Review of the Central ED Logs conducted on 04/08/19 revealed no evidence Patient #1 (MDS) dated [DATE] seeking emergency care.

Review of the report originated from the registration kiosk dated 01/03/19 revealed Patient #1 presented at the facility at 9:14 PM and the entry was deleted as abandoned.

Review of the facility surveillance video on 04/09/19 at 11:45 AM revealed evidence Patient #1 (MDS) dated [DATE] at approximately 9:15 PM and inputted her information at the registration kiosk. The video shows the patient (#1) going to the restroom, the charge nurse and security guard had a conversation, and the nurse was nodding her head left to right, indicating a no motion. Upon patient return to the ED lobby, the guard had a conversation with the patient and escorted the patient out of the facility.

A phone interview with the Security Guard conducted on 04/09/19 at 5:40 PM revealed he was on duty on 01/03/19. The guard recalled the events related to Patient #1's departure from the ED and explained the patient presented with complaints of pain. He spoke to the charge nurse to advise of the patient's condition, to inquire if they could take her in the back sooner. The Charge nurse advised him that they will not be seeing the patient, she was in the ED the day before or two days ago, cannot recall exactly and there is nothing else they can do for her. The charge nurse told the guard to relay to the patient that if she comes back again the police will be called. When the patient returned from the restroom, the guard explained to Patient #1 what the charge nurse said and escorted her out of the department.

Interview with The Director of the ED conducted on 04/08/19 at 9:40 AM revealed Patient #1 completed a negative review in Google and the marketing representative forwarded the details for further review. The Director explained the patient alleged when she came into the ED the charge nurse send her away and two days later, the patient ended up at another hospital. The Director contacted Patient #1 and the patient explained she was in rehab at the time, staying in an assisted living facility and came to the hospital for pain. The security guard, after speaking to the charge nurse, told her that she comes here too much and that she was just here two days prior and had a prescription for Tramadol (pain medicine) and she should get it filled. The security guard escorted her out of the ED and she sat on the bench outside crying for an hour. The Director stated the facility initiated a full investigation and confirmed Patient #1 was turned away. The facility self-reported the incident and the ED staff has received education related to EMTALA rules and regulations. As part of the corrective action, the facility is auditing the self registration kiosk data starting March 2019. If the reports show a patient was deleted, the director is looking for the reason. The security guards have been instructed to document every patient that leaves the department without being seen. The guards complete a form with the description of the patient and the reason for leaving. The Director explained the facility also reviews the security films to ensure compliance.

The facility failed to ensure that their policy and procedure as evidenced by failing to enter patient #1 in the facility's Central log on 1/3/2019, when she presented seeking medical assistance.

Violation Name: MEDICAL SCREENING EXAM(A-2406)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record reviews, facility surveillance video, Registration Kiosk, and interview, 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 an emergency medical condition existed for 1 of 20 sampled patients (Patient #1).

The findings included:

Facility policy titled EMTALA-Medical Screening Exam and Stabilization Policy dated 06/17 documents An EMTALA obligation is triggered when an individual comes to a dedicated emergency department and the individual or a representative acting on the individual behalf requests an examination or treatment for a medical condition.... A hospital must provide an appropriate medical screening exam within the capabilities of the hospital emergency department, including ancillary services routinely available to determine whether or not an emergency medical condition exists; to any individual who requests such examination, an individual who has such a request made on his or her behalf... an medical screening exam shall be provided to determine whether or not the individual is experiencing an emergency medical condition.

Review of the report originated from the registration kiosk dated 01/03/19 revealed Patient #1 presented at the facility at 9:14 PM and the entry was deleted as abandoned.

Review of the facility surveillance video on 04/09/19 at 11:45 PM revealed evidence Patient #1 (MDS) dated [DATE] at approximately 9:15 PM and inputted her information at the registration kiosk. The video shows the patient going to the restroom, the charge nurse and security guard had a conversation, and the nurse was nodding her head left to right, indicating a no motion. Upon patient return to the ED lobby, the guard had a conversation with the patient and escorted the patient out of the facility.

A review of the clinical records from Facility B revealed that Patient #1 presented to that facility on 01/10/2019 with complaints of generalized pain. Patient #1 was consequently admitted to Facility B with a diagnosis of urinary tract infection.

A phone interview with the Security Guard conducted on 04/09/19 at 5:40 PM revealed he was on duty on 01/03/19. The guard recalled the events related to Patient #1 departure from the ED and explained the patient presented with complaints of pain. He then spoke to the charge nurse to advise of the patient's condition, to inquire if could take her in the back sooner. The Charge nurse advised him that they will not be seeing the patient, she was in the ED the day before or two days ago, cannot recall exactly and there is nothing else they can do for her. The charge nurse told the guard to relay to the patient that if she comes back again the police will be called. When the patient returned from the restroom, the guard explained to Patient #1 what the charge nurse said and escorted her out of the department.

There is no evidence the facility provided Patient #1, within the capabilities of the staff and facilities available at the hospital, an appropriate medical screening examination to determine whether or not an emergency medical condition existed on 01/03/2019.

with a medical examination and treatment, as required to stabilize the medical condition.

The facility initiated a full investigation, interview with security guard revealed he indeed recalled the patient. Patient #1 had many paraphernalia with her and he did tell her she had to leave the facility based on the charge nurse instructions. The Director ran a search for the patient's name and found her account had been deleted. This action prompted the audits and changes to limit the access to this data to the charge nurses and if any discrepancies, they are verified by the director or the manager. The Director interviewed the charge nurse who denied the events. The facility then pulled the security films and confirmed the patient was giving the correct account of events. The facility self-reported the incident and the ED staff has received education related to EMTALA rules and regulations. The Director stated she feels this particular charge nurse was the problem, she was not very nice and other staff had made comments she did not like the homeless population. The nurse was suspended pending the outcome of the investigation and she resigned two days after her suspension. The facility has reported her actions to the Board of Nursing. As part of the corrective action the facility is auditing the self registration kiosk data starting March 2019. If the reports show a patient was deleted, the director is looking for the reason. The security guards have been instructed to document every patient that leaves the department without being seen. The guards complete a form with description of the patient and the reason for leaving. The Director explained the facility also reviews the security films to ensure compliance.

Interview conducted with The Ethics and Compliance Officer (ECO) on 04/09/19 at 9:17 AM revealed Patient #1's complaint came thru the facility website. The officer was reading the reviews and notice the patient allegation dated 01/22/19 and a generic response provided by the marketing department. She reached out to director of marketing and inquired regarding the status. The director of marketing explained anytime she sees a negative review, she will forward the concern to the corresponding director. In this case, she had just sent the information to the director of the ED. Then, she approached the director of the ED and was told the patient was contacted and was waiting for a call back. The Officer presented email communication with the director of marketing and the director of the ED on 01/23/19.

Later that day, the Director of the ED spoke to Patient #1 and reported to her, the incident could probably be a violation. The patient described the security guard and nurse and gave details such as date of service and time of the event. The facility initiated an internal investigation, reported the concern to the corporate office and the director interviewed the staff. The nurse involved was placed on investigated suspension pending the outcome. A few days later, the nurse gave her resignation. The review the security footage, revealed the nurse body language was very noticeable, she was instructing the security guard something and waving her fingers in a no motion. Due to this incident, it was determined the ED staff needed a refresher on EMTALA and the entire security staff should know their role and EMTALA laws. The Officer reached out to the division ECO and found appropriate material for their training, two classes in Healthstream (educational program), one is EMTALA for administrators on call and a good option for a live session and other courses related to EMTALA definitions and requirements. The facility has held numerous live classes to accommodate all shifts. As a result, the facility has changed some of the practices, if anything clinical needs to be communicated to a patient, the security guard will not be giving the information, a nurse needs to deliver clinical information. If a patient in the ED waiting room has clinical questions, the security staff has to get at least a registered nurse, not a paramedic or a clerk to address the concerns. In addition, the director is auditing the kiosk data and any changes made. The Officer continues to make random rounds and communicating with staff and patients.

Interview with The Medical Director, Emergency Department, conducted on 04/09/19 at 12:07 PM revealed the event related to Patient #1 had no provider involvement, the charge nurse made the decision to turn away the patient. The facility has implemented EMTALA education to providers to remain proactive and continue their due diligence. All patients are to be evaluated and treated to ensure they are medically stable. The facility will continue to monitor and self-report any further incidents.

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 2 of 5 sampled patients (Patient #6 and #7) as evidenced by failure to reassess patients after disruptive behaviors requiring medication administration and failure to implement additional measures to minimize physical altercations between patients.

The findings included:

Facility policy Assessment and Reassessment of the Patient last reviewed 02/18 documents Reassessment: Each patient is re-assessed according to discipline specific guidelines. For all patients re-assessment is at specified, regular intervals related to: Patient response to treatment/procedures including medication administration.

Clinical record review conducted on 02/27/19 revealed Patient #7 was admitted to the facility on [DATE]. Physician's admission orders dated 12/05/18 included Assault and Suicide precautions. Other precautions noted unpredictable behavior and monitor every fifteen minutes.

Nurses Notes dated 12/07/18 at 2:17 PM documents Patient #7 was in an altercation with peer (Patient #6). Staff intervened and separated the patients. No injuries or bruising noted on either patient. Department of Children and Families notified per protocol.

Review of document titled Special Observation Record/15 Minute Patient Monitoring dated 12/07/18 failed to document behaviors, it noted patient sitting in milieu. The instructions on the form noted This form is used for documentation of every 15 minutes checks. Document the patient location and behavior codes with your initials every 15 minutes.

The record indicates an Emergency Treatment/Medication Order for Geodon and Vistaril was obtained on 12/07/18. The drugs were administered to the patient at 4:34 PM. The record does not document the behaviors leading to the event or interventions implemented prior to placing the patient in the quiet room or prior to receiving the drugs.

Review of the Special Observation Record/15 Minute Patient Monitoring form and Nurses Notes dated 12/07/18 failed to provide evidence of a nursing reassessment after the medication was administered.

Nurses Notes dated 12/08/18 at 3:45 PM documents Patient #7 was yelling and cursing, and knocking over chairs and tables. Unable to be redirected. Vistaril and Geodon given. Will continue to monitor.

The record indicates an Emergency Treatment/Medication Order for Geodon and Vistaril was obtained on 12/08/18. The drugs were administered to the patient at 3:38 PM.

Review of the Special Observation Record/15 Minute Patient Monitoring form dated 12/08/18 failed to provide evidence of a nursing reassessment after the medication was administered.

Nurses Notes dated 12/08/18 failed to provide evidence of a nursing reassessment after the medication was administered.

Approximately, an hour later at 4:38 PM, the nurse documents Patient #7 was again involved in a physical altercation with another peer (Patient #6) in the unit. No injury received. Patient states my head was graced. Father was informed and call placed to DCF.

Special Observation Record/15 Minute Patient Monitoring form dated 12/08/18 documents the patient was in the milieu from 2:30 PM thru 4:15 PM and in his room reading from 4:30 PM through 5:45 PM. The patient monitoring form failed to document the patient's behavior.

Interview with Staff A, a Mental Health Technician, conducted on 02/27/19 at 3:19 PM revealed he recalls Patient #6 and #7. Patient #7 was angry and Patient #6 was the instigator. They were bickering all day; they sat by each other and that afternoon one of the boys was swinging from the desks. The other patient got angry and claimed he hit his hand and after that, they got into it. Staff A recalls he was standing by the door and separated the boys, the patients just did not mix well. He reported the incident and told the incoming shift. Staff A did not work in the adolescent unit the next day so he was not aware of the second altercation but explained the area is limited and is hard to separate the youth, as the common area is small. We try to separate the adolescent from the pewees and there is not much room left. Staff A explained assault precautions means to keep a close eye for behaviors or any signs of escalation leading to violence.

Interview with The Quality Coordinator, who navigated the electronic record, conducted on 02/28/19 at 11:13 AM confirmed the clinical record has no evidence of patient reassessment after the emergency medication administration on 12/07/18 and 12/08/18. There is no evidence of identified behaviors and interventions prior to administering psychotropic drug on 12/07/18 and there is no evidence the facility implemented additional measures to reduce the risk of further altercations between patient #6 and #7.

Violation Name: NURSING CARE PLAN(A-0396)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure nursing care plans provided to each patient is in accordance with established Standards of Practice of Nursing Care, Chapter 464.003(5). This failure affected 1 of 5 sampled patients (Patient #7) as evidenced by failure to revise plan of care after multiple physical altercations with peers.

The findings included:

Facility policy titled Standards of Care last reviewed 08/18 documents Standard of Care: Assessment

The priority of data collection activities is derived by the patient's immediate condition and anticipated needs.

Problem identification

Problems are prioritized in a manner that facilitates expected outcomes in the plan of care.

Outcome identification

Outcomes are derived from actual problems and mutually formulated with the patient and the health care team.

Planning

The plans developed collaboratively with the health careteam with each member contributing towards achieving expected outcomes and continuity of care

Implementation

Interventions are delivered in a manner that minimizes complications and life threatening situations.

Evaluation

Once initiated, interventions are evaluated by the healthcare team within an appropriate time frame.

Emergency Treatment/Medication Orders for Geodon and Vistaril were obtained and administered on 12/07/18 at 4:34 PM.

Emergency Treatment/Medication Orders for Geodon and Vistaril were obtained and administered on 12/08/18 at 3:38 PM.

Nurses Notes dated 12/08/18 at 3:45 PM documents Patient #7 was yelling and cursing, and knocking over chairs and tables. Unable to be redirected. Vistaril and Geodon given. Patient tolerated it well. Will continue to monitor.

Approximately, an hour later at 4:38 PM, the nurse documents Patient #7 was involved in a physical altercation with another peer (Patient #6) in the unit. No injury received. Patient states my head was graced. Father was informed and call placed to DCF.

