HCA Florida Woodmont Hospital

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

Based on staff interview and clinical records reviews nursing staff failed to implement approved nursing services policy for the care of Peripheral Inserted Central Catheters (PICC), and Change in patients conditions. This failure affected 1 of 5 sampled patients (#1).

Findings include:

On 03/05/15 at 11:15 a.m. the review of a list of 10 patients with PICC lines was conducted.

On 03/05/15 at 11:40 a.m. during observation of care Patient #1 was observed to have an isolation sign on the room door. An interview was conducted with the RN Assistant Director of Nursing Services, 2nd floor in the presence of the RM at 11:41 a.m., who stated Patient

#1 is on isolation for an infection in the heel wounds. She stated he is on intravenous antibiotics via a PICC line.

On 03/05/15 at 11:45 a.m. an interview was conducted with the 2nd floor Registered Nurse (RN) regarding Patient #1 who stated Patient #1. The nurse stated, diabetic wounds and a PICC line for the administration of intravenous antibiotics; the patient is in an isolation room due to an infection of the wounds. The RN stated the wound care is done daily and the PICC line is flushed every shift to maintain patency.

On 03/05/15 at 12:31 p.m. a telephone interview was conducted with Patient #1 who confirmed he has a PICC line which he had prior to admission to the hospital. He stated he has been in the hospital for three days and they are not looking after the PICC line. He stated he was receiving intravenous antibiotics at home for an infection of his wounds.

Review of the Emergency Provider Report, dated 03/02/15 at 1633 hours by the ER physician reveal documented 'Patient presents with a PICC line to the left arm.'

Review of the Initial Adult Admission assessment dated [DATE] at 2227 completed by the RN when the patient was admitted to the 2nd floor does not document any evidence Patient #1 has a PICC line.

Review of the History & Physical completed by the attending physician dated 03/03/15 at 1225 p.m. documents Patient #1 'Apparently has a PICC line in his right forearm.'

Review of a Podiatry consult dated 03/03/15 at 1308 hours did not disclosed any documentation indicating Patient #1 has a PICC line.

Review of the Infectious Disease physician consult dated 03/04/15 at 1248 hours reveal documented, 'There is a right PICC line.'

On 03/06/15 at 12:00 p.m. the electronic medical record for Patient #1 was reviewed with the RM who after reviewing the Nursing Notes and the monitoring section where the nurses sould document the assessment of the PICC line, stated it looks like there is no documentation of the PICC line assessment. The RM stated Patient #1 was admitted with the PICC line so that is why he is not on the list of patients with PICC lines. He stated the list generated are for patients with the PICC lines that were inserted after the patients were admitted to the facility.

On 03/06/15 at 12:20 p.m. an interview was conducted with the RN Assistant Director of Nursing Services 2nd floor in the presence of the RM who stated the protocol for PICC lines is to flush the catheter with 10 cc of Normal Saline every 12 hours. She proceeded to look in the electronic medical record for Patient #1 and confirmed there is no evidence of documentation of any PICC line assessment or flushes for Patient #1. The RM stated during the review of the electronic medical record, in the daily patient assessment by the nurse every shift, under the PICC line assessment section they are attesting to doing the flush per their protocol with 10 cc of Normal saline every shift and before and after medications. However review of the PICC line assessment section in Patient #1's record is blank from the date of admission on 03/02/15 to the current date. The RM stated the saline flushes are not included in the Medication Administration Record (MAR) and maybe they should get pharmacy to add it to the MAR so the nurses have to document it is done. Further review of the MAR revealed Patient #1 was started on intravenous antibiotics on 03/04/15 with the first dose given at 1014 hours. There is no evidence of nursing documentation of any type of intravenous access for Patient #1 from admission at 1735 on 03/02/15 to the first dose of intravenous antibiotic administered at 1014 on 03/04/15.

Review of the facility PICC Policy reveal in part, 'Flush PICC catheter with 10 ml normal saline after each use and every 12 hours. The initial dressing change is done 24 hours after insertion. Dressing change should be done every seven days.

On 03/06/15 at 12:45 p.m. hard copies of Patient #1's MARs were reviewed to reveal on 03/02/15 at 2126 hours the 2nd floor RN documented under the Vancomycin 1 gram intravenous order dated 03/02/15, 'I spoke to ER nurse who stated the patient refused she will document it.' Review of the Emergency RN notes dated 03/02/15 reveals documentation of an incident occurring at 1700 hours. The notes recorded at 2203 hours document, 'Attempted to administer Vancomycin to patient as ordered. Patient refused antibiotic.'

Further review of the Nursing Notes revealed no evidence of documentation the physician was notified the patient did not receive the antibiotic as ordered.

