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Based on interviews, record reviews and a review of facility documentation, to include HCA Lake Monroe's written self-report of violation, the facility failed to provide a medical screening examination for one of twenty-one sampled
patients (#1) who presented to the ED.

Findings:

Medical Record Review: A review of the medical record for patient #1 was performed. The patient initially presented to the Emergency Department (ED) at a sister hospital (Hospital AA) in a nearby town. Review of the ED physician note, from hospital AA with an "initial greet date/time" of 9:33 AM on 3/24/24 (signed on 3/29/24) by Physician- A, noted Chief complaint to include Left side weakness, other balance problems, confusion, dizziness, mental status change, and slurred speech. Record noted reason for ED visit to include acute stroke evaluation for AMS (altered mental status) and left side weakness noting new onset at 8 AM.

Review of a Neurology consult note from hospital AA dated 3/24/24 at 11:04 AM by Physician-B read: "Will need to admit for post Thrombolytic care. . . but symptoms are worrisome so will emergently transfer to thrombectomy capable hospital and they can repeat the scan there." Also noted in consult note the ED MD said they would call for the transfer and Physician-B gave them their cell phone number in case they wanted to talk to them.

The ED physician note by Physician-A stated at 11:30 AM transfer to Lake Monroe ED was accepted by Dr. (Physician-D). The note continued to reflect at 11:50 AM: (Physician-B), Tele-neuro notified. 11:50 AM: (Physician-C - Hospitalist at Hospital AA) notified of possible admit and recommends transfer due to no available Neurosurgery and patient to have a high risk of bleeding after TPA (Tissue Plasminogen Activator) administered. Note further indicated that at 12:15 PM transport arrived for patient transfer and the AOC (Administrator-on-Call at HCA Florida Lake Monroe Hospital) approved the hospital transfer despite there being a lack of LVO (large vessel occlusion) intervention and patient had been declined by stroke neuro-interventionalist. The note also continued with the mention of an event that took place after the patient had arrived at HCA Florida Lake Monroe Hospital when it read at 1:30 PM Patient #1 was transferred to another sister facility about an hour away (hospital BB) due to there being no available ICU (intensive care unit) beds at Florida Lake Monroe Hospital. This entry indicated an expectation for a direct admission to the ICU at HCA Florida Lake Monroe Hospital, which preceded the actual admission to the patient's ultimate destination, Hospital BB. Although this expectation is also reflected in transfer call center notes, record review revealed the orders in place by the ED physician at Hospital AA were specifically for a transfer to the ED at HCA Florida Lake Monroe Hospital, not the ICU. This ED Physician note also read: "Request time: 11:30 AM. Request Date: 03/24/24. Call returned time: 11:30 AM. Spoke with: Emergency physician. Receiving hospital: Lake Monroe. Transfer accepted: yes. Accepted by: (Physician-D)."

The document reviewed from Hospital AA, known as the EMTALA Memorandum of Transfer dated 03/24/24, with a final signature time of 12:10 PM read: "Patient stable for transfer" noting physician authorized this at 11:13 AM. The reason for transfer was stated as "Medically indicated". The risks and benefits for transfer were stated as "Obtain level of care/service unavailable at this facility. Service: Neurosurgery." Under the section Mode/Support during transfer as determined by physician it read: "Mode of transportation for transfer: ALWS (advanced life support)." The receiving facility and individual was stated as: Receiving MD: (Physician-D)." This had been indicated at 10:58 AM. The time of transfer was stated as 12:20 PM on 3/24/24. This indicates acceptance by the ED physician at FL Lake Monroe Hospital.

Throughout the medical record there was no mention of what was stated in the EMTALA Memorandum of Transfer or of it being rescinded and changed by the ED physician at Hospital AA to any another destination besides the ED at HCA Florida Lake Monroe Hospital.

A nurse's note at 12:30 PM on 3/24/24 read: the reason for transfer to HCA Florida Lake Monroe ED to include a Specialist was not available and the services required for transfer being Neurology with transferring facility to be Lake Monroe. Patient was to be transferred via ambulance.

Transfer Center Call/Records

Review of Transfer Center Notes revealed a form that was created at 10:58 AM on 03/24/24. It also indicated a destination of HCA Florida Lake Monroe Hospital with the requested service of neurology, reflecting communication with Physician G and Physician D. It also indicated that HCA Florida Lake Monroe Hospital accepted the patient at 11:10 AM.

An entry in transfer center documentation at 03/24/24 at 11:04 AM reflected a conversation between Physician-A and Physician-D, which read "We would like to TX (transfer) for Neuro IR (Interventional Radiology)" and asking if they had reached the stroke IT (interventional). Entry ended with confirmation that they would take the patient at Florida Lake Monroe ED. This documentation also indicated there was an agreement by the ED physician at HCA Florida Lake Monroe Hospital to accept the patient from the ED at hospital AA.