Care Plan initiated for Patient #7 on 12/05/18 documents Problem #1 Mood, patient with irritability and mood swings. Patient throwing furniture at school. No other problems were identified. Further review of the clinical record failed to provide evidence the staff updated Patient #7's nursing care plan addressing the recent physical behaviors and altercations with peer.

Interview with The Quality Coordinator, who navigated the electronic record, conducted on 02/28/19 at 11:13 AM confirmed the clinical record has no evidence of care plan revision addressing the physical altercations with peers.

Violation Name: ORDERS FOR DRUGS AND BIOLOGICALS(A-0409)

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Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established Standards of Practice of Nursing Care, Chapter 464.003(5) for 2 of 2 sampled patients (Patient #8 and #9). This failure is evident by failure to assess and reassess patient's condition during and after completion of blood transfusions as specified in facility policy for Blood Product Administration.

The findings included:

Facility policy titled Blood Product Administration dated 07/18 documents To provide guidelines for the safe administration of blood products within the facility. Procedure for Monitoring and Documentation:

All patient areas will document vitals and any transfusion reactions at the following intervals.

Baseline vital signs (blood pressure, pulse, temperature, respirations and oxygen saturation) must be taken 30 minutes prior to beginning transfusion.

5 minutes after initiation of transfusion and as patient condition requires

15 minutes after initiation of transfusion

30 minutes after initiation of transfusion

1 hour after initiation of transfusion

Every hour thereafter until transfusion is complete

A final set of vital signs should be documented 30 minutes after end time.

1) Clinical record review conducted on 02/28/19 revealed Patient #8 was prescribed a blood transfusion, one unit of red blood cells on 02/19/19 due to low hemoglobin.

The record indicates the blood transfusion was initiated on 02/20/19 at 6:33 AM.

Interview with The Director of Patient Safety and The Quality Coordinator, who were navigating the electronic documentation, on 02/28/19 at approximately 12 noon confirmed there is no evidence the nursing staff completed a baseline assessment including temperature thirty minutes prior to the initiation of the blood transfusion. There is no evidence the nurse monitored the patient's temperature post transfusion as mandated by the facility policies and procedures.

2) Clinical record review conducted on 02/28/19 revealed Patient #9 was prescribed a blood transfusion, one unit of red blood cells on 02/24/19 due to low hemoglobin.

The record indicates the blood transfusion was initiated on 02/24/19 at 2:55 PM.

Review of the Nurses Notes, Nursing Shift Assessments and Assessment and Reassessment documentation and blood administration record failed to provide evidence of the patient baseline, a complete set of vital signs was obtained thirty minutes prior to the infusion. Furthermore, there is no evidence the patient's temperature was reassessed at the five minutes and thirty minutes intervals. Subsequently, there is no evidence the patient vital signs were monitored hourly and there is no evidence of a reassessment thirty minutes after the completion of the transfusion.

Interview with The Director of Patient Safety and The Quality Coordinator, who were navigating the electronic documentation, on 02/28/19 at approximately 12:18 PM confirmed there is no evidence the nursing staff monitored Patient # 9's vital signs as specified by the facility policies and procedures.

Violation Name: COMPLIANCE WITH 489.24(A-2400)

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Violation Name: EMERGENCY ROOM LOG(A-2405)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on video surveillance review, Kiosk data review, Emergency Department central log review, policy review and staff interviews, it was determined, the facility failed to ensure the central log included all individuals who presented to the emergency department seeking treatment. This failure affected 1 of 21 sample patients (Patient #6).

The findings included:

Review of the facility video surveillance conducted on 01/29/19 at 1:45 PM revealed Patient #6, a 22 month old, was brought into the emergency room lobby being carried by an adult on 01/21/19 at 2:57 AM. The adult had words with the security guard, who then went in the back area and returned with a staff member. The staff member briefly looked at Patient #6. The adult had words with the staff member, walked towards the registration kiosk and began typing on the screen while holding a conversation with the staff member. The video indicates at 2:59 AM, the adult and Patient #6 left the emergency room and the staff returned to the emergency room treatment area.

Review of the facility central logs conducted on 01/29/19 failed to provide evidence that Patient #6 was entered into the system when (MDS) dated [DATE] seeking medical care.

Interview with the Director of Emergency Services conducted on 1/30/2019 at 11:00 a.m., revealed that the facility has a Kiosk used for patient registration, they can either scan their driver's license or manually put in name, date of birth and reason for visit ...The kiosk is a separate computer system when the staff pulls a name from the kiosk to the electronic medical record, the patient is then registered in the Central Log. Only the Charge Nurse and the triage nurse are allowed to remove names from the kiosk registry.

Multiple attempts were made to contact the security guard on duty on 1/21/2019 were made throughout the complaint survey. Interview with the Director of Security on 1/30/2019 at 12:32 p.m., revealed that he was able to contact the security guard on duty on 1/21/2019, and he has no recollection of the events on 1/21/2019.

Review of the facility registration Kiosk data for 01/21/19 documents a registration entry was initiated at 2:58 AM, the entry was removed due to incomplete data, no name or information was available. This record does not indicate refusal of care.

Facility policy, titled EMTALA-Central Log, dated 06/2018 documents The hospital shall 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 could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged . The facility failed to ensure that their policy and procedure were followed as evidenced by failing to ensure that on 1/21/2019 Patient #6 was entered into the facility's ED log.

Violation Name: MEDICAL SCREENING EXAM(A-2406)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, video surveillance review, policy and procedure review, and staff interviews, it was determined, the facility failed to ensure that an appropriate medical screening examination was provided as required, 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 after a request was made on an individual's behalf for an examination and treatment for one (#6) of 21 sampled patients.

The findings included:

Review of the facility video surveillance conducted on 01/29/19 at 1:45 PM revealed Patient #6 was brought into the emergency room lobby being carried by an adult on 01/21/19 at 2:57 AM. The adult had words with the security guard, who then went in the back area and returned with a staff member. The staff member briefly looked at Patient #6. The adult had words with the staff member, walked towards the registration kiosk and began typing on the screen while holding a conversation with the staff member. The video indicates at 2:59 AM, the adult and Patient #6 left the emergency room and the staff member returned to the emergency room treatment area.

Review of the clinical records obtained from Facility B, an acute care facility, revealed Patient #6 presented to the facility's ED, with his parent, on 01/21/19 at 3:10 AM with complaints of fever and shaking. The medical record revealed the patient's Vital signs on presentation to the ED were listed as: Blood Pressure: 138/65; Temperature: 102.1 (HI-high) degrees (normal temperature children 97.9-99.0); Heart rate: 150; Respirations: 40; Pulse Oximetry: 97% on Room Air. The ED physician documented in the medical record that Patient #6's father had presented to JFK Medical Center, North Campus prior to arriving at Facility B for the same complaints of shaking and fever and was told to come to Facility B. The physical examination was conducted by the ED physician and laboratory tests for RSV-PCR (Respiratory Syncytial Virus- a very contagious viral respiratory infection) the results were negative; and Influenza A PCR & B PCR were not detected. The patient was diagnosed with Acute Upper Respiratory infection, and discharged on [DATE] at 3:00 PM.

Interview with The Sepsis Coordinator on 01/29/19 at 12:53 PM, who navigated the electronic record, confirmed there are no records pertaining to Patient #6, there is no evidence a medical screening exam was provided.

An interview with Staff A, a Paramedic, who was identified (in the video surveillance ) as the staff member talking to the adult holding Patient #6 was conducted on 01/29/19 at 2:24 PM via telephone. Staff A had no recollection of the event or neither what conversation transpired during this encounter. After further prompting, he stated as a general statement, if patients ask if we treat children, he replies they will treat and transfer to another hospital as they don't admit pediatric patients.

Interview with the Director of Emergency Services conducted on 1/30/2019 at 11:00 AM reveled the Director had no knowledge of the incident related to patient #6. The facility process is to register, triage and evaluate every patient that comes in the department, and is not sure of what happened, any conversation deviate from their process is unwarranted. The Director confirmed the emergency room staff is trained and qualified to treat the pediatric population.

Interview with the Medical Director of the Emergency Department on 1/30/2019 at 11:45 AM revealed the emergency department evaluates all kinds of patients from pediatric to geriatrics. The physicians and midlevel providers are credentialed and qualified to treat pediatric patients.

Facility policy titled, EMTALA-Medical Screening Exam and Stabilization Policy, dated 06/17 documents An EMTALA obligation is triggered when an individual comes to a dedicated emergency department and the individual or a representative acting on the individual behalf requests an examination or treatment for a medical condition.... A hospital must provide an appropriate medical screening exam within the capabilities of the hospital emergency department, including ancillary services routinely available to determine whether or not an emergency medical condition exists; to any individual who requests such examination, an individual who has such a request made on his or her behalf... a medical screening exam shall be provided to determine whether or not the individual is experiencing an emergency medical condition. The facility failed to ensure that their policy and procedure as followed as evidenced by based on clinical medical records reviewed, and interviews the facility failed to provide written evidence that a medical record was maintained related to patient #6. The facility also failed to provide written confirmation that a medical screening examination was provided for patient #6 on 1/21/2019, when a request was made on his behalf for an examination and treatment of a medical condition.

Violation Name: APPROPRIATE TRANSFER(A-2409)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, video surveillance review, Transfer logs and interviews, it was determined, the facility failed to substantiate the provision of emergency services for 1 of 21 sampled patients (Patient #6) as evidenced by lack of an appropriate transfer. The facility failed to provide medical treatment within its capacity to minimize the risks to the individual's health (prior to discharge), failed to contact the receiving facility to verify if it had available space and qualified personnel for the treatment of the individual; failed to obtain acceptance of the transfer and failed to ensure the transfer was effected through qualified personnel and transportation equipment, as required.

The findings included:

Review of the clinical records obtained from Facility B, an acute care facility, revealed Patient #6 (MDS) dated [DATE] at 3:10 AM with complaints of fever and shaking. The record documents Patient #6's father had presented to JFK Medical Center, North Campus prior to arriving at Facility B for the same complaints of shaking and fever and was told to come to Facility B.

Review of the facility's transfer logs provides no evidence Patient #6 was transferred to Facility B.

Interview with the Charge Nurse dated 1/29/2019 at 10:40 AM, explained the physician would initiate a transfer to another facility and all the arrangements are done by the transfer Center, and the Charge nurse assures all paper work is completed. The CEO explained the transfer center has the on line Manuel which includes geographical locations of receiving hospitals, list of services provided, list of transfer agreements and name and phone numbers of the contact person designated to arrange the transfer.

An interview with Staff A, a Paramedic, who was identified as the staff member talking to the adult holding Patient #6 in the video surveillance, was conducted on 01/29/19 at 2:24 PM via telephone. After further prompting, he stated as a general statement, if patients ask if we treat children, he replies they will treat and transfer to another hospital as they don't admit pediatric patients.

Interview with director of Transfer Center phone on 01/30/2019 at 9:41 AM revealed the emergency room staff calls the call center and is routed to a nurse. The staff collects minimal information including the service requested, then they ensure patient preference if any, research the availability of the sister facilities and is the service is not available, they will check the closest facilities providing that particular service. Once a facility has been identified, they work on patient's acceptance and facilitate physician to physician communication and notify the transferring facility to complete the memorandum of transfer with all the pertinent records.

An interview was conducted with the ED Director on 01/30/2019 at 11 AM, she confirmed that the emergency room staff are trained and qualified to treat the pediatric population, if a child needs admission, a transfer would be completed.

Facility policy titled, EMTALA-Transfer Policy, dated 06/2018 documents To establish guidelines for either accepting an appropriate transfer from another facility or providing an appropriate transfer to another facility of an individual with an emergency medical condition, who request or requires a transfer for further medical care and follow up to a receiving facility as required by EMTALA, 42 USC 1395dd and all federal regulations and Florida Statutes and all related administrative rules.

A transfer will be appropriate if:

The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in case of a woman in labor, the health of an unborn child.

The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment.

The transferring hospital send the receiving hospital all medical records

The transfer is effected through qualified personnel and transportation equipment. The facility failed to ensure that an appropriate transfer was provided for patient #6 on 1/21/2019 as evidenced by failing to provide medical treatment that was within its capacity in order to minimize the risks to the individuals (#6) health; and failed to provide evidence of a written physician certification of transfer to another facility explaining the risks and the benefits of the transfer; failed to notify the receiving facility to obtain acceptance of the patient to ensure the facility had available space and qualified personnel for the treatment of patient #6 on 1/21/2019.

Violation Name: MEDICAL STAFF - ACCOUNTABILITY(A-0049)

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Based on document review and staff and physician interviews, the facility failed to ensure the medical staff evaluated the quality of services provided by the physician for 1 of 3 sampled patients (#1).

The findings included:

1. Review of the record revealed Patient #1 presented to this facility for elective Decompressive Laminectomy with Facet Fixation. The patient tolerated the procedure without any intra-operative complications. On post operative day 1, the patient requested an increased dose of Dilaudid. The pain management physician, who was managing this patient's pain, ordered 4 milligrams of Dilaudid intravenously. This was administered by the nurse intravenously. The patient subsequently, approximately 10 minutes later, developed bradycardia and respiratory depression and a Rapid Response was called. Upon responding to the code and entering the room, the Intensive Care Unit physician (resident), found the patient with evidence of peripheral cyanosis and staff was observed giving rescue breaths. The patient was on a telemetry cardiac monitor with a sinus bradycardia rate of 35, and had a weak pulse. A code blue (full code) was called. The patient was intubated and transferred to Cardiovascular Intensive Care Unit for further care.