Further review of the MAR revealed on 03/03/15 at 0917 the RN held Patient #1's Metformin (diabetic medication) with the reason documented as 'Patient not eating.' Additionally, on 03/03/15 at 1607 the RN held Patient#1's Metformin with the reason documented as 'Poor appetite'. Review of the Nurses Notes did not reveal any documentation of the patient's blood sugar prior to holding the diabetic medication. In addition there iss no evidence of documentation the RN notified the physician she was holding the diabetic medication.

On 03/06/15 at 2:50 p.m. an interview was conducted with the RN Assistant Director of Nursing Services 2nd floor, in the presence of the RM. The Assisteant Director of Nursing stated if a diabetic medication is held the physician should have been notified. After review of the electronic medical record she verified there is no documentation in the chart the RN informed the physician she held the medication. Additionally, she verified the RN did not inform the physician Patient #1 refused the intravenous Vancomycin while in the ER.

Review of the facility Change in Patient's Condition, Notification of Physician Policy reveal in part, 'The attending physician and appropriate consulting physician shall be notified immediately upon any significant changes in his/her patient's condition which may warrant immediate intervention or change in prescribed therapy..... The charge nurse or licensed personnel caring for the patient is responsible for notifying the attending physician and appropriate consulting physician immediately upon any significant changes in patient's condition which may warrant immediate intervention or change in present therapy.'

Survey not available

Based on reviews of clinical records, Policies and Procedures, Emergency Department central logs, State licensure, Medical Staff Rules and Regulations, Physician On-Call lists, University Pavilion surveillance video and interviews with staff of both facilities, patients and family, it was determined the facility failed to provide appropriate documentation in the emergency log and a Medical Screening Examination (MSE) for two Patients (Patient #1 and #21) of twenty-one patient records reviewed. Patient #1, and Patient #21 presented to the University Pavilion Respond Intake (triage) unit lobby on 4/17/14 at 11:02 AM, and 11:20 AM.

University Pavilion (UP) failed to document the Patients in the UP Psychiatric Services Central Log dated 4/17/14 and failed to provide a Medical Screening Examination (MSE) for both Patients. Refer to findings in tag A2405, A2406 and A2409.

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

Based on reviews of clinical records, Policies and Procedures, Emergency Department central logs, State licensure, Medical Staff Rules and Regulations, Physician On-Call lists, and University Pavilion surveillance video and interviews with staff of both facilities, patients and family, it was determined the facility failed to provide appropriate documentation in the Psychiatric Services Central Log for two Patients (Patient #1 and #21) of twenty-one (21) sampled patients records.

The finding includes:

Review of the facility license dated 1/26/14 revealed University Hospital and Medical Center is licensed to provide Psychiatry services. The License notes the facility is a Class I Hospital with 257 acute care licensed beds, 52 adult psych beds and 8 adolescent psych beds. University Pavilion (UP), located at 7425 North University Drive, Tamarac, Florida, is a free standing Behavioral Health Unit on the campus of University Hospital and Medical Center.

Telephone interviews were conducted with the Chief Nursing Officer (CNO) from Fort Lauderdale Hospital (FLH) on 4/28/14 at 9:45 AM, and again on 5/6/14 at 9:51 AM. She verified her allegation of an Emergency Medical Treatment and Labor Act (EMTALA) violation on 4/17/14. She states that the facility in question is University Pavilion located at 7425 North University Drive, Tamarac, Florida . On 4/17/14 around 1:30 PM, Fort Lauderdale Hospital received Patient #1 at their assessment and referral area. Patient #1 was twitching, with verbal outbursts and swinging his arms and body uncontrollably. She stated he suffers from post-concussio[DIAGNOSES REDACTED] and was treated at University Pavilion for 2 weeks sometime in February 2014. On 4/17/14, he was seen by his psychiatrist, who instructed the family to take him to University Pavilion. His family took him to University Pavilion and he was not properly triaged or assessed. Patient #1's parent was informed by an unknown Nurse, that University Pavilion did not have any beds available, that Patient #1 would be waiting at the facility in vain, and that University Pavilion could not assess him. The nurse instructed them to take Patient #1 to Fort Lauderdale Hospital and she wrote down the facility name and phone number on a sticky note and provided it to Patient #1's mother. The CNO is concerned that the facility neglected to properly triage and transfer the patient.