An entry in transfer center documentation at 11:35 AM on 3/24/24 reflected a conversation between "Dr. (Physician-A) and Dr. (Physician-E) Neuro IR (interventional radiology) Lake Monroe." The entry continued with a discussion of the case and read: "I do not know that transferring would be beneficial. . . . He already has some disability and this would be more significant change in his morbidity. I understand that he is outside the criteria for intervention." Note also reflected Dr. E to say Please document that he did not think he would be a good candidate for transfer for the purpose of intervention as patient was not a good candidate. Although the Neurologist indicated in this entry that it was unlikely that he could help the patient, the previously approved transfer orders were not cancelled.

An entry in transfer center documentation at 11:42 AM on 3/24/24 read: "Called (hospital AA) ED . . . SW (spoke with) (a Registered Nurse). Request next steps in the transfer. States Dr. (Physician-A) is going to SW (speak with) his hospitalist and see if they can keep the patient at (hospital AA) since Dr. (Physician-E) is no longer accepting the patient. Requests we put NHT (National Health Transport) on will call." During an interview of the Director of Quality on 4/3/24 at 3:10 PM, she stated that "will call" is a wait status, stating In other words, a request was made to hold the transport. However, documentation indicated NHT transport came anyway.

An entry in transfer center documentation at 11:46 AM on 3/24/24 indicated NHT (transport) was called and spoke with (staff member) and they placed Transport on "will call".

An entry in transfer center documentation at 11:53 AM on 3/24/24 read a call was placed to a Registered Nurse (RN) at hospital AA ED and requested date on transfer. RN stated her ED MD spoke with the hospitalist and they are hesitant to care for the patient at hospital AA since the patient received TNK (Tenecteplase) and may bleed and they do not have the services to care for that patient if they do start to bleed.

Another transfer center entry at 11:57 AM on 3/24/24 read they called Lake Monroe AOC (Administrator on Call) and TCC (transfer call center) was informed of the case and the decline in taking patient by Dr. (Physician-E) to consult on the case stating they could still send the pt to the ED, stating even if patient may not be an LVO (large vessel occlusion) candidate there were other services they could offer at Lake Monroe that Hospital AA does not have. Stated they can go ahead and send to Lake Monroe ED, noting an understanding that the transfer to the ED could continue.

An entry on 3/24/24 at 12:00 PM read: "Called (hospital AA) ED. SW (spoke with) (Registered Nurse) . . . . States the admitted MD (physician at hospital AA) is not comfortable with caring for the PT D/T (due to) the risk of bleeding. Requests we continue with transfer to Lake Monroe. TCC (transfer call center) informed after SW the AOC at Lake Monroe we can send the pt to the ED at Lake Monroe." indicating the transfer request Documentation from NHT (National Health Transport) transport indicated they were with the patient at 12:06 PM on 3/24/24.

An entry at 12:33 PM by a transfer center staff member on 3/24/24 read: ". . . AOC Lake Monroe called about pt (#1) at (hospital AA) ED. DX (diagnosis) stroke which is old. Per AOC at LMH (Lake Monroe Hospital) this pt will go from (Hospital AA) ED to LMH ICU (Intensive Care Unit). No additional ED workup needed and holding 2 ICU pts in ED at LMH." This entry indicated a planned direct admission to the ICU, and not an ED to ED transfer. However, there was no physician statement or physician order specifically countering the directive in the EMTALA Memorandum of patient transfer and having the ED physician at HCA Florida Lake Monroe Hospital receive the patient.

Interviews:

During an interview with the CEO/AOC, on 4/4/24 at 11:40 AM, he showed the surveyor a call on his cell phone which indicated he communicated with the transfer call center at 11:57 AM (incoming, one minute).

During an interview of the CEO/Administrator on Call, on 4/4/24 at 11:40 AM, he showed surveyor a call on his cell phone which noted he had communicated with the transfer call center at 12:26 PM (outgoing call of 4 minutes).

Continued interview with the CEO/AOC on 4/4/24 at 11:15 AM, noted he stated that an admission to the ICU would not have involved entry through the
ED. Later text revealed that this desired change to an ICU admission, authorized or not, was not
relayed to the transport company.

A text from transfer center documentation at 12:52 PM on 3/24/24 indicated that the patient left (hospital AA) ED at 12:35 PM (documentation from the transport company indicated departure at 12:47 PM).

An entry at 12:40 PM by a transfer center staff member on 3/24/24 read: SW (Registered Nurse at hospital AA) ED and asked if patient #1 was still there and nurse stated, "leaving on stretcher now." This entry did not indicate awareness by the Administrator on Call of the patient being in the hands of transporters.

Continued review of documentation through 12:40 PM indicated that a transfer was to proceed. The Facility's AOC indicated that the patient needed to go to the ICU, but the physician had not changed the orders from the patient being received in the ED. Also, the patient was leaving around 12:40 PM.

Documentation noted a sudden change of plans and an intent to stop the transfer. The plan had been changed at 12:33 PM to a direct admission, but that plan was not authorized by the physician and the patient was already on the way out of the (hospital AA) ED at this time.