2. During an interview with the Director of Pharmacy, on 01/15/19 at 2:25 PM, he stated in 2018, they implemented the criteria from Best Practice Dilaudid Administration. This criteria includes an electronic pop up alert to the provider, when the provider orders >2 milligrams of Dilaudid Intravenous. The pop up alert states, Dilaudid 2 milligrams intravenous is equivalent to Morphine 14 milligrams Intravenous. Doses 2 milligrams or more should be reserved for patients who are opioid tolerant or have had treatment failure at lower doses and require dose titration.

Review of the physician's electronic response for patient #1 was, Patient is opioid tolerant. Patient failed lower doses and the Dilaudid Intravenous dose is being titrated. The answer to the question to Specify Other Indications was not completed.

The Director of Pharmacy stated an extreme tolerance example of opioid tolerance is a patient that was given 7000 milligrams a day of Morphine. In contrast, an opioid nanve patient would be given .5 milligrams of Dilaudid and/or 5 milligrams of Morphine. He stated that his clinical pharmacist reported to him, the nurse practitioner called him to alert him that she did not want a substitution of Dilaudid from Intravenous to oral. She stated the patient required a high dose of 4 milligrams. He questioned if she was sure that she wanted 4 milligrams. The nurse practitioner said, Yes, I want 4 milligrams.

The Director of Pharmacy stated he was not sure if the patient was really opioid tolerant or nanve.

3. During an interview with the neurosurgeon, on 01/15/19 at 4:45 PM, he stated Patient #1 contacted him to perform his surgery. He stated the patient and he had an issue and difference in philosophy regarding pain control and he would not agree to order Dilaudid. He told the patient that he would order Morphine for pain, instead of Dilaudid. The patient then initiated contact with a pain management physician to manage his pain medications while he was in the hospital.

4. During an interview with the Pain Management Physician, on 01/15/19 at 4:06 PM, he stated Patient #1, who is a colleague, contacted him 2 days prior to his surgery. The patient asked this physician to manage his medications while in the hospital. He told the Pain Management physician that he was extremely opioid tolerant, specifically Dilaudid. The physician stated that he and the patient had agreed upon a pain management plan that included Dilaudid. He stated the patient called him the day after his surgery and wanted 10 milligrams of Dilaudid in addition to the Dilaudid he was receiving via Patient Controlled Analgesia (PCA); but he would only order 4 milligrams. He stated, It seems to me the patient lied to me about being opioid tolerant. He did not confirm or verify whether the patient was opioid nanve or tolerant prior to agreeing to manage the patient's pain medications.

5. Review of the medical record for medical clearance failed to reveal evidence the patient was opioid tolerant.

6. Interview with the Director of Patient Safety, on 01/16/19 at 11:30 AM, she stated the facility monitors reactions to Adverse Drug Reactions, Narcan usage and reports this information to the medication safety committee for tracking and trending and development of new initiatives. The new initiatives were not currently in effect but will be introduced in 2019.

7. Interview with the Director of Patient Safety - she stated Risk Management investigated the nurse who administered the medication but did not send this incident report to Peer Review for review of the physician's services. She stated the incident report was referred by Risk Management to Peer Review, Vice President of Quality, and Chief Nursing Officer for review and follow up. She stated, despite the request to send this case to peer review, the Vice President of Quality reviewed the incident report, reviewed the code blue, and noted post operatively it did not meet criteria for peer review. Therefore, the incident was not sent for peer review for follow up .

8 The Chief Medical Officer, on 01/17/19 at 10:50 AM, stated he was not available to be interviewed.

9. Interview with the Vice President of Quality, on 01/17/19 at 1:45 PM, she agreed the physician failed to verify or confirm the patient was opioid tolerant and the case was not sent for peer review.

Violation Name: ADMINISTRATION OF DRUGS(A-0405)

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Based on document review, staff interviews, and policy and procedure review, the facility failed to ensure the nurse monitored the patient's respirations while administering 4 milligrams of Dilaudid intravenously, when there is a high risk of respiratory depression in 1 of 3 sampled patients (#1).

The findings included:

2. Review of the nurse's documentation on 05/10/2019 revealed, family and patient requesting more pain meds and asked if the Patient Controlled Analgesia (PCA) dose could be raised to 6 milligrams an hour and other meds. The physician and nurse practitioner visited the patient in his room and placed orders for 4 milligrams Dilaudid Intravenous push stat and to increase the dose on the Patient Controlled Analgesia Dilaudid pump. The patient was given 4 milligrams intravenously of Hydromorphone/Dilaudid at the bedside at 3:47 PM. The patient became unresponsive shortly after and a rapid response was called. The doses on the Patient Controlled Analgesia pump were not increased. Cardiopulmonary Resuscitation was performed in the patient's room by the hospital code team.

3. Review of record failed to reveal the patient's respirations were monitored prior to, during, or after the 4 milligrams of Dilaudid were administered intravenously. Review of the Rapid Response Team Record revealed the nurse who administered the Dilaudid documented the patient became unresponsive 10 minutes after 4 milligrams of Dilaudid was given intravenously. The rapid response was called at 4:00 PM. The assessment at 4:00 PM revealed the blood sugar 124, blood pressure 90/50, and heart rate 35. The assessment at 4:00 PM failed to reveal the respirations or the reading on the Pulse Oximeter.

4. Review of the Medication Discharge Summary revealed the 4 milligrams of Dilaudid was given into the patient's left Jugular line at 3:47 PM.

5. An interview was requested with the nurse who administered the Dilaudid. The legal counsel for the nurse who administered the Dilaudid to patient #1, advised the nurse to decline an interview. In lieu of an interview, they provided the nurse's written statement.

Review of the nurse's statement revealed the nurse recalls some discussion regarding the dose of Dilaudid that was ordered by pain management and she deferred to the pain management physician for the appropriate dosing. She and the other staff felt comfortable with what was ordered, as a pain management physician ordered it, and the pharmacist and nurse practitioner discussed the dose and it was noted that the patient was opioid tolerant. The nurse stayed at the patient's bedside for an ample amount of time after giving the patient the Dilaudid and only left the patient's room when she was comfortable with the patient's condition and vital signs. The patient was bradycardic and unresponsive when found by the nurse approximately ten minutes later. A rapid response was initially called overhead at 4:00 PM, pulseless electrical activity was recognized shortly thereafter on cardiac monitoring despite Epinephrine, Atropine and Narcan administration, as well as chest compressions. A code blue was announced at approximately 4:10 PM.

6. During an interview with the Vice President of Quality, on 01/16/19 at 11:02 AM, she stated an event report was not generated until eight days post occurrence, by the Director of the Neuro Telemetry Unit.

7. During an interview with the Director of Patient Safety, on 01/16/19 at 11:30 AM, she stated the occurrence was referred by Risk Management to Peer Review, Vice President of Quality, and Chief Nursing Officer for review and follow up. The Vice President of Quality reviewed the incident report, reviewed the code blue, and noted post operatively it did not meet criteria for peer review. Therefore, the incident was not sent for peer review.

She stated they investigated the order and determined there was a valid order, the nurse administered it as ordered, and had appropriate responses to the patient's condition. She confirmed the nurse failed to monitor and document the patient's respirations while administering the 4 milligrams of Dilaudid and immediately following the administration. She stated there was no further investigation.

8. During an interview with the Vice President of Quality, on 01/17/19 at 1:40 PM, she agreed that Risk Management reviewed the actions of the nurse but failed to have the physician's actions reviewed by the medical staff. She agreed the nurse failed to follow the standard of care and monitor/document the patient's respirations while administering 4 milligrams of Dilaudid intravenously, when there is a high risk of respiratory depression.

Violation Name: ADMINISTRATION OF DRUGS(A-0405)

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Violation Name: ORDERS FOR DRUGS AND BIOLOGICALS(A-0409)

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Based on policy review, clinical record review and interview the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 1 of 2 sampled patients (Patient #5) as evidenced by failure to reassess patient's condition after completion of blood transfusion as specified per facility policy.

The findings included:

All patient areas will document vitals and any transfusion reactions at the following intervals.

Baseline vital signs must be taken 30 minutes prior to beginning transfusion.

5 minutes after initiation of transfusion and as patient condition requires

15 minutes after initiation of transfusion

30 minutes after initiation of transfusion

1 hour after initiation of transfusion

Every hour thereafter until transfusion is complete

A final set of vital signs should be documented 30 minutes after end time.

Clinical record review conducted on 11/28/18 revealed Patient #5 was prescribed a blood transfusion, one unit of red blood cells on 10/16/18 due to low hemoglobin.

The record indicates the blood transfusion was initiated on 10/16/18 at 2:16 PM.

Review of the Nurses Notes, Nursing Shift Assessments and Assessment and Reassessment documentation and blood administration record failed to provide evidence the patient baseline vital signs were obtained 30 minutes prior to the infusion and there is no evidence the patient was reassessed 30 minutes after the completion of the blood transfusion.

Interview with The Senior Risk Manager and The Director of Advanced Clinical on 11/28/18 at 11:26 AM confirmed there is no evidence the nursing staff completed a baseline assessment 30 minutes prior to the initiation of the blood transfusion. Furthermore, there is no evidence the nursing staff reassessed the patient 30 minutes post transfusion as mandated by the facility policies and procedures.

Violation Name: COMPLIANCE WITH 489.24(A-2400)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and staff interview the facility failed to adopt and enforce a policy to ensure compliance with the EMTALA requirements at 42 CFR 489.24 as evidenced by failure to provide appropriate medical screening examination resulting in delay in treatment and failure to appropriately transfer 1 of 20 sampled patients (Patients #2). The facility actions included failure to obtain specialty consults while in the Emergency Department, failure to prevent delay in treatment, failure to provide stabilization prior to transfer by appropriate consultants and failure to obtain surgical consultation when a time sensitive life and limb threatening condition was identified.

The findings included:

1. Based on medical record review, policy and procedure review, on- call schedules review, Physician Core Privileges review, and interviews it was determined the facility failed to maintain an on-call list of physicians on it's Medical Staff in a manner that best meet the needs of the hospital's patients by failing to obtain specialty surgical consultation when a time sensitive life and limb threatening condition Sepsis and [DIAGNOSES REDACTED] was identified for 1 (#2) of 20 sampled patients who required immediate surgical interventions. Refer to findings in Tag A-2404.

2. Based on medical record review, policy and procedure review, Core physician privileges review, on-call schedules review and interview the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services of surgical on call physicians who were on call and available in the emergency department when patient #2 presented to the ED. This failure affected 1 (#2) of 20 sampled patients (Patient #2) as evidenced by failing to ensure the patient was evaluated by appropriate surgical consults that were available. Refer to findings in Tag A-2406.

3. Based on medical record reviews, policies and procedure review, on-call schedules, Physician Core Privileges review and interviews the facility failed to provide surgical treatment within its capacity that minimized the risks to the individual's health by failing to ensure that on-call surgical consultants that were available evaluated and provided stabilizing treatment for 1 (#2)of 20 sampled patients with an identified emergency medical condition. As this resulted in an inappropriate transfer for patient #2. Refer to findings in Tag A-2409.

Violation Name: ON CALL PHYSICIANS(A-2404)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy and procedure review, on- call schedules review, Physician Core Privileges review, and interviews it was determined the facility failed to maintain an on-call list of physicians on it's Medical Staff in a manner that best meet the needs of the hospital's patients by failing to obtain specialty surgical consultation when a time sensitive life and limb threatening condition Sepsis and [DIAGNOSES REDACTED] was identified for 1 (#2) of 20 sampled patients who required immediate surgical intervention.

The findings included:

1. Medical Record Review -Patient #2

Laboratory studies indicates, Complete blood Count Normal, Bandemia (usually indication of infection or some inflammation is present) elevated troponin (test that measures proteins released when heart muscles have been damaged) and lactic acid levels(test to document presence of cell tissues that are starting to die) low sodium, elevated AST (SGOT) Liver functions tests, and elevated kidney functions tests BUN (Blood Urea Nitrogen-indicator for kidney function) and Creatinine elevated means impaired kidney function). Elevated Serum Coags(coagulation) Interpretation PT Prothrombin Times- measures amount of time it takes for blood to clot), PTT (partial Prothrombin time (Measures how long it takes for blood to clot) Radiology studies included an ultrasound of the left arm; the impression documents diffuse lateral arm subcutaneous swelling. No evidence of fluid collection or abscess. Patient #2 received antibiotics, pain medicine, antiemetic, anticoagulant and vasopressors to manage his condition.

Documentation on the H&P Addendum note dated 1/28/2017 at 4:39 P.M., revealed that the ED physician consulted a Resident in Internal Medicine Physician, and his reason for the consult was Septic Shock (sepsis induced low blood pressure that persist despite treatment with intravenous fluids). The internal medicine documented the patient's chief complaint was Exquisite L (left) arm pain. Documentation also revealed in part, in the ER he presented w/ (with) a BP lf 80/40 unresponsive to 3 L (liters) of NS (Normal Saline) boluses after which Levophed was stated through the R (Right) peripheral IV. He reports that his chest and back pain is worse after having received the fluid ...Physical Exam ... BP 83/53, Pulse 123, Oxygen 2 liters, Respirations 20 ... General appearance ...in acute distress due to pain..: Extremities: L arm w/exquisite tenderness to palpitation proximally near the shoulder; tense and red; hot to touch; ... Thready L radial pulse.

Resident documented in the section of the History and Physical note titled Diagnosis, Assessment & plan that documents patient presents with acute left shoulder [DIAGNOSES REDACTED]. Septic shock, acute [DIAGNOSES REDACTED] with pressures of 40 mm Hg on the anterior, lateral and posterior compartment. Multiple surgeons have been consulted STAT (as soon as possible) and have refused the consult or not responded starting at 4 PM on 01/28/17. General surgery on call (physician name) at 4:16 PM who said to call orthopedic on call. ([Physician Name]) orthopedic called at 4:30 PM who refused the consult. Resident saw patient in ER room 34 at bedside at 5 PM and (Physician Name), after examination said This was not [DIAGNOSES REDACTED]. Physician Name (vascular) called at 5:15 PM and refused the consult. ...additional 2 L NS boluses, and fluid at 250 cc/h, intubate as needed for respiratory distress, pain control with Dilaudid, Ct (computerized tomography) Scan of the chest, nephrology and infectious disease consulted. Renal failure secondary to [DIAGNOSES REDACTED]. This case was discussed with attending who agrees with assessment and plan.