Telephone interview with the Parent of Patient #1 was conducted on 4/29/14 at 8:05 AM, and again on 5/6/14 at 8:25 AM. The Parent stated she and her son (Patient #1) arrived to the University Pavilion lobby on 4/17/14 at approximately 11:00 AM. She complained of difficulty managing her son for the past few days, with twitching, verbal out-burst, swinging his arms and body out of control. She stated his behaviors were a result of a head injury incurred in December 2013 when his head was hit by a soccer ball during a game. Subsequently he was diagnosed with [DIAGNOSES REDACTED]#1 stated the University Pavilion Intake (Triage) Nurse (Staff #13) offered to examine her son, but she (the parent) was told by the Nurse no beds were available in the adolescent Pavilion. The Parent then agreed to have the triage Nurse find a hospital with an available adolescent bed. The Nurse provided the Parent with a hand written post-it note with the name and number of Fort Lauderdale Hospital (FLH). The Parent additionally stated she and her son spent approximately a half an hour in the lobby, but to the best of her knowledge she was not placed in the ED Log book, as her son's name was not taken. She further stated she left the Pavilion lobby once she knew of FLH's adolescent bed availability. The Parent verified she transported her son to FLH later that afternoon, and he was admitted there.

Interviews with the University Hospital Risk Manager (RM) were conducted on 4/30/14 at 2:24 PM, 5/1/14 at 10:29 AM, and again on 5/9/14 at 8:50 AM. During these interviews the University Pavilion Psychiatric Services Central Logs were requested and reviewed. The Risk Manager (RM) concurred during these interviews the Pavilion Intake (triage) unit staff did not document Patient #1 and #21 in the emergency department log book.

The Risk Manager additionally stated both Patient #1 and Patient # 21 (MDS) dated [DATE], but the Parents of Patient #1 and #21 did not complete the required Statement of Confidently/Consent to Assessment forms required to be completed so the names of the Patients and their complaints can be documented in the emergency log and triage can be started.

The Risk Manager further indicated the University Pavilion Responds Intake Log record does not show evidence that either child (seen in the security recording on 4/17/14 at 11:20 AM) was signed into the facility Respond Intake (triage) Log on 4/17/14 between 11:00 AM to 12:01 PM. The Risk Manager acknowledged no children were logged in during this date and time.

Additionally the University Hospital RM submitted a self- reported event report to the State Agency dated 5/05/14 related to an occurrence in the University Pavilion Respond Intake unit that occurred on 4/17/14 at 11:20 AM at which time a male adult with two children (Patient ID #21) complaining of chest pain & nausea/vomiting entered the Pavilion Respond Intake lobby and overheard no rooms were available. He subsequently left the lobby without being seen.

The Risk Manager further stated he was made aware of the possible Emergency Department (ED) Access and possible Emergency Medical Treatment and Labor Act (EMTALA) violation by the Fort Lauderdale Hospital CNO on 4/17/14. The University Hospital Risk Assessment team conducted an internal investigation concerning these issues from 4/18/14 to 4/24/14.

The subsequent findings indicated the Hospital did not find ED Access or EMTALA wrong doing, as the Patients (#1 and #21) and Parents left the University Pavilion without filling out the required Statement of Confidently/Consent to Assessment form that gives consent to the triage Nurse and the Physicians to conduct a Medical Screening Examination (MSE).

The Risk Manager further states, Although University Hospital did not find wrong doing on the part of the Pavilion's Respond Intake (Triage) unit staff, the facility did put in place further education concerning ED Access and EMTALA to reinforce the Regulatory requirements.

The Risk Manager provided evidence as of the follows:

? a) The Director of the University Pavilion provided counseling to the RN involved in the incident about EMTALA and Florida's Right to Access requirements.

? b) The RN attended the EMTALA presentation on 04/24/14 and has requested additional training with an online EMTALA course offered on Health Stream.

? c) A message was sent on 04/19/14, reminding staff of EMTALA and Florida ' s Right to Access requirements when a Patient presents at the behavioral health facility.

? d) The Director of Risk Management presented an EMTALA presentation on 04/23/14 and 04/24/14.

? e) Additional courses are scheduled to be presented for those staff members who could not attend these presentations.

? f) Staff members are to receive education regarding the procedure and forms to utilize when a Patient decides to leave prior to triage, prior to a medical screening examination or when a patient refuses to sign these forms and departs the facility.

Telephone interview with the University Pavilion Respond Intake (triage) Nurse (Staff #13) was conducted on 4/30/14 at 12:30 PM, and again on 5/09/14 at 10:57 AM.

Staff #13 acknowledged she did not enter Patients #1 or #21 names in the Central Log, or triage them.

Staff #13 stated she gave the parent of Patient #1 the Statement of Confidently/Consent to Assessment form and informed the Parent upon her arrival that the Pavilion adolescent beds are full, and she may be waiting a long time for an available bed. She (Staff # 13) offered to call other facilities to see who had available adolescent beds. The parent agreed to this, So I found Fort Lauderdale Hospital (FLH) had available beds and provided the Parent with FLH's name and telephone number on a post-it note. The parent and son soon left the lobby.

Additionally Staff #13 further stated that a male adult with two children (Patient ID #21) names unknown presented to the UP lobby complaining of chest pain and nausea/vomiting on 4/17/14 around 11:20 AM and overheard her telling another Parent no rooms were available, subsequently left the lobby without being seen providing their names and subsequently their names were not documented in the central log. This was reported to the Risk Manager.