An entry by transfer center staff at 12:41 PM on 3/24/24, read: "SW. . . AOC LMH . . . Informed we (HCA Florida Lake Monroe Hospital) cannot take the pt right now. . . "tap the brakes" noting they need to wait for ICU, indicating they could send nurses, but would need to redirect to (hospital BB) in Osceola County, noting they had 3 ICU holds in ED and did not have the staff. Due to this, the CEO/AOC at HCA Florida Lake Monroe requested that the transfer to the ICU be stopped.

During an interview of the CEO/Administrator on Call on 4/4/24 at 11:40 AM, he showed the surveyor a call on his cell phone which showed his communication with the transfer call center at 12:41 PM for two minutes.

Documentation from National Health Transport indicated departure from hospital AA to have occurred at 12:47 PM.

Continued interview with the CEO/Administrator on Call on 4/4/24 at 1:05 PM confirmed there was no evidence that the order to send to the ED at HCA Lake Monroe was changed and there was no evidence in the medical record that the patient no longer had an emergency medical condition when he departed hospital AA.

Documentation confirmed the patient ended up being transported without evidence that the request to cancel the transport had been relayed to the transport company.

An entry at 12:52 PM by the transfer center staff on 3/24/24 read: "Called (hospital AA) ED . . . SW (Registered Nurse). Requested next steps in the transfer. Stated the pt left at 12:35 PM to go to the ED at Lake Monroe."

An entry at 1:00 PM on 3/24/24 read: "(Registered Nurse) Oviedo ED called request to SW (transfer center staff member). Heard pt was declined by LMH and would like to SW her to figure out what is going on."

Review of ED Log

A review of the HCA Lake Monroe Hospital's ED log revealed that the patient was registered on their log at 1:37 PM . The reason for visit stated: "Transfer from (hospital AA)." The Disposition Category was stated as: "Was transferred." The Disposition Type / Disposition Place was stated as: Short term hospital. (hospital BB)." The last time notated on the log for the patient was 1:38 PM. There was no medical record for the patient, except for a few pages created by registration, and there was no evidence of a physician attempt to perform a medical screening examination.

During an interview of Physician-A at approximately 2:15 PM on 4/4/24, he confirmed that he had accepted the patient for admission in the ED and stated that he did not subsequently retract the permission.

Transfer Center notes continued after the patient had arrived at HCA Florida Lake Monroe Hospital and subsequently was turned away. An entry in transfer center documentation at 1:20 PM on 3/24/24 read: "Pt transferred from (hospital AA) to LMH ED but need to redirect to (hospital BB) and indicated patient at LMH ED in the EMS bay and waiting to transfer to the Osceola ED. . . "LMH ED MD not giving report to (hospital BB) ED. Connecting (hospital AA) ED MD Dr. (Physician-A) to (hospital BB) ED MD for MD Conf." An entry on 3/24/24 at 1:29 PM read: "Dr. (Physician-A) to Dr. (Physician-F) - ED physician at the (hospital BB) ED . . . . They don't have space at LMH. Came from (hospital BB). . . . We take everything send him over (this would be the ED physician at (hospital BB ED speaking). Talk with the IR guys and let them know. The other hospital (HCA Florida Lake Monroe Hospital) is our first transfer point and we got to you after they can't take it."

An entry at 1:37 PM on 3/24/24 read: "Called LMH ED SW (Registered Nurse). . . . Asked if any changes on the pt for transport to (hospital BB). She stated they have NHT transport with the patient and waiting to be told where to take the pt. Advised pt has acceptance to (hospital BB) and they can take the patient to the ED. Provided accepting information."

A review of the medical record of the patient while at Hospital BB was performed. The History and Physical of 3/24/24 at 6:14 PM read: ". . . is a 68 year old male with a PmHx (past medical history) of AFib not on anticoagulants, CHF (congestive heart failure), unknown EF (ejection fraction - fluid ejected from a chamber in the heart), DM (Diabetes Mellitus), HTN (hypertension), CKD (chronic kidney disease), seizure disorders (resting tremor), who was transferred from (hospital AA) for ICU admission after administration of TNK . . . " The Discharge Summary of 3/27/24 at 4:18 PM read: "Given poor functional status post stroke, patient's family decided to proceed with hospice care. Patient is to discharge hospice at this time."

Review of Policies:

Review of facility policies noted they were not in compliance with their internal policy known as Florida EMTALA Medical Screening Examination and Stabilization Policy which noted: "A MSE (medical screening examination) is required when: A request is made by the individual or on the individual's behalf for examination or treatment for a medical condition, including where: . . . The individual arrives as a transfer from another hospital or health care facility. Upon arrival of a transfer, a physician or qualified medical person ("QMP") must perform an appropriate MSE."

ED Medical Record Reviews:

Twenty ED medical records were reviewed. Although patient #1's name was found on the ED log, there was no medical record and patient was found to have been kept in the ambulance bay and not brought into the ED.

Interview with the VP of Quality on 4/5/24 at approximately 3:45 PM confirmed the findings.