Attending physician Progress Notes dated 01/28/17 documents Patient with severe sepsis with septic shock has been associated with acute kidney injury with metabolic acidosis, hypotension and elevated liver function. The non-contrast CT of the shoulder revealed extensive subcutaneous swelling in the posterior left shoulder as well as air and swelling in the deltoids and infraspinatus muscles concerning for infection/myositis with gas forming microorganisms. ER consulted general surgery, (physician name) who reportedly has noted that this is an orthopedic surgery problem since it involved the shoulder/arm. Orthopedics (physician name) was consulted, who initially refused the consult since it involved the patient's arm and referred us to a hand surgeon. (Physician Name) was called from hand surgery, who then stated that this is outside his scope of practice since this is involving a shoulder and arm and he is specifically a hand surgeon. (Physician Name) from vascular surgery also consulted but refused consult, as he reportedly does not take care of [DIAGNOSES REDACTED] especially in the shoulder. (Physician Name) Chief of Surgery has spoken to the Orthopedic surgeon, who agreed to see the patient tomorrow, he states that per his research in literature, the patient may do well if we have interventional radiology place a drain.

Interventional Radiology was consulted to review the films. In the meantime, with help from the chief nursing officer and chief executive officer, we contacted the transfer center and got in touch with the Trauma Surgeon on call at Hospital B (Trauma Center), and the Trauma surgeon recommended calling general surgery on call at their institution. Spoke to (MD Name) from general surgery (at Hospital B) via transfer center. The general surgeon from Hospital B accepted the patient to be transferred as soon as possible for possible surgical intervention at Hospital B (trauma center). Transfer is being arranged. I have discussed in detail with the patient and wife.

The EMTALA memorandum of Transfer form dated 1/28/2017 was reviewed. The section of the EMTALA form titled REASON FOR TRANSFER revealed the transfer was medically indicated because of the presumed diagnosis of [DIAGNOSES REDACTED]

Further review also revealed that the reason for the transfer was that the On-call physician refused or failed to respond within a reasonable period of time. The section of the EMTALA transfer form titled Risks and Benefits for Transfer revealed in part, Medical Benefits: documented obtain level of care/service unavailable at this facility. The hospital had multiple surgical consultants routinely available and on staff capable of treating [DIAGNOSES REDACTED] (a flesh eating disease, is an infection that results in the death of parts of the body's soft tissue) , a time sensitive life and limb-threatening condition for patient #2 on 1/28/2017.

3. Medical Record Review Patient #2 at Receiving Facility

Review of the receiving facility medical records indicates Patient #2 underwent a debridement and washout of [DIAGNOSES REDACTED] to the left arm and shoulder on 01/29/17 by a general surgeon specialist. The patient had multiple surgical procedures and debridement and was discharged home with home health and wound care on 02/25/17.

4. On-Call Schedules

Review of the facility's On Call schedules conducted on 09/05/18 and 09/06/18, revealed the facility had surgical, vascular, and orthopedic on-call coverage available on call on 01/28/17, when the patient presented to the hospital's ED on 1/28/2017.

5. Core Privileges Orthopedic Surgeon

The Core Privileges for the Orthopedic Surgeon who was on call and called on 1/28/2017 regarding patient #2 was reviewed. The Core Privileges were approved on 7/18/17 and effective 7/1/2017 through 6/30/2019. His Core Privileges were listed in part, Privileges to admit, evaluate, diagnose, consult, and provide non-surgical and surgical care to patients 18 or older-except as specifically excluded from Practice and except for those special procedures privileges listed below- to correct or treat various conditions, illnesses, an injuries of the musculoskeletal system including the provision of consults. PROCEDURE LIST ...Fasciotomy (surgical procedure where fascia is cut to relieve tension and/or pain-life saving procedure when used to treat [DIAGNOSES REDACTED]). The review of this credentialing file verifies the Orthopedic surgeon was privileged to perform , incision and drainage surgical procedures.

6. Interviews

Interview with the Director on 09/05/2019 at 9:55 AM revealed the On Call list is posted daily on the electronic format and all staff has access to the schedule and updates.

Interview with the Physician conducted on 9/5/2019 at 10:20 AM revealed the facility has four to six physicians on duty during peak times and physician coverage is twenty-four hours a day. There is an on call schedule for all the services provided and if a service is needed and not available, the staff contacts the transfer center who makes all of the arrangements.

Telephone interview with The Emergency Department Physician conducted on 09/06/18 at 11:19 AM revealed Patient #2 presented with pain and swelling to the arm. The Physician stated he did not make any consults for this patient as his main concern was addressing the septic shock.

Multiple attempts to interview the orthopedist on-call when Patient#2 presented to the hospital were made throughout the survey. The on-call physician did not return the calls.

7. Policies and Procedures

Facility policy titled Provision of On Call Coverage with a review date of 06/2018, documents the following:

The hospital must maintain a list of physicians on its medical staff who have privileges at the hospital or if it participates in a community call plan, a list of all physician who participate in such plan. Physicians on the list must be available after the initial examination to provide treatment to relieve or eliminate emergency medical conditions to individuals who are receiving services in accordance with the resources available to the hospital. The cooperation of the hospital's medical staff members with this policy is vital to the hospital's success in complying with the on call provisions of EMTALA.

The facility failed to maintain a list of physicians on its Medical Staff who have privileges and were on-call (Orthopedic surgeon, Vascular surgeon and General Surgeons) and available on 1/28/2017 when patient #2 presented to the ED with an identified emergency medical condition, [DIAGNOSES REDACTED], but refused to evaluate the patient to provide treatment in order to relieve or eliminate an emergency medical condition as stated in their policy and procedure.

Violation Name: MEDICAL SCREENING EXAM(A-2406)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

2406

Based on medical record review, policy and procedure review, Core physician privileges review, on-call schedules review and interview the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services of surgical on call physicians who were on call and available in the emergency department when patient #2 presented to the ED. This failure affected 1 (#2) of 20 sampled patients (Patient #2) as evidenced by failing to ensure the patient was evaluated by appropriate surgical consults that were available.

The findings included:

1. Policy and Procedure review

Facility policy titled Medical Screening Examination (MSE) and Stabilization, last revised 04/01/18, documents the following:

A hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available in the emergency department.... Extent of the MSE is an ongoing process. the individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an Emergency Medical Condition (EMC), and if he or she does, until the EMC is relieved or eliminated or the individual is appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.

2. Medical Record Review -Patient #2

Clinical record review conducted on 09/05/18 thru 09/06/18 revealed Patient #2 (MDS) dated [DATE] at 12:15 PM with chief complaint of Abscess to left shoulder. The patient was triaged at 12:26 PM as urgent. The medical screening exam conducted at 1:04 PM documents the patient complained of shoulder problem, weakness and dizziness. Patient received a testosterone injection three days ago, that evening he started to have pain and it has gotten worse. On arrival, his blood pressure was low 81/59 (normal Blood Pressure ) and had elevated heart rate 20 (normal heart rate 60-100). The physical exam revealed pain and swelling to left arm. There is a palpable abscess, no drainage or tightness. Laboratory studies indicates elevated troponin and lactic acid levels, low sodium and elevated kidney functions. Radiology studies included an ultrasound of the left arm; the impression documents diffuse lateral arm subcutaneous swelling. No evidence of fluid collection or abscess. Patient #2 received antibiotics, pain medicine, antiemetic, anticoagulant and vasopressors to manage his condition.

Physician reevaluation documents the patient's blood pressure continued to be low after three liters of fluid. Patient is complaining of increased pain to the arm but still has a palpable pulse. He has received antibiotic (vancomycin and Rocephin) and started on Norepinephrine (drug used to raise blood pressure). Resident History and Physical dated 01/28/17 at 4:39 PM documents patient presents with acute left shoulder [DIAGNOSES REDACTED]. Septic shock, acute [DIAGNOSES REDACTED] with pressures of 40 mm Hg on the anterior, lateral and posterior compartment. Multiple surgeons have been consulted STAT (as soon as possible) and have refused the consults or not responded starting at 4 PM on 01/28/17. General surgery on call (Physician name) at 4:16 PM who said to call orthopedic on call. (Physician Name) orthopedic called at 4:30 PM who refused the consult. Resident saw patient in room 34 at bedside at 5 PM and (Physician Name) examination said This was not [DIAGNOSES REDACTED]. (Physician Name) (vascular) called at 5:15 PM and refused the consult. Plan noted intubate as needed for respiratory distress, additional bolus of fluid, pain control with Dilaudid, Ct (computerized tomography) Scan of the chest, nephrology and infectious disease consulted. Renal failure secondary to [DIAGNOSES REDACTED]. The EMTALA memorandum of Transfer form dated 1/28/2017 was reviewed. The section of the EMTALA form titled REASON FOR TRANSFER revealed the transfer was medically indicated because of the presumed diagnosis of [DIAGNOSES REDACTED]

Further review also revealed that the reason for the transfer was that the On-call physician refused or failed to respond within a reasonable period of time. The section of the EMTALA transfer form titled Risks and Benefits for Transfer revealed in part, Medical Benefits: documented obtain level of care/service unavailable at this facility. The hospital had multiple surgical consultants available and on staff capable of treating [DIAGNOSES REDACTED], a time sensitive life and limb-threatening condition for patient #2 on 1/28/2017. As this resulted in an inappropriate Medical Screening Examination for patient#2.

3. Medical Record Review for patient #2 at Receiving Facility

4. On-Call Schedules

5. Core Privileges Orthopedic Surgeon

The Core Privileges for the Orthopedic Surgeon who was on call and called on 1/28/2017 regarding patient #2 was reviewed. The Core Privileges were approved on 7/18/17 and effective 7/1/2017 through 6/30/2019. His Core Privileges were listed in part, Privileges to admit, evaluate, diagnose, consult, and provide non-surgical and surgical care to patients 18 or older-except as specifically excluded from Practice and except for those special procedures privileges listed below- to correct or treat various conditions, illnesses, an injuries of the musculoskeletal system including the provision of consults. PROCEDURE LIST ...Fasciotomy (surgical procedure where fascia is cut to relieve tension and/or pain-life saving procedure when used to treat [DIAGNOSES REDACTED]). The review of this credentialing file verified the on-call Orthopedic surgeon was privileged to perform surgical procedures when patient #2 presented on 1//28/2017.

6. Interview

Violation Name: APPROPRIATE TRANSFER(A-2409)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record reviews, policies and procedure review, on-call schedules, Physician Core Privileges review and interviews the facility failed to provide surgical treatment within its capacity that minimized the risks to the individual's health by failing to ensure that on-call surgical consultants that were available evaluated and provided stabilizing treatment for 1 (#2)of 20 sampled patients. As this resulted in an inappropriate transfer for patient #2.

The findings were;

1. Medical Record Review- Patient #2

Review of the medical record for patient #2, the History and Physical dated 01/28/17 documentation reveals the patient presents with acute left shoulder [DIAGNOSES REDACTED] and septic shock. Multiple surgeons have been consulted STAT (as soon as possible) and have refused the consults or not responded. Patient #2's transfer form titled EMTALA Memorandum of Transfer form documentation revealed in part, The patient is stable for transfer. Reason for transfer: On Call physician refused or failed to respond within a reasonable period of time. Medical Benefit documents Obtain level of care service unavailable at facility. Trauma Surgeon and medical benefits outweighs the risk.

2. Medical Record Review Patient #2 at Receiving Facility

3. On Call schedules

Review of the On Call schedules conducted on 09/05/18 and 09/06/18, revealed the facility had surgical, vascular and orthopedic coverage available and on call on 01/28/17, when patient #2 (MDS) dated [DATE].

4. Core Privileges for the Orthopedic surgeon

Review of the Core Privileges for the Orthopedic surgeon on call conducted on 09/06/18 verifies the surgeon has active privileges to perform , incision and drainage: when patient #2 (MDS) dated [DATE].

5. Interviews

Interview with The Vice President of Quality on 09/05/18 at 3:24 PM revealed the case related to Patient #2 has been settled. The facility had no idea this was a concern until they received the notice of intent. The facility did not conduct a peer review or implement a corrective action as a result of this case. The physician felt this case was out of the orthopedic surgeon scope of practice; the surgery was complex and required a trauma surgeon.

Interview with The Chief of Surgery conducted on 09/06/18 at 8:55 AM revealed Patient #2 presented to the Emergency Department with pain and swelling to the arm. The first clinical impression was an abscess and possibly [DIAGNOSES REDACTED]. The general surgeon was consulted and based on the fact the area affected was the arm, he declined the consult and suggested the orthopedic on call should be contacted. The clinical guidelines related to who should treat [DIAGNOSES REDACTED] are vague. The Chief recalled he spoke to the orthopedist and the plan was for him to do an incision and drainage and place a drain, the next day. At this time, this was a reasonable plan. In the meantime, the patient was being treated in intensive care for his hypotension. Then the Computed Tomography Scan results indicated possible diagnosis of [DIAGNOSES REDACTED]. The Chief stated all the surgeons involved responded in a timely manner, but they felt this case was out of their scope of practice.

6. Policy and Procedure

The facility's policy titled, FL Transfer Policy Effective date 2/1/2016, Review date 6/2018 and Approval date 6/2018 was reviewed. Review of the policy revealed in part, Transfer of Individuals Who Have Not Been Stabilized ...b. A transfer will not be appropriate if the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that surgical treatment was provided within its capacity that minimizes the risks to Patient #2's health and time sensitive emergency medical condition, necrotizing fasciitis.