Staff #13 further stated she has attended in-services on emergency department (ED) access, and Emergency Medical Treatment and Labor Act (EMTALA) training upon hire and annually, but she was under the impression that the Pavilion's Respond Intake (triage) unit was not considered an Emergency Department (ED) triage area subject to ED access and EMTALA rules and regulations.

She continued to state she has had further training since 4/17/14 provided by the Risk Manager and currently understands that the Pavilion Intake unit is in fact the same as a Hospital Emergency Department with the same Patient Rights to examination, assessment and Medical Screening Examination (MSE), and ED access and EMTALA requirements.

Interview with the Pavilion Respond Intake Security Guard (Staff # 7) on 4/30/14 at 12:40 PM revealed Patient #1 and their parent entered the Pavilion Respond Intake (triage) lobby on 4/17/14 at approximately 11:00 AM. He states he was in the triage security lobby area upon the entry of Patient #1 and their leaving but was not in the security guards lobby booth at 11:20 AM when Patient #21 entered the lobby and then left. He stated at this time he was delivering a meal tray.

The University Pavilion Psychiatric Services Central Log dated 4/17/2014 was reviewed with the Risk Manager on 5/1/14 at 10:29 AM. The Risk Manager acknowledged Patient #1 and #21's names are not documented on the Log. The Risk Manager stated; Once a patient or family has filled out the Statement of Confidently/Consent to Assessment Form provided to them by the Pavilion Intake security guard or the Triage Nurse, the Nurse will write the patient's name, chief complaint, date and time of presentation to the triage area in the Central Log record sheet. The Risk Manager further stated to explain why the Patient #1 and #21' s name are not in the 4/17/14 ED Log, The Parent of Patient #1, and #21 did not complete the Statement of Confidently / Consent to Assessment form, nor did they directly ask to be cared for by the staff.

The Risk Manager additionally stated the male and two children that entered the lobby at 11:20 AM did not give their names, and the adult male did not complete the Statement of Confidently/Consent to Assessment form.

The Risk Manager additionally stated, Since 4/18/14, the triage staff have been in-serviced to triage and obtain a Medical Screening Examination (MSE) to all presenting Patients, and not tell them there might be a wait for an adolescent's bed.

The security video dated 4/17/14 of the Pavilion's Intake (triage) lobby was viewed. The video showed the Parent and Patient identified by the Risk Manager as Patient #1 walked into the lobby on 4/17/14 at 11:02 AM. The parent received a clip board with an attached white paper. A few moments later she is viewed talking on a hand-held telephone, not visibly filling out the paper on the clip board. Staff #13 is observed in the lobby and appears to be engaged in a conversation for approximately 5 minutes. The Parent is observed placing the clip board on the seat next to her without evidence of having written on the clip board. The parent walks out of the lobby with her son at 11:40 AM and does not return. The Security Guard (Staff #7) is observed on the video to retrieve the clip board from the vacant lobby seat at 11:41 AM. During this 38 minute recording there is no visual evidence that Patient #1 was triaged or a Medical Screening Examination (MSE) was conducted.

Additionally this security recording revealed a male adult entering the Respond Intake Lobby at 11:15 AM with 2 children. A brief interaction of approximately 1 minute is observed on this recording in which Staff #13 is observed standing in front of the male. He is observed nodding his head in an up and down motion, and she is observed motioning her hands in responds to him.

The recording is video only; as such the conversation cannot be hear. The male and two children are observed for 3 minutes in the University Pavilion Responds Intake (triage) lobby. During this time the Parent is not observed to sign any paper work and then leaves the lobby after 3 minutes.

Review of the facility's policy, Florida Transfer Policy: EMTALA-2009-010 indicates under Procedures, 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. Additionally, All hospitals must maintain the Central Log in an electronic format.

Patient #1 and Patient #21 presented to the University Pavilion Respond Intake (triage) unit lobby on 4/17/14 at 11:02 AM, and 11:20 AM.

There is no documentation of their names and presenting conditions in Psychiatric Services Central Log.

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

Based on reviews of clinical records, Policies and Procedures, Emergency Department central logs, State licensure, Medical Staff Rules and Regulations, Physician On-Call lists, University Pavilion surveillance video and interviews with staff of both facilities, patients and family, it was determined the facility failed to provide an appropriate Medical Screening Examination (MSE) for two of twenty-one sampled patients (Patient #1 and # 21). Patient #1 and #21 presented to the University Pavilion Respond Intake (triage) unit lobby on 4/17/14 between 11:02 AM to 11:40 AM, and the facility failed to provide a Medical Screening Examination (MSE).

