HCA Florida Northwest Hospital

Based on interview and record review the provider failed to make reasonable attempts to notify the primary care provider of the patient's admission, as chosen by the patient, for 1 of 3 patients (Patient #1).

The findings included:

Review of the clinical record revealed Patient #1 was admitted to a medical surgical floor on 11/25/19. The clinical record documents Patient #1 was alert and oriented and made his own medical decisions. Patient #1's face-sheet documents his primary care physician as (Nurse Practitioner's name, to be referred to as Nurse Practitioner Z).

During interview on 01/15/20 at 1:20 PM, the Patient Safety Director stated they do not notify midlevel providers such as Nurse Practitioners of patient admissions but could provide no evidence that staff asked Patient #1 for his primary physician's contact information.

During review of Patient #1's intake information with Registrar, Staff C, on 01/15/20 at 3:19 PM, Staff C showed and explained Nurse Practitioner Z was identified as his primary care provider (PCP) upon admission 11/25/19 and that he answered yes to notify the PCP of his admission. Staff C denied responsibility to notify the PCP of admission herself but stated the Unit Secretary may do that.

During interview on 01/15/20 at 3:23 PM, Unit Secretary, Staff D, showed where and how she can document if she calls PCPs and connects them to the emergency room physician. Staff D reviewed Patient #1's record and showed documentation of a call to the admitting physician for admission orders but was unable to find evidence of any attempts to notify the primary provider, Nurse Practitioner Z, of Patient #1's admission.

During interview on 01/15/20 at 5:31 PM, the Patient Safety Director stated she talked to the Physician Liaison who described an automated system whereby physicians can elect to receive notifications of their patients' admissions and may choose from various intervals at which to get a list of their patients who have been admitted , such as daily or more or less often. The Patient Safety Director stated if a patient answers to the Registrar that they would like their PCP notified of their admission, the notification would go out according to that PCP's set preferences. The Patient Safety Director stated since this PCP was not in the system, they could not receive such notification. The Patient Safety Director did not describe a system for notifying PCPs promptly, or at the time of admission, as required.

Based on interviews and record reviews, the hospital failed to develop nursing care plan interventions in response to ongoing assessments of the patient's needs in 1 of 3 patients reviewed (Patient #1).

The findings included:

On 06/16/19 at 2:44 AM, Patient #1 arrived at the Emergency Department (ED), via Emergency Medical Services (EMS). The patient presented with altered mental status and generalized weakness. His wife accompanied him, stating that he woke at 2:00 AM to go to the bathroom and slid off the bed. She could not get him back to bed and called 911. The patient's history included a cerebrovascular accident (CVA) 15 years ago with mild residual right hemiparesis and expressive aphasia.

At 2:49 AM, a stroke alert was called. The ED physician report revealed no new motor deficit, but the patient was uncooperative on examination, needing sedation, Ativan 2 milligrams IV (intravenous), for CT (computerized tomography) scan of brain, and angiograms of the head and neck. Neurology was called and found the patient was not a candidate for a Tissue plasminogen activator (TPA) as the patient was on coumadin and his international normalized ratio (INR) >1.7 (greater than 1.7).

The impression of the CT Scan of the brain revealed 'a large chronic left middle cerebral artery territory left temporal parietal infarct with encephalomalacia. No acute intracranial hemorrhage. The angiograms of the head and neck revealed no large vessel occlusion and the physicians ruled out a stroke.'

On 06/16/19 at 3:16 AM, the patient's toxicology test revealed Alcohol, Quantitative (0-10mg/dl) was 15 high.

On 06/16/19 at 8:41 AM, the patient was admitted to the telemetry floor.

On 06/16/19 at 4:09 PM, the Nursing Plan of Care revealed document neurovascular checks; 4:53 PM, create fall precautions; and 7:43 PM, create Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA).

On 06/16/19 at 8:00 PM, the clinical / nursing documentation revealed a fall intervention in use: bed exit alarm, family presence, patient at high risk for falls.

On 06/16/19 at 8:22 PM, review of RN-A's (Regisitered Nurse-A) nursing note revealed 'report given to RN-E; RN-B (night charge nurse) present and aware of patient status. Patient is combative and at risk for fall. Fall precautions in place. Patient would benefit from a sitter, in addition to family presence, due to confusion and combativeness. Concerns verbalized to the night charge nurse (RN-B), and the covering nurse (RN-E).'

On 06/16/19 at 8:30 PM, review of charge nurse RN-B's nursing note revealed report received from RN-A. The report included: 'Patient very combative. Jumping out of bed, not following instructions and very high risk for falls, due to noted unsteadiness. Unable to leave bedside to complete shift change reports at this time due to patient's impulsiveness and my concern for his safety. Charge RN-B aware and reaching out to MD's A & B (Medical Doctor) for orders. Patient's spouse at bedside for most of the day. Also, having a difficult time trying to control patient. Patient pulling on IV and monitor leads constantly. Safety protocol in place.'