Violation Name: PATIENT RIGHTS: NOTICE OF RIGHTS(A-0117)

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Based on record reviews and interviews, the hospital failed to inform the patient's representative, in advance, of discharging a patient for one (Patient #1) of 10 patient records reviewed.

The findings included:

Patient #1

05/31/17 - Review of the record, of Patient #1, revealed the patient presented to the emergency room complaining of left wrist pain and left shoulder pain. She reported having an abscess on her right calf. The patient was triaged by a nurse and treated while in the emergency room .

06/01/17 - Review of the record, revealed she was admitted to the hospital with right leg cellulitis.

06/01/17 - Review of the case management report, revealed the discharge plan was for the patient to be discharged home.

During an interview with Daytime Charge Nurse on the medical/surgical floor, on 06/20/17 at approximately 3:00 PM, she stated she remembers the case. She stated that she met the patient's guardian while she was visiting the patient. She stated the guardian gave her business card to her and said the patient had been here before in the pavilion. She stated she told her that she would pull the guardianship document and put it in the patient's chart. She stated she received a copy of the Plenary Guardianship from medical records. She placed the document into the paper chart and notified the physician.

Review of the Guardianship Document confirmed plenary guardianship of the patient.

During an interview with the Chief Nursing Officer, on 06/20/17 at 3:45 PM, she confirmed the guardian should have been notified of the patient's discharge.

Violation Name: DISCHARGE PLANNING PERSONNEL(A-0818)

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Based on record reviews and interviews, the hospital failed to develop or supervise the development of a discharge plan when there was an indication of a need for a discharge plan for one (Patient #1) of 10 patient records reviewed.

The findings included:

Patient #1

06/01/17 - Review of the record, revealed she was admitted to the hospital with right leg cellulitis.

06/01/17 - Review of the case management report, revealed the discharge plan was for the patient to be discharged home.

During an interview with the Case Manager, on 06/20/17 at approximately 2:09 PM, she stated regarding Patient #1, she checked to see if the patient met criteria for admission. She stated that she did not talk to the patient because the patient was refusing to speak to staff. She explained the physician usually orders discharge planning when the patient has a guardian and that is her trigger to work with the patient regarding the discharge. She stated that unless she has received a discharge referral, she would not have seen or known about the patient's Guardianship. She stated all legal documents in hard copy are placed in the patient's hard copy chart that is kept at the nursing station. She stated the case managers rarely look at the hard copy charts. The documents are scanned into the patient's electronic medical record when the patient is discharged .

During an interview with Staff A, on 06/21/17 at approximately 10:15 AM, she stated that she discharged the patient by herself with a bus pass to go home. She stated that she did not look at the patient's face-sheet for the address. She acknowledged, that had she looked at the face-sheet, she would have noticed she was giving a bus pass to a patient whose address is Hilton Head, South Carolina. She stated that she did not look at the hard copy chart to see if there were legal documents, and she did not remember attending a 2- day training session regarding appropriately discharging patients.

During an interview with the Director of Patient Safety and Risk Management, on 06/20/17 at 2:30 PM, she confirmed the staff had failed to notify the responsible party, Plenary Guardian, failed to appropriately discharge the patient by discharging her with a bus pass and not having the Plenary Guardian arrange for patient's transportation and destination upon discharge.

During an interview with the Chief Nursing Officer, on 06/20/17 at 3:45 PM, she confirmed the patient was not appropriately discharged , the guardianship should have been included on the face sheet, the guardian should have been notified of the patient's discharge, and the discharge plan should have been developed to include the guardianship.

Violation Name: IMPLEMENTATION OF A DISCHARGE PLAN(A-0820)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review and interview, it was determined the facility failed to ensure discharge planning was implemented for 4 of 8 sampled patients (Patient # 2, 4, 9 and 11) as evidenced by a failure to provide pertinent discharge instructions to meet the patient's needs and ensure continuity of care.

The findings included:

The Facility policy titled, Discharge of Patient from Hospital last revised 10/2015 documents, To ensure that there are effective processes for the discharge of patients which meets the needs of the patient, ensures continuity of care and facilitates discharge in a timely manner.

Requirements for Discharge: Completed medication reconciliation and discharge instructions.

Discharge Process: After completing the discharge instructions in Meditech, the discharge instructions, prescriptions and medication reconciliation is reviewed verbally with the patient and or caregiver/family if appropriate. Patient is given the opportunity to ask questions, and to verbalize understanding of instructions.

The Facility policy titled, Against Medical Advice Discharge last revised 05/2015 documents, To document patient electing to leave the hospital without a physician ' s discharge order.

1. Notify the attending physician immediately. Encourage patient to wait for physician visit or return call.

2. Notify the charge nurse and nursing supervisor.

3. Request patient signs discharge against medical advice form and place on chart.

4. If patient refuses to sign document refusal on discharge against medial advice form under- patient signature.

5. Record specific details on chart.

6. Complete occurrence report.

7. Send computerized discharge.

8. Follow routine discharge procedures including completion of the discharge instruction sheet and appropriate follow up care. Escort patient out of hospital building when possible.

Clinical record review conducted on 01/14/16 revealed the following:

1) Patient # 2 was admitted to the facility on [DATE] with multiple medical conditions.

Physician progress notes dated 11/18/15 revealed the physician had spoken to the patient that has been here for 12 days and stated, cannot wait anymore. The physician located an orthopedic oncologist in another county and the patient should follow up with an oncologist's rapidly. The physician noted, the patient needs to remain non-weight bearing and placed a consult with case management about providing crutches.

A Document titled, discharged Against Medical Advice revealed, Patient # 2 signed out of the facility on 11/18/15.

Further review of the record indicates Patient # 2 received multiple prescriptions for insulin and diabetic supplies. The record does not provide evidence of discharge instructions related to follow up care or obtaining crutches as specified in the physician' s progress notes.

Interview with the Risk Manager who was navigating the electronic record, on 01/14/16 at 11:09 AM revealed, after further review of the electronic record, there is no evidence written instructions, specifying follow up care and the requested durable medical equipment was provided to the patient prior or after discharge.

2) Patient # 4 was admitted to the facility on [DATE] with multiple medical conditions. Consulting physician progress notes dated 11/29/15 documents recommendations related to diet and medication management anticipating patient discharge.

A Document titled, Discharge Against Medical Advice, revealed Patient # 4 signed out of the facility on 11/30/15.

Further review of the record failed to provide evidence of discharge instructions and follow up care. The clinical record does not contain documentation related to the discharge.

3) Patient # 9 was admitted to the facility on [DATE] with multiple medical conditions. The patient underwent a peripheral inserted central catheter (PICC) insertion on 12/27/15 due to a need of intravenous antibiotic therapy. The patient was discharged home on 12/29/15 with a caregiver. The written discharge instructions failed to address care of the recently inserted PICC line.

4) Patient # 11 was admitted to the facility on [DATE] due to multiple medical conditions. Nursing assessments dated 05/13/15 thru 05/15/15 documents the patient had a wound/skin tear to the right forearm. Patient # 11 was discharged on [DATE]. Discharge instructions failed to address care for the wound/skin tear to the right forearm. Patient # 11 returned to the facility on [DATE] and was diagnosed with cellulitis to the right forearm.

Interview with the Risk Manager conducted on 01/14/16 at 2:36 PM while navigating the electronic record and subsequent interview with the Director of Patient Safety on 01/14/16 at 4:12 PM revealed, after researching the clinical records for the patients identified above, there is no evidence pertinent discharge instructions were given to Patients # 4, 9 and 11 and there is no evidence Patient # 2 received discharge instructions, follow up care instructions and durable medical equipment as recommended by the physician.

Violation Name: COMPLIANCE WITH 489.24(A-2400)

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Violation Name: APPROPRIATE TRANSFER(A-2409)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, Policies and Procedures, Emergency department outgoing transfer logs, Physician credentialing files/Core Privileges, and staff interviews, it was determined that JFK inappropriately transferred two (2) individuals as evidenced by failing to provide treatment that was within the facility's capacity and capability to minimize the risk to the health of individuals, and failure to ensure all medically necessary transfers were in accordance with policy and procedures. This failure affected 2 of 20 sampled patients (#1 and #3) who presented to JFK Medical Center Emergency Department (ED) and were subsequently inappropriately transferred to receiving facilities (65 miles away) for continued care of their emergent medical conditions.

The findings include:

1. JFK Emergency Department Outgoing Transfer Logs

The hospital's Outgoing Transfer log revealed that on 9/26/2015 at 10:25 a.m., that Patient #3 was transferred to a tertiary hospital, and the diagnoses was listed as Airway Obstruction. The category needed was ENT (Ear, Nose and Throat, Surgery, and Anesthesia. Further review revealed that Patient #1 was transferred to a tertiary hospital on [DATE] at 6:11 p.m., with a diagnosis of Ruptured Globe (tear in the outer surface of the eyeball severe pain and loss of vision). The service needed was Ophthalmology (Branch of medicine concerned with the study and treatment of disorders and diseases of the eye.

2) JFK Medical Record Review for Patient #3.

Review of the clinical record revealed Patient #3 (MDS) dated [DATE] at 0557 hours with a chief complaint of shortness of breath (SOB) for 1 week according to the ED Triage notes. The objective Assessment was documented as, Audible Wheeze, Congestion, Cough. The ESI (Emergency Severity Index- acuity of patient health-level 2 -Emergent-High risk of deterioration or signs of a time critical problem) level as was listed as 2/Emergent.

The physician assessed the patient at 0558 hours. The ED physician documents the patient has an abnormal thyroid (enlarged). The patient presents with increasing SOB times two months. The patient has no private MD (PMD) or medical evaluation.

The patient's vital signs on admission were as follows: Blood Pressure (B/P) 198/114, (optimal normal blood pressure 120/80 ) pulse 98, respirations 24 and Oxygen Saturation 99% on room air. The patient had no wheezing or rhonchi.

The medical screening exam (MSE) included Complete Blood Count (CBC), Platelet Count, Chemistry, Coagulation studies. The lab results were within normal limits except for elevated Basophils (blood cells that digest bacteria). The patient had a Neck/Soft Tissue (Computerized Tomography-computerized images of the neck) and Chest X-ray.

The Radiologist discussed the findings with the ED physician at 0720 hours. The Neck Soft Tissue exam revealed: Prominent focal prevertebral soft tissue widening and proximal airway narrowing. CT (computerized tomography) with contrast is recommended. The chest x-ray noted: No evidence of acute pulmonary findings.

A CT of the neck with contrast was done at 0730 hours. The findings were reported to the ED physician at 0828 hours. The Impression: Markedly heterogeneous and enlarged thyroid gland with severe mass effect on the adjacent airway. The mass is most severe in the subglottic region where the airway is narrowed down to approximately 5 x 5 millimeters (mm). Thyroid malignancy is not excluded. There are some prominent lymph nodes on both sides of the neck. Follow-up is recommended.

The patient had Arterial Blood Gas (ABG-sampling of blood levels of oxygen and carbon dioxide within the arteries) drawn at 0958 hours. The results PH 7.49 (H), pCO2 32.6 (L), pO2 81.4, Bicarbonate 24.5, Oxygen Saturation 97.0 %3 and Base Excess 1.8 on room air. The physician writes at 0610 hours the patient presenting with complaints of SOB but on exam, mild stridor (noisy breathing), will eval (evaluate).

The ED physician re-evaluated the patient at 0715 and 0815. He documented the results of the CT of the neck. The ED physician documented the patient is stable.

The patient received the following medications between 0625- 0858 hours Hydralazine (medication used to treat high blood pressure) HCL 10 milligrams (mg) intravenously (IV) times 2 doses; Albuterol/Ipratroponin (drug used to treat wheezing and SOB) per inhalation; and 2 doses of Decadron (medication used to treat inflammation) 8 mg IV.

The ED physician documented he called consults with Ear, Nose and Throat (ENT)/Otolaryngology, Anesthesia, ICU and Surgery, they will come to the ED and evaluate the patient. The times that the consults were called were not documented. There was no documentation in the clinical record to indicate the Cardiothoracic surgeon or the ICU (Intensive Care Unit) Physician came to the ED to evaluate patient #3 on 9/26/2015.

The patient received additional medications Pipercillin sodium/Tazobactam Sodium (medication antibiotic used to treat infections) 3.375 Gram (GM) IV in 100 ml. of Normal Saline and Epinephrine (S-2 2.25% solution) 1 ml. at 1004 and 1023 hours respectively.

The On- Call ENT (Ear Nose and Throat) physician, Dr. B__, documented a History and Physical (H&P) at 1023 hour on 9/26/15. The patient with history of progressive dyspnea for 1-2 months now. She developed increased dyspnea, cough productive yellow mucus, and noisy breathing yesterday. The patient's daughter brought her to the emergency room (ER) this morning. The ER team noted stridor on her arrival in the ER. She received Decadron (medication used to treat inflammation) 16 mg. IV in ER with relief of dyspnea and noisy breathing.

The ENT physician reviewed the results of the CT of the Neck, Chest X-ray and medications. The ENT physician documented the patient has no stridor or respiratory distress. The Oxygen Saturation is 98% on 2 Liters of Oxygen.

At 1030 hours the ENT physician documented an examination was performed using a Flexible Fiberoptic Laryngoscopy at the bedside without sedation or anesthetic. There is no edema or lesions. External compression and narrowing of the upper to mid trachea was visualized.