The finding includes:

Review of the facility license dated 1/26/14 revealed University Hospital and Medical Center is licensed to provide Psychiatry services. The License notes the facility is a Class I Hospital with 257 acute care licensed beds, 52 adult psych beds and 8 adolescent psych beds. University Pavilion (UP), located at 7425 North University Drive, Tamarac, Florida, is a free standing Behavioral Health Unit on the campus of University Hospital and Medical Center.

Telephone interviews were conducted with the Chief Nursing Officer (CNO) from Fort Lauderdale Hospital (FLH) on 4/28/14 at 9:45 AM, and again on 5/6/14 at 9:51 AM. She verified her allegation of an Emergency Medical Treatment and Labor Act (EMTALA) violation on 4/17/14. She states that the facility in question is University Pavilion Hospital (UP) located at 7425 N University Drive, Tamarac, Florida . On 4/17/14 around 1:30 PM, Fort Lauderdale Hospital received Patient #1 at their assessment and referral area. Patient #1 was twitching, with verbal outbursts and swinging his arms and body uncontrollably. She stated he suffers from post-concussio[DIAGNOSES REDACTED] and was treated at University Pavilion for 2 weeks sometime in February 2014. On 4/17/14, he was seen by his psychiatrist, who instructed the family to take him to University Pavilion. His family took him to University Pavilion and he was as not properly triaged or assessed. Patient #1's parent was informed by an unknown Nurse, that University Pavilion did not have any beds available, that Patient #1 would be waiting at the facility in vain, and that University Pavilion could not assess him. The nurse instructed them to take Patient #1 to Fort Lauderdale Hospital and she wrote down the facility name and phone number on a sticky note and provided it to Patient #1's mother. The CNO is concerned that the facility neglected to properly triage and transfer the patient.

Telephone interview with the Parent of Patient #1 was conducted on 4/29/14 at 8:05 AM, and again on 5/6/14 at 8:25 AM. The Parent stated she and her son (Patient #1) arrived to the University Pavilion lobby on 4/17/14 at approximately 11:00 AM. She complained of difficulty managing her son for the past few days, with twitching, verbal out-burst, swinging his arms and body out of control. She stated his behaviors were a result of a history of a head injury incurred in December 2013 when his head was hit by a soccer ball during a game. Subsequently he was diagnosed with [DIAGNOSES REDACTED]

The Parent of Patient #1 stated the University Pavilion Intake (Triage) Nurse (Staff #13) offered to examine her son, but she (the parent) was told by the Nurse no beds were available in the adolescent Pavilion. The Parent then agreed to have the triage Nurse find a hospital with an available adolescent bed. The Nurse provided the Parent with a hand written post-it note with the name and number of Fort Lauderdale Hospital (FLH).

The Parent additionally stated she and her son spent approximately a half an hour in the lobby, but did not enter the Triage room. The Parent stated the staff did not triage or provided a Medical Screening Examination (MSE) on her son. She further stated she left the Pavilion lobby once she knew of FLH's adolescent bed availability. The Parent verified she transported her son to FLH later that afternoon, and he was admitted there.

Interviews with the University Hospital Risk Manager (RM) were conducted on 4/30/14 at 2:24 PM, 5/01/14 at 10:29 AM, and again on 5/09/14 at 8:50 AM. During these interviews the University Pavilion Psychiatric Services Central Logs were requested and reviewed.

The Risk Manager (RM) concurred during these interviews the Pavilion Intake (triage) unit staff did not conduct a Medical Screening Examination (MSE) on Patient #1 or #21 when the Parents presented with Patient #1 & #21 in the Pavilion Intake unit lobby on 4/17/14, as the Parents did not complete the Statement of Confidently/Consent to Assessment form required to be completed before a triage can be started.

A review of the UP Respond Intake (triage) unit lobby security recording taken on 4/17/14 from 11:02 AM to 11:40 AM reveals the Parent and Patient #1 and a male and two children entering the lobby separately and leaving separately.

The Risk Manager upon viewing the recording and reviewing the log records dated 4/17/14 acknowledged the University Pavilion Responds Intake clinical records does show evidence that either the Parent of Patient #1 or the male with Patient #21 signed in as Patients, nor did they receive a Medical Screening Examination (MSE).

Additionally, the University Hospital RM submitted a self-reported event report to the State Agency dated 5/5/14 related to an occurrence in the University Pavilion Respond Intake unit that occurred on 4/17/14 at 11:20 AM at which time a male adult with two children (Patient ID #21) entered the Pavilion Respond Intake lobby and overheard no rooms were available. He subsequently left the lobby without being seen.

The Risk Manager further stated he was made aware of the possible Emergency Department (ED) Access and possible Emergency Medical Treatment and Labor Act (EMTALA) violation by the Fort Lauderdale Hospital CNO on 4/17/14. The University Hospital Risk Assessment team conducted an internal investigation concerning these issues from 4/18/14 to 4/24/14.