On 06/16/19 at 8:54 PM, review of charge nurse RN-B's nursing note revealed 'spouse at bedside. Patient at times is combative. Patient is non-verbal, non-compliant with safety precautions. Patient is extremely agitated. Does not follow instructions. Patient is very high risk to fall. MD-B notified by phone call. Order received for Ativan IV one dose. Second call placed to MD-A via service. Bedside RN advised.'

On 06/16/19 at 9:53 PM, review of charge nurse RN-B's nursing note revealed 'MD-A notified by phone of patient's condition and aware patient received Ativan IV per MD-B. MD-A suggests CIWA Protocol. MD-B notified no new orders received from MD-A. CIWA ordered by MD-B. Bedside RN advised.'

On 06/17/19 at 3:18 AM, review of charge nurse RN-B's nursing note revealed at approximately 3:00 AM, 'staff heard loud noise from patient's room. Upon entering the room, patient and his daughter found on floor. Patient has bump over his left eye and laceration on left eyebrow. Patient assisted back to bed with the assistance of 4 staff. MD-B notified immediately of fall. Stat CT Brain ordered.'

On 06/17/19 at 4:00 AM, review of nursing note revealed 'heard loud noise behind patient's bedroom door while speaking to patient care technician (PCT) nearby in the hallway side regarding his care. Daughter heard screaming and quickly entered room followed by other staff. Daughter noted on floor with her left leg supporting father's head, and bleeding noted on his forehead. Assisted by other staff, patient picked up and eased onto bed. Patient taken to CT Stat as ordered. CT completed and patient back to floor. Patient still somewhat agitated but being monitored by PCT sitting in room now along with daughter.'

On 06/17/19 at 5:24 AM, review of the nursing note revealed the radiologist reported the results of the CT Scan of Brain shows acute right hemorrhagic infarct. MD-A and MD-B notified.

On 06/17/19 at 3:49 AM, the findings of the CT Brain Scan revealed acute right posterior division middle cerebrovascular accident infarct with small degree of hemorrhagic conversion measuring 11 x 8 millimeters.

On 06/17/19 at 7:36 AM, the patient was transferred to the Intensive Care Unit (ICU) accompanied by his daughter. Patient does not respond. Bruising noted to left eye with gauze dressing in place.

On 06/18/19 at 12:50 PM, review of MD-C's Progress Note revealed the patient required transfer to the ICU after he fell with a CT Brain showing Intracranial Hemorrhage (ICH). Impression: 1. Traumatic ICH status/post fall; 2. Agitated Delirium/ETOH Withdrawal; 3. Diabetes Mellitus.

06/19/19 at 11:24 AM, review of MD-C's Progress Note revealed initially thought Traumatic ICH status post fall, later assessed as Acute Right-CVA with hemorrhagic conversion.

On 06/25/19, the patient was discharged to hospice.

Reviewed the facility report for Patient #1, with the Patient Safety Director, on 09/25/19 at 12:11 PM, revealed she stated she was the Director of the Telemetry Unit when the patient fell . A facility report was generated, and she conducted the investigation. She stated that when the patient was found on the floor, after a thud was heard, no bed alarm was heard. The CT scan was ordered, and the patient was transferred to ICU.

Review of the facility Corrective Action revealed: The Director of Telemetry implemented the Patient Safety Performance Improvement Team. Their purpose is to coach and teach staff purposeful hourly rounding, the Go Green Initiative (checking each of the fall precautions when doing your rounds such as, bed in low position, bed exit alarm on, bedside table & personal affects in reach, call bell near patient, urinals are empty). She stated that there was no investigation as to why the Sitter Justification Policy & Procedure was not followed and a sitter assigned to Patient #1.

Review of the Sitter Justification Policy & Procedure revealed the following procedure:

1. The nurse will identify patients at risk for harm or in need of additional attention.

2. The nurse will document the risk factors in the medical record.

3. The nurse will assess and document at least every shift.

4. The nurse will request a sitter by completing the Sitter Justification Record and requesting the Department Director's approval or the Nursing Supervisor's approval in the absence of the Director.

5. The Department Director/Nursing Supervisor will review the medical record to determine whether all appropriate interventions have been implemented. The Director/Supervisor will approve of deny sitter request after consultation with the Chief Nursing officer or Administrator On-Call.

6. Upon Departmental approval of the sitter, the Director/Supervisor will sign the Sitter Justification Record and place the form in the Sitter Justification notebook.

On 09/24/19 at 1:15 PM, the Patient Safety Director stated that the staff were treating the patient with medication sedation per the CIWA Protocol, for alcohol withdrawals and were not focusing on the fall risks. Although they did have the patient on fall precautions, including the bed exit alarm, she stated the decision regarding fall risk precautions and/or sitters being assigned is the responsibility of nursing.

On 09/25/19 at 4:45 PM, the Patient Safety Director stated that after RN-A reported to RN-B & RN-E, the patient's condition and that he would benefit from a sitter, they should have contacted the physicians for an order for a sitter. She stated they contacted the physicians, but the order given was for the CIWA protocol and Ativan medication for alcohol withdrawals. She stated that RN-A was following the Sitter Justification Policy & Procedure by notifying RN-B & E. She stated RN-B & E should have ordered the sitter themselves, per the Sitter Justification Policy & Procedure, as there were 8 sitters available in the hospital.