The findings were reviewed with the ED physician and On-Call Physician for Anesthesia (a physician trained wide variety of areas, i.e., perioperative and airway management). The tracheal airway narrowing made it not technically feasible to intubate her. The thickness of the of thyroid mass made it unsafe to undertake an awake tracheostomy. Dr. F__, Thoracic Surgery was contacted regarding cardiac bypass and sternal split. Dr. F___, agreed to helicopter transfer to a tertiary Hospital/Center (a hospital or Medical Center with specialized consultive care). The patient and her daughter were apprised of the consensus plan. Both were in agreement to transfer to a tertiary center for a higher level of care. Dr. GI___, (ED Physician) initiated the transfer from the ER (JFK Medical Center). The transfer was rapidly accepted.

At 1050 hours the On-Call physician for Anesthesia, Dr. Gu___, consults. The On-Call physician for Anesthesia wrote called to ER emergently by ER physician for patient with stridor secondary to thyroid nodule airway compression. Dr. Gu___, documented in part, Minimal stridor on respiration ...Good air exchange. Per history, patient has had longstanding goiter and compression that was now aggravated by upper respiratory infection. Patient had received racemic epinephrine during admission. The On-call Anesthesia Physician wrote that the patient was in no acute distress.

The plan per the Anesthesiologist: Given the degree of airway compression and the need for very narrow tube, the patient would need to be potentially difficult intubation and ventilation. There is not a good fall back if intubation failed or ventilatory issues developed. Given that the patient is currently stable with good vital signs and responsive to the medical management and given the potential for severe morbidity or mortality, the recommendation for transfer to [Tertiary Hospital] was made. Case was discussed with ENT and Cardiothoracic (CT). Per Dr. B__, the ENT, the patient is not a candidate for awake tracheostomy. Dr. F___, felt that there was not a good local option for managing this patient. The ER physician, ENT, CT Surgery all in agreement with plan to transfer. Process initiated by ER physician.

The ED physician documented on a fourth progress note, (not timed) on page 8 of 8. He wrote after consultation and multiple evaluations: Ear, Nose and Throat (ENT), Anesthesia, ICU and Surgery believes the patient needs higher level of care. The patient to transfer via helicopter for definitive management. The patient never had a desaturation (when the blood does not have enough oxygen) or difficulty breathing during her stay. Stable at the time of transfer.

The ED physician also documented on what was identified as page 9 of 8 pages revealed the following: Patient is transferred to [Tertiary Hospital]. The disposition time 1916 hours on 9/26/15. The ED physician documented all vital signs were reviewed; counseled patient and family (diagnosis, lab results, need for transfer). The ED physician documented the following:

TRANSFER

Transfer request call: 0941

Transfer date: 9/26/15

Call returned at 0955.

Spoke with: Emergency physician

Receiving Hospital: [Tertiary Hospital]

Transfer accepted: Yes

Transfer accepted by Dr. A__.

The medical record lacked evidence of the consults made by the CT (Cardio Thoracic) surgeon and the ICU Physician.

Review of the Patient Transfer Center ' s document titled: Pre Admit Face Sheet, verified the ED physician, Dr. GI___, called the Transfer Center on 9/26/15 at 0953 hours. The Call Center's documentation revealed the following: ED physician wants us to begin the process for a possible Emergent transfer to [Tertiary Center ED] for airway stabilization. Patient may need tertiary facility to have this done. The sending ED physician possible is contacting Cardiothoracic (CT) surgery first and then will update us. Dr. GI___, requests we contact [Tertiary Center Hospital]. Patient will need potential intubation and ventilatory support.

At 0958 hours the call center documented: the unit secretary (US) stated the CT surgeon, Dr. F___, could not handle the case.

At 1025 hours: The US updated on case status- accepting information given. Advised we are awaiting word from Trauma Hawk to see if they will accept the case. Also the nurse will need to go through US to connect to [Tertiary Hospital] Transfer Center to give report.

10:40 hours: Call to US- Nurse (names) from Trauma Hawk did speak with her.

The Date/Time of decision: 9/26/15 at 1005 hours.

1006 hours: Dr. A___, the ED physician accepted the patient after conference call with sending physician. Accepting Service and Provider: Otolaryngology, Head & Neck Surgery

1008 Hours: Awaiting call back from Trauma Hawk to see if they can accept this case. Advised it was Emergent.

Date/Time of decision: 9/26/15 at 1042 hours.

Transfer Priority: Capability- Service offered outside physician scope.

Trauma Hawk arrived at JFK 1049 hours.

Reason for Transfer: Outside physician scope to manage this particular problem. The ED physician, Dr. GI___, requested tertiary facility. He advised their ENT, Anesthesia and CT Surgery department felt they were not able to manage this patient.

Review of the JFK Transfer Sheet reveals the reason for transfer: Medically indicated is checked. The Risk and Benefits for Transfer: Obtain a level of care/service unavailable at this facility, Service: ENT/Anesthesia/Surgery.

2a. Tertiary Hospital Medical Record Review for Patient #3.

Review of the medical record revealed that patient #3 was seen by the ED physician on 9/26/2015 at 11:50. The ED physician documented on the ED Physician Note, Patient presents with ear, nose throat, problem, transferred from palms west and stridor goiter airway compromise ...Physical Examination: ...General: Mild distress ...Neck: Supple, thyromegly, painful range of motion, stridor ...Ears, nose, mouth, and throat ...Throat: severe ...Cardiovascular: Tachycardia (fast heart rate). The ED physician documented that at 11:55 that ENT consults had been called prior to patient #3 ' s arrival. Patient #3 was on 9/26/2015 at 12:05 to an in-patient unit under the care of an Otolaryngology (Physician trained in medical and surgical management and treatment of patients with disorders of ear, nose and throat and relates structures of the neck and head- ENT Physician ) specialist. On 9/27/2015 the ENT physician was consulted and documented in part on the History and Physical, CHIEF COMPLAINT: Shortness of breath. History: 49 ... air transferred from JFK ...after she presented with severe SOB and stridor ...At JFK she was found to be in respiratory distress and with obvious stridor. She was not able to voice (talk) ...Plan: -Plan for total thyroidectomy (removal of the thyroid gland by surgery), central neck dissection-CT (cardio thoracic) consult for possible sternotomy (heart surgeon performs surgery through small incisions on the right side of your chest.)-Nasopharyngeal fiberoptic intubation (management of difficult airway to secure the airway) is preferred method securing airway if patient decompensated.- tracheostomy tray at bedside at all times in case of need for emergency surgical airway. Patient #3 was subsequently taken to surgery for a total thyroidectomy.

3. JFK Medical Record Review for Patient #1.

Review of the clinical record revealed sampled Patient #1 (MDS) dated [DATE] at 1359 hours with a chief complaint of left eye pain.

A Medical Screening Exam (MSE) reveals the patient has an atraumatic, 2 cm. bleeding mass protruding outwardly from the left eye. The patient has been blind in the left eye for 3 years due to Glaucoma. The patient's visual acuity on the right eye is 20/20 with an ocular pressure on the right of 8,10. The patient was seen here on 9/23/15 and diagnosed with conjunctivitis and perceptual cellulitis of left eye that was seen on the CT Scan of the orbits. The patient was told to follow-up with Dr. S___, from Ophthalmology the next day. The patient did not have a ride to the Ophthalmologist office and did not keep the appointment.

The patient had lab work drawn (CBC, Chemistries, Coagulation studies, and a CT of the Orbits with/without contrast. The impression per radiologist: Markedly abnormal appearance of the left orbit. Suspect retinal detachment.

A call was placed to the On-Call Ophthalmologist (A medical Doctor who treats problems of diseases of the eye), by the ED Physician. The time the call was returned is 1354 hours.

A re-evaluation note by the ED Physician reveals Dr. S___, at the bedside.. He requested CT of Orbits with contrast. The results were evaluated by the Ophthalmologist. The Ophthalmologist writes the patient needs surgery which he does not feel comfortable managing at JFK. Patient will be transferred to (the Tertiary Hospital). Dr. S___, spoke to the residents on call (Eye Institute) who cross cover at (Tertiary Hospital). Aware the patient is on his way.

The Ophthalmologist came in to see the patient and dictated an H&P at 1711 hours on 9/26/15. The Ophthalmologist documents he received a call for consult at 1400 hours. The ED physician said I had to come right in to see the patient. The ED Physician got me out of the barber chair.

The Ophthalmologist did a repeat CT Scan plus an CT Angiogram. The interpretation is that the eye has ruptured and there is vitreous coming forward. The impression: Radiology evidence of spontaneous globe rupture.

The Ophthalmologists documents we have given the patient IV antibiotics and pain medications. The ED Physician is going to arrange transfer to have him taken to the Eye Institute (Miami). I offered to call the resident there, but she said she could take care of it, but had to go through the Transfer Center first. I told her if it is impossible to get him that he could be transferred to the Tertiary Hospital and the residents from the Eye Institute would take care of him there as well. We also believe there are some friends of the family members they may drive him to the Eye Institute. We might leave this to the capable hands of the ED staff.

Review of the Call Centers Log reveals Dr. S___, the ON-Call Ophthalmologist, called Dr. P___, at the Eye Institute at 1742 hours. The Eye Institute would accept to their ER by ambulance.

At 1755 hours a discussion between the Call Center and Dr. S___, reveals Dr. S___, stated we are back to trying the Tertiary Hospital. At 1719 the transfer center notifies JFK, another physician heard the case and they will call back after consulting with the specialist.

At 1758 hours the physician at the Eye Institute will accept the patient. The Transfer Priority: Capability - Service not offered at sender ED.

The Date/Time of acceptance 9/26/15 at 1807. The reason for transfer- Capability: Ophthalmology Ruptured Globe.

Review of the Certificate of Transfer reveals the Reason for Transfer: On Call physician refused or failed to respond within a reasonable period of time. The Medical Benefits: Obtain a level of care/services unavailable at this facility, Specialized Ophthalmology.

A second physician, unknown specialty, Dr. Fr___, documents the transfer reason: Transfer to Higher Level of Care. Patient Status: Stable Consent was obtained.

3a. Tertiary Hospital Medical Review of the Medical Record for Patient #1.

The medical record revealed that Patient #1 arrived to the facility on [DATE] at 8:20 p.m., via ambulance. The ED Note-Physician dated revealed that Patient #1 was immediately seen upon arrival to the ED. The ED physician documented in part, The patient presents with eye drainage and globe rupture. The onset was just prior to arrival. The course/duration of symptoms is constant ...Location: Left eye ...symptoms is drainage and bleeding. The degree of symptoms is severe ...Therapy today: prescriptions medications including Dilaudid (medication for pain) ...Review of Systems ...Eye Symptoms: Pain, discharge ...Physical Examination ...Eye: extrusion of material from left globe ...Impression and Plan: Diagnosis Ruptured Globe ...Condition: Guarded ...Patient was given ...Educational materials: MEDICAL SCREENING EXAMINATION, Non Urgent ...Follow up with ...Eye Institute.

4. Policy and Procedure Review

The facility ' s Policy & Procedure Manual, the section entitled, EMTALA-FL Transfer Policy Effective Date, 05/31/2012, 5/13, Reviewed Date 6/15 was reviewed. The transfer policy specified in part, b. A Transfer will be an appropriate transfer if: 1. the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual ' s health...

5. Credentialing Files/Core Privileges for Specialty Physicians review- for Patient #1 and #3

Review of the Credentialing files verified ENT Core privileges included: admission, evaluation, diagnose and provision of both surgical and non- surgical for patients with illnesses, injuries, and disorders of the head and neck to include the thyroid, Parathyroid and lymphatic system.

Core privileges for Ophthalmology include: admission, evaluation, diagnose, consults and provision of both surgical and non- surgical for patients with illnesses, injuries, and disorders of the eye.

Core privileges for Anesthesia include: management of patients with difficult airway and support life functions and vital organs under stress of anesthesia.

The CT physician is privileged for Cardio-Vascular Surgery to treat the heart and related blood vessels. The CT is privileged to diagnose, treat, and consult for patients with illnesses, and disorders of the thoracic cavity including the chest wall.

6. Interviews

Review of the medical records were conducted with the Risk Manager (RM). The RM verified at 1400 hours on 10/15/15 there were no hand written or electronic documentation to support consults or visits were made by the CT Surgeon and/or by ICU physician, as documented by the ED physician and Call Center for Patient #3.

The Assistant Medical Director (AMD) for the ED stated on 10/16/15 at 1100 hours the response time for the ON-Call physician is 30 minutes. The time the calls were made to the consults and the response time are documented in the Call Log. The AMD stated if the On-Call physician is unavailable we can go by the chain of command, Department Chair or the Administrator On - Call. The AMD stated, in response to patient #3, initially stated the On-Call physician (CT) needs to come in to see the patient. The AMD stated, in response to patient #1, if it's pretty obvious if they feel it's something they can't handle it requires a university level of care setting. The AMD stated, I think [tertiary Hospital] is the closest. The AMD also stated at 1120 hours, in response to no evidence to support the CT surgeon came in to see patient #3, I think that's fine. I'm not sure the CT needs to come in.

An interview with the ED physician, Dr. GI___, was conducted on 10/16/15 at 1150 - 1205 hours. The ED physician stated after speaking with a General Surgery resident, CT, ENT and Anesthesia, patient #3 needed University/Tertiary level facility. The ED physician was asked the name of the General Surgery resident that was consulted because the record lacked evidence of that consult. The ED physician could not recall the name of the resident. The ED physician, in response to questioning related to the reason for the transfer to the tertiary level facility stated, They were out of the scope of practice because of the risk. The services were unavailable because they (ENT, Anesthesia and CT) felt they could not do it (surgery) here (JFK). The specialty services felt they did not have the capability and capacity.

Interview with the 9/26/15, On-Call CT surgeon, Dr. F___, was conducted on 10/16/15 1400 - 15 hours. A second CT surgeon, Dr. N___, and the Anesthesiologist, Dr. GU___, were present at the time of the interview. Dr. F__, stated, I never spoke to the ED physician. I was called by resident and asked a question. I was asked what I thought about putting a patient on Cardio-Bypass/Heart Lung Machine to do surgery (Tracheostomy/Thyroidectomy). The CT stated there was no indication for the use of the Cardio-Bypass/Heart Lung Machine. The CT stated emphatically, I Was Not a Consult. The Anesthesiologist verified the CT was not a consult.