The subsequent findings indicated the Hospital did not find ED Access or EMTALA wrong doing, as the Patients (#1 and #21) and Parents left the University Pavilion without filling out the required Statement of Confidently/Consent to Assessment form that gives consent to the triage Nurse and the Physicians to conduct a Medical Screening Examination (MSE).

The Risk Manager further states, Although University Hospital did not find wrong doing on the part of the Pavilion's Respond Intake (Triage) unit staff, the facility did put in place further education concerning ED Access and EMTALA to reinforce the Regulatory requirements.

The Risk Manager provided evidence as follows:

? a) The Director University Pavilion provided counseling to the RN about EMTALA and Florida's Right to Access statute.

? b) The RN attended the EMTALA presentation on 04/24/14 and has requested additional training with an online EMTALA course offered on Health Stream.

? c) A message was sent on 04/19/14, reminding staff of EMTALA and Florida's Right to Access requirements when a Patient presents at the behavioral health facility.

? d) The Director of Risk Management presented an EMTALA presentation on 04/23/14 and 04/24/14.

? e) Additional courses are scheduled to be presented for those staff members that could not attend these presentations.

? f) Staff members are to receive education regarding the procedure and forms to utilize when a Patient decides to leave prior to triage, prior to a medical screening examination or when a patient refuses to sign these forms and departs the facility.

Telephone interview with the University Pavilion Responds Intake (triage) Nurse (Staff #13) was conducted on 4/30/14 at 12:30 PM, and again on 5/9/14 at 10:57 AM.

Staff #13 acknowledged she did not enter Patients #1 or # 21 names in the emergency log, or triage them. Additionally, a Medical Screening Examination (MSE) was not conducted on Patient #1 or # 21 when they presented by his Parent in the Responds Intake (triage) unit on 4/17/14 at 11:02 AM or 11:20 AM.

Staff #13 stated she gave the parent the Statement of Confidently/Consent to Assessment form and informed the Parent upon her arrival that the Pavilion adolescent beds are full, and she may be waiting a long time for an available bed. She (Staff #13) offered to call other facilities to see who had available adolescent beds. The parent agreed to this, So I found Fort Lauderdale Hospital (FLH) had available beds and provided the Parent with FLHs name and telephone number on a post-it note. The parent and son soon left the lobby.

Additionally, Staff #13 further stated that a male adult with two children (Patient ID # 21) names unknown presented to the UP lobby complaining of chest pain & nausea/vomiting on 4/17/14 around 11:20 AM and overheard her telling another Parent no rooms were available. He subsequently left the lobby without being seen, triaged or a Medical Screening examination (MSE) being completed. This was reported the Risk Manager Staff #1.

Staff #13 further stated she has attended in-services on emergency department (ED) access, and Emergency Medical Treatment and Labor Act (EMTALA) training upon hire and annually, but she was under the impression that the Pavilion's Respond Intake (triage) unit was not considered an Emergency Department (ED) triage area subject to ED access and EMTALA rules and regulations.

She continued to state she has had further training since 4/17/14 provided by the Risk Manager and currently understands that the Pavilion Intake unit is in fact the same as a Hospital Emergency Department with the same Patient Rights to examination, assessment and Medical Screening Examination (MSE), and ED access and EMTALA requirements.

Interview with the Pavilion Respond Intake Security Guard (Staff #7) on 4/30/14 at 12:40 PM revealed Patient #1 and his parent entered the Pavilion lobby on 4/17/14 at approximately 11:00 AM. He states he observed them in the lobby for 30 to 40 minutes; the Parent and Patient did not leave the lobby during this time, and subsequently left the lobby around 11:40 AM. Additionally, he stated he did not observe the male adult with 2 children seen on the security recording on 4/17/14 from 11:15 AM to 11:18 AM as he had left the security lobby area for a few minutes to deliver a meal tray.

The University Pavilion Psychiatric Services Central Log dated 4/17/14 was reviewed with the Risk Manager on 5/0/14 at 10:29 AM. The Risk Manager acknowledged Patient #1 and Patient #21's names are not documented on the Central Log. The Risk Manager stated, Once a Patient or family has filled out the Statement of Confidently/Consent to Assessment Form provided to them by the Pavilion Intake security guard or the Triage Nurse, the Nurse will write the patient's name, chief complaint, date and time of presentation to the triage area in the Central Log record sheet.

The Risk Manager further acknowledged that no Medical Screening Examinations (MSE) was conducted for Patient #1 or #21 as they were not registered as Patients.

The Risk Manager additionally stated, Since 4/18/14, the triage staff have been in-serviced to triage and obtain a Medical Screening Examination (MSE) to all presenting Patients, and not tell them there might be a wait for an adolescent's bed.