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

Based on interview and record review, the facility failed to reassess a discharge plan for 1 of 3 sampled patients reviewed for discharge planning, Patient #1, as evidenced by discharging Patient #1 out of the hospital while a discharge appeal was in process.

The findings included:

Review of the facility policy, titled Addendum: Case Management/Discharge Planning, states in part, 'IV- Reassessment of the patient is done at least within the geometric length of stay. Reassessment is especially necessary in cases where patient's condition or situation may have changed and to ensure the medical necessity of service continues.'

Review of the clinical record for Patient #1 revealed she was admitted on [DATE]. The initial hospital course included admission to the intensive care unit with subsequent transfer to a telemetry unit on 02/05/19.

Review of the initial assessment Case Management Notes' dated 01/31/19, involving Patient #1's spouse as Patient #1 was unable to participate due to her medical condition, documentation by Case Manager (CM) 'A' stated the discharge plan was home health versus SNF (skilled nursing facility) pending clinical outcome. Review of the demographic sheet generated on admission, documented Patient #1's spouse as the next of kin and person to notify in case of an emergency.

Review of Case Management Notes dated 02/06/19 by CM 'A' document 'Transfer to (telemetry unit) on 02/05.'

Review of the next Case Management Note entry dated 02/11/19 at 1:30 PM by CM 'B' documents 'Discharge planning discussed with spouse, spouse agrees to send referrals to SNF in the insurance network, also patient's sibling wants to be updated, he can be reached at ....'

Review of the clinical record revealed no evidence of documentation the patient or the patient's spouse authorized this sibling to be involved in Patient #1's discharge planning.

Review of a Case Management Note entry dated 02/11/19 at 1:44 PM by CM 'B' documents 'Received call from sibling. Refuses SNF '1', awaiting on accepting facilities.' There is no evidence of documentation by CM 'B' that a referral was even sent to SNF '1'.

Review of a Case Management Note entry dated 02/11/19 at 3:41 PM by CM 'B' documents 'CM spoke with (insurance company representative) stated that he will authorize SNF if CM can find accepting facilities in insurance network in (County). If CM cannot find any, to send referrals to SNF '3' (outside of County). Referral were sent to SNF '3'. CM to follow.'

Review of a Case Management Note entry dated 02/12/19 at 2:35 PM by CM 'B' documents 'Call to family member in reference to SNF '2' accepting patient. Sibling notified.'

Review of a Case Management Note entry dated 02/12/19 at 2:43 PM by CM 'B' documents 'Call received from sibling, refuses SNF '2', insurance representative notified.'

Review of a Case Management Note entry dated 02/12/19 at 2:57 PM by CM 'B' documents 'SNF '3' accepting. Authorization pending. CM to follow.'

Review of a Case Management Note entry dated 02/12/19 at 3:38 PM by CM 'B' documents 'Sibling appealing discharge, sibling wants patient to stay in the hospital to receive therapy until ready to go home. Sibling notified that discharge orders in place, that patient has an accepting facility. QIO (Quality Improvement Organization) information provided with clear instruction to call CM with reference number. Copy of MEM (Important Message from Medicare) along with notification of discharge explained and provided to patient/family.'

Review of a Case Management Note entry dated 02/12/19 at 4:01 PM by CM 'B' documents ' Family file appeal, Reference # ( 5...). CM to follow.

On 03/25/19 at 12:35 PM, during a tour of the telemetry unit, an interview was conducted with CM 'D' who stated the appeal process is initiated when the patient or responsible party does not agree with the discharge. She stated they give them the Medicare Information Message form to complete and advise them to call Medicare and file an appeal. She stated Medicare will take down the information and within 24 hours Medicare will call us to say there is an appeal pending. They will request 3 days' worth of clinical information that we fax to them and then within another 24 hours they will call with the determination.

On 03/25/19 at 2:22 PM, an interview was conducted with the Director of Case Management and an inquiry made about Patient #1' sibling being involved in the discharge process when there was no documentation in the clinical record authorizing this to which she stated sometimes families are big and everyone wants to get involved and the CM will speak to families if they call if the patient and/or spouse agree it is okay to do so. Further, she stated maybe the face sheet has not been updated and sometimes it does not get updated until after discharge or at the next hospital visit. The Director of Case Management confirmed there was no documentation in the clinical record stating Patient #1's sibling had any rights to be making discharge plan decisions and no explanation why the Patient's sibling filed a discharge appeal.

Review of a Case Management Note dated 02/14/19 at 10:32 AM documentation by CM 'C' states 'Received call from spouse he is in agreement for SNF '3', call to insurance representative.'

Review of the last Case Management Note entry dated 02/14/19 at 11:11, documentation by CM 'C' states 'Call to family and spoke to patient regarding transport time, they are in agreement for discharge to SNF '3' at 3 PM.'

Further review of the clinical record revealed no documentation of any follow up with the discharge appeal that was initiated by the Patient's sibling as documented by CM 'B' on 02/12/19; there was no documentation of any clinical records sent to the QIO; and there was no documentation of the status of the discharge appeal.