Dr. N___, the CT surgeon stated, We work on the Heart and Lungs only and not on the Neck. A Thoracic or ENT needed to manage the case. Dr. Gi___, (ED physician) needs to make that decision. Can you imagine putting a patient on the Cardio-Bypass Heart Lung Machine at the bedside in the ED.

The Anesthesiologist Dr. GU__, stated at 1410 hours, There was no fall back we could not get an intubation tube in and ventilate the patient. The ED physician wanted to do the surgery at the bedside. It was Saturday and there were not enough services/personnel available to do a surgery at the bedside without anesthesia. The airway was too compressed. ENT needs to intervene. There was no consideration of a Thoracic Surgeon to do the tracheostomy.

A telephone interview with the ENT, Dr. B___, was conducted on 10/16/15 at 1415 hours. The ENT stated, In my assessment, plan, and multiple consults with General Surgery, Anesthesia and CT, led to making the decision to transfer. Dr. F___, he could not manage the patient here at JFK. The ED MD communicated with the tertiary facility. There was no hesitation per the receiving facility to accept the patient. I scoped the patient because of the narrowing of airway. The thyroid tissue was compressing the trachea. The General Surgeon recommended we need evaluation by all disciplines before we admit. I felt we consulted everyone as to the appropriateness.

The facility failed to ensure that their transfer policy and procedure was followed as evidenced by failing to ensure that medical treatment was provided that was within its capacity to minimize the risks to Patients #1 and #3 health and safety on 9/26/2015. As this resulted in inappropriate transfers for patient #1 and #3 on 9/26/2015.

Violation Name: ORDERS FOR DRUGS AND BIOLOGICALS(A-0409)

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Based on policy review, clinical record review and interview the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care for 3 of 5 sampled patients (Patient #2, #4 and #11) as evidenced by failure to monitor vital signs during blood transfusions as specified per facility policy.

The Findings include:

Facility Policy titled Blood Product Administration last revised 02/2014 documents Baseline vital signs must be taken before within 30 minutes of transfusion.

During transfusion: Repeat vital signs at 15 minutes and as patient condition requires and compare to baseline. If there are no signs of transfusion complications, adjust flow to the prescribed rate. The patient is to be reassessed every 30 minutes thereafter for possible signs of transfusion reaction. Refer to Nursing procedure.

1. The pre transfusion temperature will be used as a baseline for determining if there is a transfusion reaction. Any temperature increase of 2 degrees Fahrenheit above the baseline will be reported.

2. Marked change in other vital signs

3. Chills

4. Pain

5. Itching

6. Skin rash

7. Facial swelling

8. Nausea

9. Tingling

10. Muscle cramps

11. Respiratory distress

Clinical record review conducted on 03/26/15 through 03/27/15 revealed the following:

Transfusion Record for Patient # 11 documents blood transfusion was administered on 02/24/15. Further review of the record failed to provide evidence the patient was reassessed as specified per facility policy for signs of transfusion reaction. The clinical record provides no evidence a complete set of vital signs was done every thirty minutes during the transfusion.

Transfusion Record for Patient # 2 documents blood transfusion was administered on 03/26/15. Further review of the record failed to provide evidence the patient was reassessed as specified per facility policy for signs of transfusion reaction. The clinical record provides no evidence a complete set of vital signs done every thirty minutes during the transfusion.

Transfusion Record for Patient # 4 documents blood transfusion was administered on 03/26/15. Further review of the record failed to provide evidence the patient was reassessed as specified per facility policy for signs of transfusion reaction. The clinical record provides no evidence a complete set of vital signs was done every thirty minutes during the transfusion.

Interview with The Chief Nursing Officer (CNO) conducted on 03/27/15 at 4:10 PM revealed the CNO reviewed the facility policy and verified patient reassessments are to be completed every 30 minutes and the reassessment should include vital signs, specifically temperature readings as the policy describes signs of transfusion reaction as an increase of 2 degrees or marked changes in other vital signs.

Interview with The Director of Patient Safety conducted on 03/27/15 at 4:45 PM revealed the Risk Managers and The Director of the Unit are researching the records for Patient # 2, # 4 and # 11 for further evidence of monitoring during the blood transfusion. The facility was not able to locate additional documentation to validate monitoring was provided to the patients as specified per policy.

Violation Name: COMPLIANCE WITH 489.24(A-2400)

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Violation Name: RECIPIENT HOSPITAL RESPONSIBILITIES(A-2411)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on documentation review, staff interview and policy review, the hospital emergency service personnel failed to accept a patient on whose behalf a request for transfer, for a higher level of emergency care and specialized neurological services within JFK Medical Center's capabilities, was made. This failure affected 1 of 22 sampled patients, Patient #7.

The findings include:

Review of the facility's administrative policy & procedure titled EMTALA - Florida Transfer Policy revealed Under Policy: A hospital with specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units or with respect to rural areas, regional referral centers) shall accept from a transferring hospital an appropriate transfer of an individual with an EMC(Emergency Medical Condition) who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. The transferring hospital must be within the boundaries of the United States. Under Policy 1. B. A transfer will be an appropriate transfer if: i. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual ' s health and, in the case of a woman in labor, the health of the unborn child; ii. The receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment ...iii. The transfer is effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transfer. Under the same policy c. Higher Level of Care: i. A receiving hospital with specialized capabilities or facilities that are not available at the transferring hospital ...must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual ...Under 2. Other Transfer Situations ...c. PreExisiting Transfer Agreements, Appropriate transfer agreements should be in place and in writing between the hospital ...Under 6. B. When a facility is a potential receiving facility, it has a duty to accept Medically Necessary Transfers regardless of whether Facility is the geographically closet hospital ...

Review of the Medical Staff Rules and Regulations titled Emergency Services Under section F revealed, Transfer upon Request by the Medically Unstable Patient or Legally Responsible Person Acting on the Individual ' s behalf ...Receiving or Recipient Hospital Responsibilities ...A Hospital that has specialized capabilities or facilities ...or is designated as a regional referral center, may not refuse to accept from a referring hospital an appropriate transfer of an individual requiring such specialized capabilities or facilities if the receiving or recipient hospital has the capacity to treat the individual ...Non-Discrimination, The hospital shall not refuse to accept an appropriate transfer of an individual with an emergency medical condition if the individual requires a specialized services ...available at the hospital, if the hospital has the space and personnel available necessary to treat the individual and the transferring facility does not have the specialized services needed ...

Review of JFK Medical Center's State license and Emergency Department (ED) posted service capabilities revealed the facility offers the services of neurology and neurosurgery, which was requested for sampled patient #7 on 08/11/2014.

Review of the on-call specialty list for JFK Medical Center revealed a neurosurgeon is documented as being on call the day and night of 8/10/14 and 8/11/14.

There is a current transfer Agreement documented and in place for transfers to JFK Medical Center from the transferring facility (B).

2. Review of JFK Medical Center documentation related to Patient #7 revealed There is no ED Clinical record for Patient #7 as the patient did not present to their ED, as a result of a refusal to accept the patient without specific stipulated test(s).

Review of the Emergency Transfer Log / Request for Transfer completed by the nursing supervisor revealed: 8/11/14, 0215 (2:15 AM), emergency room - emergency room transfer, Other - went to Facility C; the diagnosis documented is Possible Arteriovenous Malformation (AVM). Reason - Neurointervention; Under Patient Condition at Time of Transfer - Transfer Center (JFK Medical Center's) was told by charge at the transferring facility (Facility #B), facility B Neurosurgeon did not have the test capabilities; sent to Facility C; Administrator on Call for JFK Medical Center was notified; JFK Interventionalist told facility B ED doctor he wanted a CT Angio (angiogram) of patient #7's Brain.

Review of the ED record for Patient #7 from Facility B, the transferring hospital, revealed: the patent (MDS) dated [DATE] at 11:14 PM with complaint of dizziness, nausea / vomiting & generalized weakness; The patient was triaged at 11:27 PM; A Medical Screen Examination (MSE) was done at 11:33 PM & patient with Headache & increased blood pressure; A Computerized Tomography (CT) scan of the patient's head was completed on 8/11/14 at 00:40 AM. Facility B's ED physician documented diagnosis of Intracerebellar Bleed and possible Anteriovenous Malformation (AVM)/cerebellar. Review of the Transfer Form dated 8/11/14 revealed: diagnoses of Intracerebellar bleed, possible AVM for neurosurgical intervention, risks & benefits were explained; Receiving hospital: JFK Medical Center is documented on the Form and crossed off, and Facility-C is documented; The name of the received ED physician at JFK Medical Center was crossed off, and Facility-C 's neurosurgeon name is documented with facility-C's ED's physician name also documented. The patient is documented as transferred to Facility-C at 3:20 AM via Ambulance.

Review of the ED Record documentation for Patient #7 from Facility-C Hospital, which accepted Patient #7 revealed: Patient #7 (MDS) dated [DATE] and had a MSE performed on 8/11/14 with diagnosis of Intracerebral Hemorrhage. A Cerebral Angiogram was done.

3. The ED manager at JFK Medical Center said on 10/02/2014 at approximately 9:00 AM: All transfers go through the Transfer Centers; ED physician makes a determination based on patient needs; patient transfers-in go through the Transfer Center; the call goes directly to the ED physician (with transferring physician on the line), and then to the nursing supervisor, the nursing supervisor would accept the patient based on facility capacity; ED physician accepts from a physician stand point. Normally the process is pretty quick; ED physician would let the nursing supervisor know giving details of the patient coming in. It is the same process on all shifts.

Interview with a Nursing supervisor (7a-7pm) on 10/02/2014 at 9:50 AM revealed:

Transfer-in calls from any ED to ED are documented; Right now for ED patient transfers in, we receive a call from the HCA Transfer Center saying that the ED-physician has accepted a patient from another ED, and the Supervisors are given the patient's name and reason for required transfer. The call is not received until the ED physician has accepted the patient. She agreed JFK Medical Center offers neurology & neurosurgery.

Interview with the Ethics & Compliance Officer on 10/02/2014 at 10:18 AM revealed a self reported incident in which JFK Medical Center newly hired ED doctor may not have been fully informed of their facility process fro transfers. A transferring facility (Facility B) had alleged their CT scan was down and had some question as to whether the MRI/MRA (Magnetic resonance imaging/angiogram) could be done by them (facility B) at nighttime or if a team was not available. ED Physician said we could not accept the patient (#7) without the MRI/A. The compliance officer said the ED physician should have accepted the patient anyway. The patient (#7) was transferred to another facility for pending or possible pre-stroke to rule stroke, by facility B.

She said it is JFK Medical Center's process to accept any patient for neurology or neurosurgery. The new ED physician engaged other physicians in the ED & the on-call neurologist in making the decision whether to accept the patient instead of just accepting the patient. She said the on-call physician/specialist should not have been contacted until the patient was accepted and enroute to JFK Medical Center.

She also said: The transferring ED called the transfer center, which in turn contacted our facility ED doctor for ED-ED conversation. Normally the Transfer center would notify the nursing supervisor also, it was determined this was not done so the ED physician did not have the additional input/knowledge of the nursing supervisor.

The Transferring facility's (facility B) ED doctor was told the patient needed a CTA (Computed Tomography Angiogram) prior to being accepted for transfer; Facility-B had said they could not do the CTA but wanted to transfer the patient to a higher level of care. The Compliance Officer said our ED physician should have accepted whether an Agreement was signed or not.

The Compliance Officer agreed the time frame from the initial call from the Transfer Center to accepting patient #7, was approximately 2 hours, when it should not be more than 20 minutes. The nursing supervisory was not notified by the Transfer Center initially per protocol, and when she became involved (2:15 AM) and called the transferring hospital (facility B) back, Patient #7 was already being sent to another facility (C) for higher level of care. The Compliance Officer said the ED physician was relatively new but should have accepted patient without calling the specialty on-call or engaging other physicians prior to accepting the patient. The Compliance Officer said, JFK Medical Center had the capability and the capacity to accept Patient #7.

Review of the Timeline of Transfer Call for 8/11/14 revealed: 1:25 AM - connected with referring doctor; 2:10 AM - administrator (JFK) notified; 2:05 AM - nursing supervisor notified of transfer request; 3:04 AM - nursing supervisor advised the transfer to JFK was canceled. It was determined from listening to the audio-tape of the transfer call that Physician-A said need to discuss with our neurosurgeon before accepting and will get back to Facility-B; there were several calls placed; the nursing supervisor was notified by the Transfer Center of the delay in accepting Patient #7; JFK Medical Center ED-physician called Facility-B saying if Patient has just intracranial bleed, that you can handle, will not accept; If an AVM that you can't handle, will accept patient. JFK Medical Center was notified Patient #7 was transferred to Facility-C, after 2 hours delay in accepting the patient.

Review of documentation provided by the Compliance Officer revealed Physician #A told the Medical Director at JFK Medical Center that he was notified of the request to transfer Patient #7 in at approximately 1:13 AM, and that the patient has complaints of headache, dizziness, and vomiting, was neurologically intact, alert & oriented; that subsequently was found to be intraparenchymal bleed; Facility-B stated their Radiologist said, bleed was possibly due to AVM and recommended MRA; was told it was discussed with Facility-B's neurosurgeon who said they do not treat AVMs and the patient needs to be transferred to higher level of care for MRA. Physician A was told facility B does not do MRAs at night; JFK Medical Center's ED physician discussed the concerns with the neurosurgeon on call and it could not be determined, based on the current scan at Facility-B, if the patient had AVM. JFK Medical Center's neurosurgery team was notified; Shortly after this, the Transfer Center station called and said the ED physician had a duty to accept the patient; the ED physician then told the Transfer Center he would accept the patient but needed the neurosurgeon involved and on board because if patient arrives and decompensates, they need to be on board for definitive therapy. After discussion with the neurosurgeon, the ED physician called Facility-B to accept the patient, after CTA was completed. Later, approximately 2 hours, the Transfer Center called back and stated Facility-C has accepted the patient.