The security video dated 4/17/14 of the Pavilion's Intake (triage) lobby was viewed. The video showed the Parent and Patient identified by the Risk Manager as Patient #1 walked into the lobby on 4/17/14 at 11:02 AM. The parent received a clip board with an attached white paper. A few moments later she is viewed talking on a hand-held telephone, not visibly filling out the paper on the clip board. Staff #13 is observed in the lobby and appears to be engaged in a conversation for approximately 5 minutes. The Parent is observed placing the clip board on the seat next to her without evidence of having written on the clip board. The parent walks out of the lobby with her son at 11:40 AM and does not return. The Security Guard (Staff #7) is observed on the video to retrieve the clip board from the vacant lobby seat at 11:41 AM. During this 38 minute recording there is no visual evidence that Patient #1 was triaged or a Medical Screening Examination (MSE) was conducted.

Additionally, this security recording revealed a male adult entering the Respond Intake Lobby at 11:15 AM then leaving at 11:18 AM with 2 children. The recording revealed Staff #13 standing in front of the male interacting in what appears as a conversation (no audio is on this recording) for approximately 1 minute. The male is not observed signing any papers during this 3 minutes in lobby.

The tour of the University Pavilion Adolescents unit revealed a capacity for seven (7) Adolescent beds. Review of the census dated 4/17/14 revealed seven beds were occupied, while two (2) overflow Adolescent patients were in the Adult II unit, as there was no available space in the Adolescent unit.

The Risk Manager states the facility is licensed for 8 adolescent beds, but due to construction only 7 beds were available on 4/17/14. During the observation tour of the University Pavilion triage area on 4/30/14, two (2) adolescent patients (Patients # 9 and #10) were observed in holding status in the Pavilion triage area waiting available beds: Patient #9 was waiting for an available in-house bed and Patient #10 was awaiting transfer to Fort Lauderdale Hospital for continued treatment. These two (2) patients have been waiting 9 to 14 hours for adolescent beds.

Review of the Florida Medical Screening Examination and stabilization Policy Policy # EMTALA-2009-009 dated 2/26/09 indicates on page #4, number 2 in the first paragraph: When an MSE is required: A Hospital must provide an appropriate MSE within the capacity of the hospital's emergency department, including ancillary services routinely available to the Dedicated Emergency Department (DED), to determine whether or not an Emergency Medical Condition (EMC) exists.

Triage procedure Policy #NUR-2012-233 dated 4/26/12 indicates on page 2 section III line B: All patients presenting to the Respond Psychiatric Intake Unit for Emergency medical services will be triaged by the respond registered nurse/administrative nursing supervisor regardless of diagnosis, financial status, race, color, national origin, age, gender or disability.

The facility did not follow their policy for conducting a Medical Screening Examination (MSE) for Patient #1 or #21, when they arrived at the University Pavilion Respond Intake unit on 4/17/14 at 11:02 AM and 11:30AM. Patient #1 was subsequently admitted to FLH on 4/17/14 as a voluntary admission.

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

Based on reviews of clinical records transfers documents, Policies & Procedures and interviews, it was determined the facility failed to provide an appropriate transfer of 1 of 6 patients (Patient #1) with Behavioral Health care needs transferred from the University Pavilion Hospital Respond Intake (triage) Unit to other Behavioral Health facilities, as evidenced by failure to provide a medical screening exam and stabelizing treatment prior to the patient leaving the Emergency Department (ED). In addition the facility failed to provide documentation that the patient was informed of and understood the risk versus benefit of transfer, and failed to provide a physician certification prior to transfer.

The finding includes:

The security video dated 4/17/14 of the Pavilion's Intake (triage) lobby was viewed. The video showed the Parent and Patient identified by the Risk Manager as Patient #1 walked into the lobby on 4/17/14 at 11:02 AM. The parent received a clip board with an attached white paper. A few moments later she is viewed talking on a hand-held telephone, not visibly filling out the paper on the clip board. Staff #13 is observed in the lobby and appears to be engaged in a conversation for approximately 5 minutes. The Parent is observed placing the clip board on the seat next to her without evidence of having written on the clip board. The parent walks out of the lobby with her son at 11:40 AM and does not return. The Security Guard (Staff #7) is observed on the video to retrieve the clip board from the vacant lobby seat at 11:41 AM. During this 38 minute recording there is no visual evidence that Patient #1 was triaged or a Medical Screening Examination (MSE) was conducted.

A review of the facility Emergency Department (ED) Central Logs revealed six University Hospital & Medical Center (UH&MC) in-house transfers to the University Pavilion (UP) Behavioral Health facility; seven University Pavilion Hospital (UPH) admissions; and six University Pavilion (UP) transfers to other Behavioral Health Hospitals. Patient #1 was not listed on the log.