On 03/25/19 at 2:28 PM, an interview was conducted with CM 'C' who arranged the transfer of Patient #1 on 02/14/19. She stated she vaguely remembers the case and stated she remembered the Charge Nurse told her the following day the patient's spouse had called after hours around 4:30 PM asking for information and the spouse was told the patient was no longer there and was transferred to SNF '3'. CM 'C' stated the Charge Nurse told her the spouse was very upset but was not sure about what. An inquiry was made about the patient's sibling being involved in the discharge planning when there was no documentation of authorization to do so, to which she stated she never spoke to the sibling, only the spouse. CM 'C' reviewed the case management documentation and was not able to find any documentation that consent was given for involving the sibling in the discharge plans. An inquiry was made about the discharge appeal to which she stated the appeal was submitted by the sibling 2 days before the discharge and the patient was discharged to where the patient and spouse agreed to. An inquiry was made why would the spouse call the hospital around 4:30 PM to speak to the nurse if he was aware Patient #1 had been transferred to SNF '3' at 3 PM. No comment was forthcoming.

On 03/26/19 at 10:21 AM, a telephone interview was conducted with Patient #1's spouse and an inquiry made if Patient #1's sibling was authorized to be involved in the discharge decisions to which he stated they are very close and he relies on the support he and Patient #1 get. An inquiry was made if he was aware on 02/11/19 the sibling refused a referral to SNF '1' to which he stated that is where they wanted her transferred to but there were no beds available. He stated the case manager told him to check out different facilities so he went to SNF '2' which he did not like and to SNF '3', which was okay but very far away. He stated he called the hospital around 4:30 PM to speak to the nurse about bringing in some special drinks for Patient #1 and he was told Patient #1 was already gone to SNF '3' and he got very upset and called Patient #1's sibling right away as they were not aware she was being transferred. Patient #1's spouse confirmed a discharge appeal was in process but was not sure what the status was at the time of her discharge. Patient #1's spouse requested this surveyor contact the Patient's sibling, stating he can explain things better.

On 03/26/19 at 10:46 AM, a telephone interview was conducted with Patient #1's sibling who stated they were not aware she was being transferred to SNF '3' and they were very upset when they found out. He was apprised the patient's spouse stated SNF '1' was where they wanted to go to but there were no beds, however review of the case management notes documents on 02/11/19 SNF '1' was refused to which he stated their choice was SNF '4' not SNF '1', both of which have the name of the city in the facility names, however are 2 different entities. He stated they checked out SNF '2' which they did not like and his brother in law checked out SNF '3' which was okay but it was too far away and would take too long to get to to visit. He stated he filed a discharge appeal and called the hospital with the case number and was assured by the hospital that they would not transfer Patient #1 until the appeal decision. He stated when his brother in law called the hospital around 4:30 PM to ask the nurse about a special drink and was told Patient #1 was discharged an hour and a half ago that is when he called him. He stated Patient #1 had no mental capacity to agree to the transfer. He stated they did not agree to the transfer to SNF '3'. His brother in law checked the facility out and said it was okay, and when they called, they took okay to mean he agreed to the transfer but he was saying the facility was okay. Further, they were waiting on the appeal decision and ultimately they wanted a transfer to SNF '4' and maybe by that time a bed would be available.

Review of the Case Management Notes revealed no evidence of documentation of the families' preference for discharge to SNF '4'.

On 03/26/19 at 1:47 PM, a telephone conference call commenced with the hospital Director of Case Management, CM 'C', Vice President of Regulatory Compliance and Quality and Quality Manager and an inquiry made what the process was for discharging a patient if they have submitted an appeal and would the discharge be on hold while waiting for the appeal decision. The Director of Case Management stated they would wait for the determination or if the family or patient are agreeable to discharge that would negate the appeal decision at which time they would fax a document to the QIO notifying them the patient was agreeable to the transfer and to revoke the appeal. A request was made to provide evidence of documentation of the fax that was sent to the QIO, to which the Director of Case Management stated they do no keep any of that documentation and do not keep a copy of the appeal either. An inquiry was made would that not be considered a part of the patient's medical record to which she had no comment.

On 03/26/19 at 1:52 PM, an inquiry was made to CM 'C' if she followed up with the status of the discharge appeal prior to transferring Patient #1 to SNF '3' to which she stated she did not ask any questions or follow up with the appeal status because she was 100% certain the patient and spouse agreed to the transfer therefore the appeal would no longer apply. She stated looking at her documentation on 02/14/19, she documented she spoke to the spouse and the patient and they agreed to the transfer. The conference call attendees were apprised of the conversation conducted with the patient's spouse and sibling, clarifying the spouse thought he was saying SNF '3' was okay as a facility as he had toured it, but he was not saying okay consenting to the discharge to SNF '3'. The attendees were apprised the family was waiting on the appeal decision before making the final discharge arrangements. Further, in reviewing the Case Management Notes, revealed there was no documentation of the family touring facilities and no documentation of the family preference for SNF '4'. It was pointed out CM 'B' documented SNF '1' was refused however after the conversation with Patient #1's sibling, it was discovered the family preference was for SNF '4' which coincidently had the same name of the city in the facility name however are 2 separate entities.