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

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Based on staff interviews and clinical record reviews, it was determined nursing staff violated professional standard of practice by failing to promptly notify the physician of a change in condition for 1 of 12 sampled patients (Patient #2).

The findings include:

Clinical record review revealed Patient #2 was transferred to the Intensive Care Unit for close observation at 1500 hours on 2/7/14. Review of the physician progress notes reveals the patient had episodes of agitation following an Upper Endoscopy .

On 2/7/14 at 9:20 PM the physician ordered bilateral soft wrist restraints (Medically necessary Restraints) due to the patient's attempts to remove medical device, and medically unsafe attempts at mobility.

Review of the Patient Care Notes on 2/7/14 at 9:50 PM reveals patient #2 was observed by the nurse pushing his left arm under the side-rail. The nurse documented, he assisted the patient in removing the arm The nurse wrote, he explained to the patient he could cause himself injury. The patient stated: he didn't care; that his left arm is broken, and accused the nurse of breaking his arm.

Per the 02/07/14 nurse's note in the clinical record, the nurse assessed the patient's left arm as follows: no swelling, no bruising at the site. The patient has full range of motion. The nurse wrote, it is of some concern at this time, that the patient seems to be trying to cause self-injury.

At 3:00 AM the nurse document, the patient is trying to get out of the bed, and is instructed about safety and call bell use. The patient still complains of pain and swelling to his left arm. The patient was assessed by a second RN who explained to the patient, his arm is not swollen, and also instructed the patient again on safety and call bell use. The RN the explained the patient 's condition to the Charge Nurse.

Review of the nurse's notes at 3:10 AM on 02/08/14 reveals the patient is still complaining of pain in the left arm. The RN documents there is some bruising at the site; the bruising appears to be old; There is no edema noted; The nurse took a photograph of the patient's left wrist at this time.

The nurse placed a call to the physician at 4:18 AM on 02/08/14. The physician ordered a portable x-ray of the left wrist. Further review of the medical record revealed a second request for a x-ray was made on 02/08/14 at 10:37 AM.

A request for Orthopedic consult was made 02/08/14 at 10:58 AM. The reason for the consult: Left wrist fracture.

The facility policy and procedures titled Restraint Monitoring specifies, monitoring of the restrained patient is to be documented every 20 minutes as per policy and procedure. The assessment includes signs of injury associated with restraint. Any change in physical or psychological response will be reported to the RN. The RN will determine if medical intervention is required. There is no supportive evidence found, or provided, in the medical record indicating monitoring of patient #2's wrist restraints every 20 minutes per policy.

The nurse failed to promptly notify the physician of a significant change in patient #2's condition. The patient began to complain of pain in the left arm, as of 9:00 PM on 02/07/14, the physician was not notified until 4:18 AM on 02/08/14. Furthermore nursing staff failed to substantiate / document evidence of monitoring the restrained patient as per policy.

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, and staff interview the facility failed to ensure the quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care. This failure affected 1 of 10 sampled patients (Patient # 10).

The findings include:

Clinical record review for Patient # 10 revealed the patient was admitted to the facility on [DATE] with diagnosis of Distal Left Femur Fracture.

The Initial Nursing assessment dated [DATE] documents the patient ' s skin as intact; The Braden Pressure Ulcer Risk Assessment documents a score of 16 (low risk).

The Care Plan titled Skin Impairment dated 09/05/11 documents the goal as patient will maintain optimum skin integrity as evidenced by no further skin injury during this hospital stay. The interventions are noted as assist to off load Buchs Traction, off load heels and wound care as ordered. Further review of the care plan revealed the facility developed a care plan based on the patient ' s identified needs and the care plan includes approaches for treatment and services. The care plan however does not include approaches for care of the patient ' s surgical post- operative wound.

Review of the clinical record revealed Patient # 10 underwent an Open Reduction Internal Fixation of the left femur (ORIF) on 09/06/11. A physician order dated 09/06/11 documents leave surgical dressing intact unless soiled . This care approach for the surgical wound / incision is not documented or incorporated in the care plan. There are no further instructions for care of the surgical incised wound documented on the medical record.

Interview with RN # 1 was conducted on 11/02/11 at 11:33 AM. Registered Nurse # 1 stated post- operative care is dictated by the physician orders, and that most commonly wound care is provided on the second day after surgery and then daily.

Interview with the 5th floor Charge Nurse conducted on 11/03/11 at 10:25 AM revealed the facility does not have postoperative wound care policies and procedures, and the post-operative care is driven by physician orders. In addition the Charge Nurse stated, the facility has a Protocol to change surgical dressings on the second day post operatively and then daily. The Charge Nurse explained, nursing assessments includes incision/wound assessments and those assessments are to be done every shift. The Charge Nurse reviewed the electronic clinical record for Patient # 10 and stated the facility ' s protocol / practice for wound care is also determined by the type of surgical dressing. The Charge Nurse stated Patient # 10 had a dressing called Island or paper dressing, which according to the Protocol is to be changed on post- op day two and then to be changed daily.

The surveyor requested to review the Protocol and was informed there is no written Protocol. Nurses #1 and the Charge Nurse were interviewed and they both acknowledged the Protocol is to change surgical dressings on post-operative day two, unless the physician ordered a different treatment.

The facility failed to develop written standards of nursing practice and related policies and procedures to define and describe the scope and conduct of patient care provided by the nursing staff as it relates to post-operative incisional wound care.

Review of Patient # 10 clinical record revealed the delivery of care by nursing as follows:

Nurses Notes dated 09/06/11 through 09/08/11 reveals the surgical incision to the left femur was assessed and the first dressing change is documented to have been done on 09/08/11. Subsequent Nurses Notes dated 09/09/11 and 09/10/11 fail to substantiate the performance of wound assessments or dressing changes to the patient ' s left femur. Daily dressing changes to the surgical incision are documented from 09/11/11 thru 10/05/11 with the exception of 09/22/11 and 09/24/11.

The Nursing Shift assessment dated [DATE] at 8:00 PM documents, dressing change to left hip as family requested, they were told it was not changed yet . The Assessment also document another wound to the patient ' s left femur described as skin tear . The skin tear measured 2 centimeters in length and 2 centimeters in width. The assessment also notes wound site # 2 to the patient ' s left lower extremity. This wound is described as a skin tear that is partially granulated. The nurse also documented the physician was notified of both skin tears/wounds.

Physician ' s Order dated 09/11/11 documents the performance of a wound care consult. Skin Wound Management Protocol Order Sheet dated 09/12/11 documents as follows:

Skin tears and abrasions: Cleanse with Normal Saline and apply Safegel then cover with Mepilex border or Mepitel Dressing and Gauze. Change every other day. This entry is not marked off, indicating nursing acknowledgement, on the order sheet.

The entries checked off on the document are as follows:

? Reposition every two hours in bed and every 15-30 minutes when in chair. Seat cushion while in chair at all times. Offload heels to relieve pressure while in bed at all times.

? Suspected deep tissue injury to left heel and top of left foot. Off load area to relieve pressure at all times. Cleanse with saline apply Xeroform cover with dry gauze and Kerlix daily.

? The document also includes an order for nutritional consult.

Further review of the Nursing Shift Assessments and Nurses Notes failed to disclose wound care was provided for Patient # 10 in accordance with the spoken facility protocol (for the surgical incision wound) as per the charge nurse, or based on the specified physician orders for the patient ' s skin tears:

Skin Wound Management Protocol Order Sheet dated 09/12/11 documents as follows:

Skin tears and abrasions: Cleanse with Normal Saline and apply Safegel then cover with Mepilex border or Mepitel Dressing and Gauze. Change every other day. (This order is not marked off in the medical record ' s order sheet, indicating nursing acknowledgement).

The nurses documentation reflects the following:

Wound (skin tear) care to left heel was not provided on 09/14/11, 09/15/11, 09/16/11, 09/17/11, 09/18/11, 09/19/11, 09/20/11, 09/22/11, 09/24/11, 09/25/11, 09/26/11, 09/29/11, 09/30/11, 10/04/11 and 10/05/11.

Wound (skin tear) care to top of left foot was not provided on 09/16/11, 09/17/11, 09/18/11, 09/22/11, 09/24/11, 09/28/11, 10/04/11 and 10/05/11.

The Nurses Notes dated 09/21/11 documents the incision wound is necrotic, and another and new wound to the patient ' s left lower leg/left ankle was identified. The physician and surgeon were informed per the nurse ' s note. Pictures were taken and the dressing was changed.

A physician order dated 09/21/11 documents wound care with Xeroform to left ankle with 4x4 Kerlix daily.

Further review of the Nurses Notes failed to substantiate the provision of wound care, to the left ankle/lower leg wound, was rendered to Patient # 10 on 09/24/11, 10/03/11, 10/04/11 and 10/05/11.

In addition the clinical record contained a physician order dated 09/26/11for Santyl ointment to be applied to affected areas. The physician order did not identify wound location. Review of the Nurses Notes documented the Santyl ointment was applied to the left hip incision area.

Interview with the 5th floor Charge Nurse was conducted on 11/03/11 at 10:25 AM. The Charge Nurse reviewed the entire (all) electronic Nurse ' s Notes contained in the clinical record of patient #10. She stated she recalled Patient # 10, as the patient was in the unit for almost a month. The Charge Nurse stated the wound care order dated 09/12/11 was only for the left top of the foot, not the heel. She acknowledged the order sheet documents treatment orders to both the heel and the top of the foot, but she added the heel was not open and there was no reason to do this dressing to the heel . (The charge nurse ' s position is in direct conflict with the skin wound management protocol orders for skin tears dated 09/12/11).

The Charge Nurse reviewed the Nursing Assessments and acknowledged the discrepancies found and mentioned in this report above, relating to wound assessments and the treatment provided. The Charge Nurse stated the nurses are documenting the dressings were not performed and the assessments were deferred. The Charge Nurse stated some of the nurses documented the wound to the top of the foot twice and they failed to document the heel. The Charge Nurse was not able to provide written clarification of the wound orders dated on 09/12/11, nor clear and concise evidence of nursing personnel ' s adherence to the spoken standards of care (Protocol) or written physician ' s orders. The Charge Nurse stated the nurses follow physician orders for post-operative care, and the protocol is to change the dressing to the incision on post- operative day two and then daily. She stated the only exception would be for patients who had the Dermabond dressing or skin glue (a clear dressing that would stay in place until the patient is seen by the physician as an outpatient). The Charge Nurse was unable to locate and provide the facility ' s written protocols / standards that define and describe the approaches to be rendered in providing surgical incisional care, and as it relates to Patient # 10 a care plan that includes the approaches for care to be rendered for the incision wound was not established nor provided during the survey.

Interview with the Wound Care Nurse was conducted on 11/03/11 at 12:00 PM. The Wound Care Nurse stated the wound care order dated on 09//12/11 was written by one of the Wound Care Nurses. She stated the wound care was for both the heel and the top of the foot. The Wound Care Nurse stated, the floor nurses do the wound care but the Wound Care Nurses monitor the wound periodically. The Wound Care Nurse presented an electronic order dated 09/26/11 for Santyl ointment. She stated this order was written by the wound care physician. The Wound Care Nurse was not able to explain which wound was to receive this treatment. The physician order read Santyl Ointment to affected areas.

Review of the policy titled Wound Care Assessment revealed nursing documentation should include the following: Daily skin assessments and treatment interventions and response to treatment.

The above described provision of care does not comply with the physician orders for wound care. The clinical record failed to substantiate the actions taken by nursing in providing care and services related to wound care is consistent with the medical practitioner ' s goals.

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HCA Florida JFK Hospital

32 CMS Violations since 2011-11-03

Non Immediate Jeopardy Violations

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: EMERGENCY ROOM LOG(A-2405)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: DISCHARGE PLANNING EVALUATION(A-0808)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: EMERGENCY ROOM LOG(A-2405)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: NURSING CARE PLAN(A-0396)

Violation Name: ORDERS FOR DRUGS AND BIOLOGICALS(A-0409)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: EMERGENCY ROOM LOG(A-2405)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: APPROPRIATE TRANSFER(A-2409)

Violation Name: MEDICAL STAFF - ACCOUNTABILITY(A-0049)

Violation Name: ADMINISTRATION OF DRUGS(A-0405)

Violation Name: ADMINISTRATION OF DRUGS(A-0405)

Violation Name: ORDERS FOR DRUGS AND BIOLOGICALS(A-0409)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: ON CALL PHYSICIANS(A-2404)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: APPROPRIATE TRANSFER(A-2409)

Violation Name: PATIENT RIGHTS: NOTICE OF RIGHTS(A-0117)

Violation Name: DISCHARGE PLANNING PERSONNEL(A-0818)

Violation Name: IMPLEMENTATION OF A DISCHARGE PLAN(A-0820)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: APPROPRIATE TRANSFER(A-2409)

Violation Name: ORDERS FOR DRUGS AND BIOLOGICALS(A-0409)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: RECIPIENT HOSPITAL RESPONSIBILITIES(A-2411)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Respect us. Protect us. Pay us!

HCA Florida JFK Hospital

32 CMS Violations since 2011-11-03

Non Immediate Jeopardy Violations

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_3cca1d4004d5c958f839aa5b30845142','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_39360fc5a073dddc896e8bd95bdfe4c0','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_b9a13a453cb37cc11804ac2d270f6e5c','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)