Telephone interview with the Parent of Patient #1 was conducted on 4/29/14 at 8:05 AM, and again on 5/6/14 at 8:25 AM. The Parent stated she and her son (Patient #1) arrived to the University Pavilion lobby on 4/17/14 at approximately 11:00 AM. She complained of difficulty managing her son for the past few days, with twitching, verbal out-burst, swinging his arms and body out of control. She stated his behaviors were a result of a head injury incurred in December 2013 when his head was hit by a soccer ball during a game. Subsequently he was diagnosed with [DIAGNOSES REDACTED]#1 stated the University Pavilion Intake (Triage) Nurse (Staff #13) offered to examine her son, but she (the parent) was told by the Nurse no beds were available in the adolescent Pavilion. The Parent then agreed to have the triage Nurse find a hospital with an available adolescent bed. The Nurse provided the Parent with a hand written post-it note with the name and number of Fort Lauderdale Hospital (FLH). The Parent additionally stated she and her son spent approximately a half an hour in the lobby, but to the best of her knowledge her son's name was not taken. She further stated she left the Pavilion lobby once she knew of FLH's adolescent bed availability. The Parent verified she transported her son to FLH later that afternoon, and he was admitted there.

The Risk Manager upon viewing the recording and reviewing the log records dated 4/17/14 acknowledged the University Pavilion Intake clinical records do not show evidence that the Parent of Patient #1 signed him in as a Patient, nor did he receive a Medical Screening Examination (MSE) or stabelizing treatment.

Patient chart reviews conducted with the Risk Manager on 5/09/14 at 11:00 AM, revealed no documentation that Patient #1 received a medical screening exam or stabelizing treatment prior to leaving the ED on 4/17/2014. There was no documentation of a transfer form entitled Memorandum of Transfer certifying that the Patient has an Emergency Medical Condition (EMC). There was no documentatation a receiving facility was contacted.

A review of the facility Policy entitled EMTALA-2009-010 pages 7 of 15 indicates the following: in section VI: Qualified Medical Personnel (QMP). If a Physician is not physically present at the time of the transfer, a QMP (qualified medical professional) may sign the certification, after consultation with the Physician, and transfer the individual as long as the medical benefits expected from transfer outweigh the risk. If a QMP signs the certification, a Physician shall counter it within 24 hours or a reasonable time period specific by the hospital bylaws, rules or regulations.

The Risk Manager acknowledged the physician or designee failed to complete the Physicians Certification of Transfer form for Patient #1.

See additioanl information under A2405 and A2406.

Based on interview, clinical record review and the facility policy & procedures review, it was determined the facility failed to ensure 1 of 10 sampled patients (#6) care was provided in accordance with hospital policy for critical laboratory results.

The finding includes:

Clinical record review reveals Patient #6 was admitted through the Emergency Department (ED) to the 2nd floor Intensive Care Unit (ICU) on 2/01/14, with a previous medical history that included Status post (S/P) left hip intertrochanteric fracture with a past surgical repair, Atrial Fibrillation, Anemia, Current Multiple Pressure ulcers, and Cardiac Pacemaker.

A review of the record with the ICU director, Staff ID #10, revealed a blood result positive for yeast Candida Glavrata. Results were called by the laboratory on 2/09/14 at 4:37 AM to the ICU Nurse. The ICU nurse then called and left a telephone voice mail message to the attending Physician (ID #12) as a critical lab finding at 4:55 AM (within 30 minutes as required). The Physician (#12) responded to the critical laboratory result when making rounds on 2/09/14 at 4:40 PM (approximately 12 hours later) by ordering the anti-fungal medication Fluconazole 400 mg IV daily one time dose for treatment of this blood yeast infection.

The Infectious Disease (ID) Physician (#12) who attended Patient #6 was not available for interview during this compliant survey. Physician (ID #11) was interviewed by telephone on 3/13/14 at 12:06 PM. This interview revealed that the 12 hours period between the critical blood culture results posting and Physician order for anti-fungal medication (Fluconazole) administration May or may not be significant as the Patient currently was receiving several other anti-biotics. Review of the clinical record indicates the following medication were currently in the patient's medication regimen: Flagyl 750 mg, Ceftriaxone 2 GM, Rocephin 2 Gm IV, Cefazolin 2 GM IV every 8 hours.

The Vice President of Regulatory Compliance (ID #1) was interviewed on 3/13/14 at 12:15 PM. During this interview she stated the Physician may have not received this telephone voice mail of the lab results and saw the critical lab results upon his Patient rounds on 2/09/14 at 4:10 PM.

The Vice President of Regulatory Compliance (ID #1) acknowledged the facility P&P for Critical values page #2 of 11 indicates in the section C to D. Critical values/interpretations will be reported to a responsible physician within thirty (30) minutes, and the responsible Physician will respond within thirty (30) minutes.