On 03/26/19 at 4:44 PM, during the exit conference with the Vice President of Regulatory Compliance and Quality and Quality Manger, the issues were discussed to include not following hospital policy; no documentation of any follow up with the discharge appeal; no documentation of any records sent to the QIO; no documentation of a fax sent to the QIO; no documentation the patient/family revoked the discharge appeal; and no documentation the QIO was informed of a revocation if there was one. Further, there was no documentation of the family's preference for SNF '4' and not SNF '1', which had been refused with no clarification of the names of the facilities. An inquiry was made if CM 'B' was aware they were 2 different facilities, which coincidently had the same name of the city in their names. The attendees could not speak to whether CM 'B' was aware SNF '1' and SNF '4' were not one in the same.

Review of the facility policy for Utilization Management Plan documents in part, 'If the beneficiary chooses to appeal the discharge decision, Case Management/Social Worker (CM/SW) will be responsible for providing the Detailed Notice of Discharge to original Part A Medicare beneficiaries only within the required timeframes. A copy of the notice will be maintained in the medical record. CM/SW will copy, fax and/or overnight deliver all documentation requested by the QIO in the required timeframe.'

Review of the facility Discharge Planning, Interdisciplinary Clinical Practice Manual policy states in part, 'Discharge planning is a systematic, coordinated program designed to bring about the timely discharge of a patient from a hospital to the next appropriate level of care or to return them to their normal living situation. It is an ongoing process that is continually refined in coordination with the patient and/or family representative or guardian, to meet the anticipated needs of the patient.'

1. Based on review of medical records, policy and procedures, on-call schedules, facility license and medical staff and staff interviews the facility failed to ensure that an appropriate medical screening examination was provided according to the individual's presenting signs and symptoms, and 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 exists for 1 (#15) of 20 sampled patients. Refer to findings in Tag A-2406.

2. Based on medical record review, policy and procedure review, bed census reports and facility License review, and staff interview the facility failed to provide medical treatment within its capacity that minimizes the risk to the individual's health as evidenced by transferring a patient to another acute care hospital when the transferring hospital had the capability and capacity to treat the emergency medical condition on an inpatient basis for 1 (#1) of 20 sampled patient records reviewed. Refer to findings in Tag A-2409.

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

Based on review of medical records, policy and procedures, on-call schedules, facility license and medical staff and staff interviews the facility failed to ensure that an appropriate medical screening examination was provided according to the individual's presenting signs and symptoms, and 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 exists for 1 (#15) of 20 sampled patients.

The findings included:

1. Medical Record Review Patient #15

A review of the medical record revealed that patient #15 (MDS) dated [DATE] at 4:25 PM. The Emergency Department physician documented on the section of the HPI (History of Present illness) specified in part, Fifty-two (52) year old. . .presents to the ED due to assumed seizure just prior to arrival to the ED. . . found pt. (patient) with seizure-like activity and rushed here to the ED. Associated symptoms include headaches, slurred speech, disorientation, confusion, and inability to control herself. She denies both suicidal and homicidal intentions. Pt. has a PM (past Medical) Hx (history) of seizures ...Pt began acting erratically in the ED flinging herself back and forth on the bed saying nonsensical things. . . Basic Physical Exam: Vital Signs Pulse Ox: 98 B/P:132/75 ...Temp: 97.9 Pulse: 87 Resp: 20 ... General/Const (constitution): awake. Alertness: Confused, Disoriented. Behavior: Uncooperative ...Head: Atraumatic, Normocephalic . . . Psychiatric: Not Suicidal, Not homicidal Abnormal Thinking/Perception; Judgement abnormal, Confused. The radiology results for the chest x-ray revealed no evidence for acute cardiopulmonary process. The CT scan of the brain impression was: No CT evidence for acute intracranial pathology. The ED physician documented the patient's Clinical Impression: Primary Impression: Seizure and Secondary Impression: Acute psychosis. The ED physician documented for safety concerns Patient+ #15 was being transferred to an acute care hospital for further evaluation and treatment. Review of the EMTALA Memorandum of Transfer form dated 01/24/18 documents receiving facility (name of hospital) and documented under Section III Medical Benefits to include 'Obtain level of care/service unavailable at this facility - psychiatry/neurology.' The hospital failed to ensure that their policy and procedure was followed as evidenced by the hospital ancillary services, a neurologist and a psychiatrist were available to provide an evaluation for patient #15 on 1/24/2018. The hospital had a neurologist listed on-call and psychiatry was listed as available emergency medicine services for the hospital.

2. Facility P&P

The facility's Policy and procedure titled, EMTALA Medical Screening Policy Policy #4666, Effective date: 05/25/2016, Last revision Date: 05/25/2016 was reviewed. The policy stated in part, The hospital with an emergency department must provide to an individual that is not a patient who comes to the emergency department an appropriate MSE (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 (EMC) exists. . .If an EMC is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer ... PROCEDURE: . . . Capabilities of a main hospital provider means the physical space, equipment, supplies and services (e.g., Trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry) including ancillary services available at the hospital . . . The capabilities of the hospital staff mean the level of care that the hospital's personnel can provide within the training and scope of their professional licenses . . . Emergency Medical Condition. . . A medical conditions manifesting itself by acute symptoms of sufficient severity (including sever pain, psychiatric disturbances and/.or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in jeopardy ...Medical Screening Examination (MSE) is the process required to reach within clinical confidence, the point at which it can be determine whether or not an EMC exists. . .Such screening must be done within the facility's capability and available personnel, including on-call physicians.. . With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening. . . On Call list refers to the list that is required to maintain that defines those physicians who are on-call for duty after the initial MSE to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. The purpose of the on-call list is to ensure that the dedicated emergency department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilize individuals with EMC's. If a hospital offers a service to the public, the service should be available through on-call coverage of the emergency department . . . How to Provide the Medical Screening Examination . . . 9. . . The psychiatric MSE includes as assessment of suicide or homicide attempt or risk, orientation and assaultive behavior that indicates danger to self and others.

3. On-Call Schedule

Review of the January 2018 Neurology and Stroke Alert on-call physician list documents a physician on-call each day of the month. On January 24, 2018 a Neurologist, an ancillary service was on call and routinely available to the ED to provide further evaluation and treatment for patient #15.

4. Hospital State License

Review of the Hospital State License documents Psychiatry is included in the services the hospital provides.

5. Interviews

On 04/03/18 at 2:20 PM, an interview was conducted with the ED Director and ED Charge Nurse who stated their psychiatry services is for admitted inpatients and those patients who come through the ED on an involuntary basis are transferred out to hospitals that have a behavioral unit. The ED Director stated they would stabilize the medical condition and admit the patient for treatment and would have psychiatry assess the patient on an inpatient basis.

On 04/04/18 at 11:06 AM, an interview was conducted with the VP of Regulatory Compliance and Quality who confirmed they do not have psychiatry on call. She stated they have a psychiatry group consisting of 3 behavioral health specialist MDs who they call for inpatient consults. The VP of Regulatory Compliance and Quality confirmed they do have Neurology physicians on call 24/7 as they are a Stroke Center.

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

Based on medical record review, policy and procedure review, bed census reports and facility License review, and staff interview the facility failed to provide medical treatment within its capacity that minimizes the risk to the individual's health as evidenced by transferring a patient to another acute care hospital when the transferring hospital had the capability and capacity to treat the emergency medical condition on an inpatient basis for 1 of 20 sampled patient (#1) records reviewed.

The findings included:

Policy and Procedure

1. The facility's policy entitled EMTALA Florida Transfer Policy Original date: 1/1/99; Review date: 9/11, 5/12, 5/15, 12/17. The policy states in part, Policy: 2. a. Transfer will be an appropriate transfer if: a. the transferring hospital provides medical treatment within its capacity that minimizes the risk to the individual's health ... Lateral Transfers - Transfers between hospitals of comparable resources and capabilities are not permitted unless the receiving facility would offer enhanced care benefits to the patient that would outweigh the risks of the transfer. Examples of such situations include a mechanical failure of equipment or no ICU beds available ...

2. Review of the facility EMTALA Florida Medical Screening Examination and Stabilization policy states in part, 'Extent of the MSE (medical screening exam) - An on-going process: The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an 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 to the completion of the MSE and until discharge or transfer.... Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others.'

3. Medical Record Review Patient #1

Patient #1 presented to the Emergency Department (ED) on 03/10/18 at 9:24 PM initially with a chief complaint of pain to the right ankle. Review of the Nursing Progress Notes dated 03/10/18 at 9:24 PM documents the patient was brought in by family who stated the patient has been acting weird and erratic. Per the nursing notes 'Patient hasn't 'used' since 7 PM yesterday. Patient also states his right ankle hurts. Objective assessment - Alert, oriented x 1; acting erratic. Patient seems confused at times speaking of things not there.' The file documents the patient is uninsured.

An assessment was conducted by an ED Physician Assistant (PA) on 03/10/18 at 9:59 PM, documenting the chief complaint was right ankle pain. Blood and radiological studies were ordered; intravenous fluids and medications were administered. At the time of the initial assessment completed by the ED PA on 03/10/18 at 9:59 PM, he documented under Psychiatric - change mental status; confused, disoriented The ED physician further documents 'Patient family is concerned because patient has admitted to them before that he wants to end himself.' Further review of the clinical record revealed no evidence of any suicide safety precautions ordered or implemented for Patient #1.

Review of the laboratory studies completed, revealed the patient had critically abnormal liver study results. The x-ray of the right ankle was negative for fracture.

Further review of the clinical record revealed documentation by the ED PA on 03/11/18 at 12:23 AM stating 'ED MD is currently speaking to ICU. Patient will eventually go to ICU' (intensive care unit).

Documentation by the ED PA on 03/11/18 at 12:28 AM states 'Condition: Stable. Disposition Decision: Admit. Request Time: 12:28 AM.'

Review of an ED MD (medical doctor) documentation with notation the (attending) MD for the patient is the MD the ED PA was in communication with in reference to admitting the patient to ICU. The ED MD's Progress Note assessment dated [DATE] at 1:40 AM, now documents the patient's chief complaint is acute [DIAGNOSES REDACTED]. The ED MD documented the patient was brought in by a 'family member' for acute confusion stated. 'Family member' concerned because patient has had issues of suicidality and was suspicious of intentional drug overdose. The ED MD further documented the patient is a known polysubstance abuser stating the details on the timing of ingestion and progression of [DIAGNOSES REDACTED] are not available. Further review of the clinical record revealed no evidence of any suicide safety precautions ordered or implemented for Patient #1.

Review of a notation in the clinical record dated 03/11/18 at 1:51 AM, author undetermined, documents '(Name of Hospital) transfer coordinator refused this patient because of his poly substance abuse.'

Further review of the clinical record revealed a note dated 03/11/18 at 3:51 AM, author undetermined, documenting a request for transfer to another hospital.

Review of a Nursing Progress Notes dated 03/11/18 at 0351, documents '(Name of Hospital) Transplant Team denied patient because of substances he's on.'

Review of the Diagnosis, Assessment & Plan dated 03/11/18 at 4:20 AM, documentation by the ED MD documents under Impression: Acute [DIAGNOSES REDACTED]/drug overdose; acute liver failure; acute kidney failure; query sepsis/lactic acidosis; query suicide attempt. Plan: discuss disposition with ED (attending MD) regarding transfer to liver transplant center.

Review of an ED Nursing Progress Note by the Registered Nurse (RN), dated 03/11/18 at 4:23 AM, documents a Suicide Assessment was completed, over 6 hours after the ED PA made notation of the patient's families concerns regarding possible suicidal ideations. The RN documented the patient was not at risk for suicide, despite the ED MD documenting in his final impression on 03/11/18 at 4:20 AM, query suicide attempt. At no point from when the patient (MDS) dated [DATE] to transfer to the accepting hospital were any suicide safety precautions implemented.

Review of an ED Nursing Progress Note by the same RN dated 03/11/18 at 5:29 AM, documents under Patient Disposition: Transfer. Chief complaint: Ingestion. Transfer Assessment- Reason for transfer: Services not offered. Services required for transfer: Surgical. Transferred via: Ambulance.

Review of the EMTALA Memorandum of Transfer form, dated 03/11/18, revealed a medical condition of Hepatic Failure and Polysubstance Abuse; no notation if the patient is stable; Medical Benefits to include: Obtain level of care / service unavailable at this facility - Service Liver Specialist and Psych; and Medical Benefits outweigh the risks; accepted by acute care hospital in Miami, Florida; and patient unable to sign a consent for the transfer.

Patient #1 was transferred out of the hospital on [DATE] at 5:31 AM per the ED RN's documentation on 03/11/18 at 5:29 AM in stabilized condition.

Review of the receiving hospital records, revealed Patient #1 was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Review of the ED MD note, dated 03/11/18 at 12:59 PM, documents Patient #1 was improving, waking up and more alert. At 2:30 PM, the ED MD documented the patient is downgraded to telemetry and totally awake and ambulating and talking. Patient #1 was treated with intravenous fluids, medications and intravenous antibiotics. He was placed on a one to one sitter and psychiatry was consulted for past medical history of [DIAGNOSES REDACTED]#1 was cleared by psychiatry and discharged from psychiatry with the one to one sitter discontinued. On 03/16/18, the blood cultures emerged positive for a bacteria and Patient #1 was admitted to a transitional care setting on 03/16/18 for intravenous antibiotic therapy for a diagnosis of [DIAGNOSES REDACTED].

4. Intensive Care Unit Bed Census Report

Review of the transferring hospital's Intensive Care Unit (ICU) status revealed a capacity of 16 beds. Review of the ICU Census Report for 03/10/18 revealed a census of 14. Review of the ICU Census Report for 03/11/18 revealed a census of 10.

5. Facility License

Review of the transferring hospital's State License effective 09/01/16 and expiring on 08/31/18, revealed the services offered at the facility include Emergency Services, Internal Medicine and Psychiatry.

6. Interview

On 04/05/18 at approximately 4:00 PM, during the exit conference with one of the attendees being the Chief Nursing Officer (CNO), were apprised of the issues identified and an inquiry was made if they monitor or track their patient transfers, to which the CNO stated, that has not been their practice to do so.

The facility failed to ensure that their own transfer policy and procedure was followed as evidenced by inappropriately transferring patient #1 on 3/11/2018 to another acute care hospital, when Northwest Medical Center had the capability and capacity to provide the care and treatment for the patient. As this resulted in an inappropriate transfer for patient #1 on 3/11/2018.

Survey not available

Based on record review and interviews, the facility failed to ensure the implemented nursing plan of care was consistent with the physician orders: the physician orders were not followed for one of ten patient clinical records reviewed, Patient #1, related to ensuring the ordered radiology scan was completed on 12/23/11.

The findings include:

Interview with the Chief Nursing Officer on 4/10/2012 at approximately 9:38 AM revealed the facility has adopted the Lippincott Manual as their standard of practice which included following physician orders. She verbalized the policy is for nurses to follow physician orders. Further interview with the Director of Quality Assurance (QA), the Nurse Manager of Telemetry and the Computer Provider Order Entry (CPOE) Registered Nurse on 4/12/2012 at approximately 4:12 PM revealed it is the expectation that nurses follow physician orders as per the policy.

Review of the physician order for Patient #1 of 12/23/2011 at 1:38 PM, revealed the physician ordered a routine (not STAT) MRI of the brain with - without contrast. Review of the record revealed a CT scan of the brain was completed, and not the MRI. Interview with the Nurse Manager of Telemetry, the Director of Quality Assurance (QA) and the RN Computer Provider Order Entry (CPOE) on 4/10/12 at approximately 4:10 PM and again on 4/11/12 at approximately 4:30 PM, revealed they believe the secretary hit the CT scan button instead of the MRI button when scheduling the procedure. They all agreed the MRI was ordered (and as per record review) and the CT scan was completed. The physician reordered the routine MRI on 12/24/11 but later canceled it on 12/26/11.

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

Based on record review and staff interviews and policy review the facility failed to assess 1 of 3 sampled patients (#1) to evaluate the patient's response to blood transfusion during the first 15 minutes after the blood was started and every 30 minutes throughout the blood transfusion as required by the hospital policy for the administration of blood and blood components effective 03/27/10.

The findings include:

Clinical record review revealed patient #1 was admitted on [DATE] for blood transfusion for diagnosis of [DIAGNOSES REDACTED].

On 05/26/11 a physician ordered type and cross match of 2 units of packed red blood cells to be transfused in 4 hours, followed by 20 mg Lasix IV for diagnosis of [DIAGNOSES REDACTED]

A type and cross match report dated 07/26/11 revealed the patient's blood type is A Rh negative.

The patient signed consent for blood /blood product transfusion on 05/27/11 at 9:00 AM.

A registered nurse documented in an outpatient treatment record at 0930 on 05/27/11, the patient is admitted for blood transfusion. A pre transfusion assessment revealed the patient is alert and oriented x 3, Hematocrit (HCT) 20.3, B/P 107/52. Temp 97.6 Pulse 78 SpO2% 100 and IV Peripheral to left arm (LA) with saline lock. The patient complained of aching pain intermittently all over the neck, back and right arm and the patient was placed in bed for blood transfusion. The nurse documented on 5/27/11, the patient and husband were taught pre transfusion, to report signs and symptoms of [DIAGNOSES REDACTED]

A transfusion record indicated on 05/27/11 at 0936 a registered nurse (#6) verified the blood by bar code transfusion administration procedure and began infusing the first unit of Red blood Cells (Unit # W 35, Product PC E0316). The record revealed the patient' vital signs were checked at 09:50 AM and at 12:50. The blood transfusion was administered in 3 hrs and 16 minutes and was completed at 12:50 PM.

Further review of the clinical record revealed a registered nurse (#6) verified the second unit of blood (Unit # W 55, Product LPC E4532) by bar code transfusion administration procedure and began infusing the blood at 1300 (1:00 PM) on 05/27/11. There is no documented evidence in the clinical record to substantiate the nursing staff had evaluated the patient fifteen (15) minutes after the second blood transfusion was started or the patient had been observed every 30 minutes throughout the blood transfusions on 05/27/11, as specified in the hospital policy.

A registered nurse (#6) documented on 05/27/11, at approximately 1400 while the patient was receiving a second unit of blood transfusion, the patient's husband came from the room and stated the patient needs help. When the nurse went to the room, the patient was unresponsive, without pulse or respirations. CPR (cardiopulmonary resuscitation) was initiated. At 14:03 (2:03 PM) the Code Blue team arrived, the patient was found to be in Ventricular Fibrillation, The patient was resuscitated, intubated and admitted on [DATE].

On 8/1/11 at 3:45 PM an interview was conducted with the director of out- patient services. The director stated the patient's transfusion record does not have the vital signs documented 15 minutes after the second blood was started on 05/27/11.

The Hospital policy titled: Administration of blood and blood components (effective date 03/27/10) specifies The Transfusionist (RN) shall remain with the patient for the first five (5) minutes of the transfusion which should be started slowly... After the first fifteen (15) minutes, the patient should be observed and the vital signs recorded on the transfusion slip. Completion of the transfusion should be prior to component expiration or within 4 hours, whichever is sooner. The patient should be observed periodically throughout the transfusion (every thirty 30 minutes) and up to an hour after completion if indicated.

Interview with registered nurses on 08/01/11 at 3:00 PM and 8/2/11 at 3:00 PM the nurses stated they are required to verify the blood and patient identity by a scanning on each blood unit and completing a blood transfusion check list electronically, using the bar code transfusion administration (BCTA) procedure. The nurses also stated the vital sign should be monitored and documented before the transfusion, 15 minutes after starting the transfusion and at the end of the transfusion. The nurses stated the patient is periodically observed, the observation is not documented if the patient condition is stable..